Transcript Day 1_9-945_Rutherfo..

Progress in the MA STAAR Collaborative and
Working Across the Continuum
Pat Rutherford
Rebecca Steinfield
(The presenters have nothing to disclose)
MA STAAR Collaborative Learning Session
October 11, 2011
Session Objectives
Participants will be able to:
• Describe the case for creating a more patientcentered transition from the hospital to post-acute
care
• Describe IHI/CMWF strategies and identify key
interventions promoted in the MA STAAR
Collaborative to reduce avoidable rehospitalizations
• Share an overview of the MA STAAR Collaborative
progress to-date
Systems of Care
“The quality of patients’ experience is the
“north star” for systems of care.”
–Don Berwick
Rebecca’s Story
Rebecca Bryson lives in Whatcom County, WA and she suffers
from diabetes, cardiomyopathy, congestive heart failure, and a
number of other significant complications; during the worst of her
health crises, she saw 14 doctors and took 42 medications. In
addition to the challenges of understanding her conditions and the
treatments they required, she was burdened by the job of
coordinating communication among all her providers, passing
information to each one after every admission, appointment, and
medication change.
http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCentered
CareGeneral/ImprovementStories/PursuingPerfectionReportfromW
hatcomCountyWashingtononPatientCenteredCare.htm
Rebecca’s Story
Rebecca said if she were to dream up a tool that would be
truly helpful, it would be something that would help her
keep her care team all on the same page. Bryson described
typical medical records as being “location or process
centered, not patient-centered.” She also describes how
difficult it can be for patients to navigate a large health care
system. Rebecca summarizes her experience in this way –
“Patients are in the worst kind of maze, one filled with
hazards, barriers, and burdens.”
http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCentered
CareGeneral/ImprovementStories/PursuingPerfectionReportfrom
WhatcomCountyWashingtononPatientCenteredCare.htm
“North Star” in STAAR?
Whose experience of care is the
“north star” for your system of care?
Strategic Questions for
Executive Leaders
• Is reducing the hospital’s readmission rate a strategic priority
for the executive leaders at your hospital? Why?
• Do you know your hospital’s 30-day readmission rate?
• What is your understanding of the problem?
• Have you assessed the financial implications of reducing
readmissions? Of potential decreases in reimbursement?
• Have you declared your improvement goals?
• Do you have the capability to make improvements?
• How will you provide oversight for the collaborative, learn from
the work and spread successes?
What can be done, and how?
There exist a growing number of approaches to reduce
30-day readmissions that have been successful locally
Which are high leverage?
Which are scalable?
Success requires engaging clinicians, providers across
organizational and service delivery types, patients, payers,
and policy makers
How to align incentives?
How to catalyze coordinated effort?
STAAR Initiative: Two Concurrent Strategies
• Provide technical assistance to front-line teams of providers working to
improve the transition out of the hospital and into the next care setting
•
•
•
Actively engage hospitals and their community partners in co-designing processes to
improve transitions
Provide coaching by content experts and facilitate collaborative learning with the goals
of creating exemplary cross continuum models in each state and identifying highleverage changes in each care setting
Develop quality improvement expertise and content experts to mentor others
• Create and support state-based, multi-stakeholder initiatives to
concurrently examine and address the systemic barriers to improving
care transitions, care coordination over time.
•
•
•
State leadership, steering committees, key allies, aligning initiatives
Technical assistance to “staff” challenges in framing the issue, designing strategy,
scanning for developments in best practice/policy
Specific focus areas: understanding the financial impact of success, aligning payment
to support high leverage interventions, developing state rehospitalization data reports
Evidence-Based Interventions
• Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective
Interventions to Reduce Rehospitalizations: A Compendium of
15 Promising Interventions. Cambridge, MA: Institute for
Healthcare Improvement; 2009
• Kanaan SB. Homeward Bound: Nine Patient-Centered
Programs Cut Readmissions. CHCF, Sept 2009.
• Osei-Anto A, Joshi M, Audet AM, Berman A, Jencks S, Health
Care Leader Action Guide to Reduce Avoidable
Readmissions. Health Research & Educational Trust,
Chicago, IL. January 2010
IHI’s Roadmap for Improving
Transitions and Reducing Avoidable
Rehospitalizations
Post-Acute Care
Activated
Transition from
Hospital to Home • MD Follow-up Visit
Alternative or
Supplemental Care
for High-Risk
Patients *
• Hospice/Palliative Care
• Home Health Care • Transitional Care
• Enhanced
(as needed)
Models
Assessment
• Social Services (as • Intensive Care
• Teaching and
needed)
Management (e.g.
Learning
Patient-Centered
or
• Real-time Handover
Medical Homes, HF
Communications
Clinics, Evercare)
• Skilled Nursing
• Follow-up Care
Facility Services
* Additional Costs
Arranged
for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
Improved
Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations
IHI’s Roadmap for Improving
Transitions and Reducing Avoidable
Rehospitalizations
Post-Acute Care
Activated
Transition from
Hospital to Home • MD Follow-up Visit
Alternative or
Supplemental Care
for High-Risk
Patients *
• Hospice/Palliative Care
• Home Health Care • Transitional Care
• Enhanced
(as needed)
Models
Assessment
• Social Services (as • Intensive Care
• Teaching and
needed)
Management (e.g.
Learning
Patient-Centered
or
• Real-time Handover
Medical Homes, HF
Communications
Clinics, Evercare)
• Skilled Nursing
• Follow-up Care
Facility Services
* Additional Costs
Arranged
for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
Improved
Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations
Co-designing Processes to
Improve Transitions
Hospitals
• Perform an
enhanced
assessment of
post-hospital
needs
• Provide effective
teaching and
facilitate enhanced
learning
• Ensure posthospital care
follow-up
• Provide real-time
handover
communications
Office
Practices
• Provide timely
access to care
following a
hospitalization
• Prior to the visit:
prepare patient
and clinical team
• During the visit:
assess patient and
initiate new care
plan or revise
existing plan
• At the conclusion
of the visit:
communicate and
coordinate ongoing
care plan
Home Care
Skilled
Nursing
Facilities
• Meet the patient,
family caregiver(s),
and inpatient
caregiver(s) in the
hospital and review
transition home
plan
• Assess the patient,
initiate plan of
care, and reinforce
patient selfmanagement at
first post-discharge
home care visit
• Engage,
coordinate, and
communicate with
the entire clinical
team
• Ensure that SNF
staff are ready and
capable to care for
the resident
patient’s needs
• Reconcile the
Treatment Plan
and Medication List
• Engage the
resident and their
family or caregiver
in a partnership to
create an overall
place of care
• Obtain a timely
consultation when
the resident’s
condition changes
4 Key Changes to Improve the
Transition from Hospital to Home
1.
Perform an Enhanced Assessment of
Post-Hospital Needs
2.
Provide Effective Teaching and Facilitate
Enhanced Learning
3.
Ensure Post-Hospital Care Follow-Up
4.
Provide Real-Time Handover
Communications
1. Enhanced Assessment
1. Perform an Enhanced Assessment of Post-Hospital Needs
A. Involve the patient, family caregiver(s) and community
provider(s) as full partners in completing a needs assessment of
the patient’s home-going needs.
B. Reconcile medications upon admission.
C. Create a customized discharge plan based on the assessment
2. Effective Teaching and
Facilitate Learning
2. Provide Effective Teaching and Facilitate Enhanced Learning
A. Involve all learners in patient education.
B. Redesign the patient education process.
C. Redesign patient teaching print materials.
D. Use Teach Back regularly throughout the hospital stay to assess
the patient’s and family caregivers’ understanding of discharge
instructions and ability to perform self-care.
3. Follow-up Care
3. Ensure Post-Hospital Care Follow-up
A. Reassess the patient’s medical and social risk for readmission.
B. Prior to discharge, schedule timely follow-up care and initiate
clinical and social services based upon the risk assessment.
4. Handover Communications
4. Provide Real-Time Handover Communications
A. Give patient and family members a patient-friendly post-hospital
care plan which includes a clear medication list.
B. Provide customized, real-time critical information to next clinical
care provider(s).
C. For high-risk patients, a clinician calls the individual(s) listed as
the patient’s next clinical care providers(s) to discuss the patient’s
status and plan of care.
IHI’s Roadmap for Improving
Transitions and Reducing Avoidable
Rehospitalizations
Post-Acute Care
Activated
Transition from
Hospital to Home • MD Follow-up Visit
Alternative or
Supplemental Care
for High-Risk
Patients *
• Hospice/Palliative Care
• Home Health Care • Transitional Care
• Enhanced
(as needed)
Models
Assessment
• Social Services (as • Intensive Care
• Teaching and
needed)
Management (e.g.
Learning
Patient-Centered
or
• Real-time Handover
Medical Homes, HF
Communications
Clinics, Evercare)
• Skilled Nursing
• Follow-up Care
Facility Services
* Additional Costs
Arranged
for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
Improved
Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations
New Frontiers in the STAAR Initiative
Engaging Payers:
• Payers are motivated to reduce avoidable rehospitalizations
• Individual payer efforts
─ Mostly focus on pre-discharge preparation
─ CMS 3026 to pay for additional community-based care
─ Discrepancies between what providers get paid for and what is needed
for care
─ Supplemental services for high-risk patients are of paramount
importance
─ What is the comparative effectiveness for various interventions for
high-risk patients?
• Myriad payer-based discharge planning and care coordination
services create chaos at provider level. How can interests be
aligned and coordinated?
Improving Transitions and Reducing
Avoidable Rehospitalizations
Will
Build
confidence
New
possibilities
RESULTS
Ideas
Sequencing and tempo
Execution
What Changes Are You Working On?
What Changes Are You Working On?
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Cohort 1
Baystate Medical Center
Berkshire Medical Center
Beth Israel Deaconess Medical Center
Brigham and Women's Hospital
Cambridge Health Alliance
Cooley Dickinson Hospital
Fairview Hospital
Faulkner Hospital
Lahey Clinic Medical Center
Massachusetts General Hospital
MetroWest Medical Center
Newton-Wellesley Hospital
North Shore Medical Center
Northeast Hospital Corporation
Saint Vincent Hospital
Saints Medical Center
South Shore Hospital
St. Elizabeth's Medical Center
Sturdy Memorial Hospital
Tufts Medical Center
UMass Memorial Medical Center
VA Boston Healthcare System
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Cohort 2
Baystate Franklin Medical Center
Baystate Mary Lane Hospital
BIDMC Needham
Cape Cod Hospital
Carney Hospital
Emerson Hospital
Falmouth Hospital
Good Samaritan Medical Center
Hallmark Health System
Harrington Hospital
Heywood Hospital
Holy Family Hospital & Medical Center
Holyoke Medical Center
Jordan Hospital
Lawrence General Hospital
Lowell General Hospital
Merrimack Valley Hospital
Milford Regional Medical Center
Milton Hospital
Morton Hospital & Medical Center
Mt. Auburn Hospital
New England Baptist Hospital
Norwood Hospital
Sisters of Providence Health System
St. Anne's Hospital
Winchester Hospital
Wing Memorial Hospital and Medical Center
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Analysis of Results-to-Date
• Reducing readmissions is dependent on highly functional
cross continuum teams and a focus on the patient’s journey
over time
• Improving transitions in care requires co-design of
transitional care processes among “senders and receivers”
• Providing intensive care management services for targeted
high risk patients is critical
• Reliable implementation of changes in pilot units or pilot
populations require 18 to 24 months
The Next Year in the
MA STAAR Initiative
• Two 1.5-day state-wide Learning Sessions plus monthly content
coaching calls
• State Leaders and IAs facilitate monthly networking/peer
coaching calls
• Improvement Science in Action Workshop (for day-to-day leaders
in hospitals, SNFs, HC agencies and OPs) plus monthly
coaching calls
• IHI and expert faculty will facilitate Learning Networks for
clinicians and staff in OP, SNFs and HC Agencies
• MA STAAR State Leaders and State-wide Steering Committee
Meetings align initiatives and address systemic barriers