Transcript Beth Hennessey Presentation - HomeCare Association of Arkansas

Integrated Care Management (ICM):
Positioning Home Care as a
Value Added Partner
Better Health
Better Care
Lower Cost
© 2014 Sutter Health
Learning Objectives
1. Provide an overview of healthcare
reform and the urgency for change in
our care delivery model
2. Provide an overview of Integrated
Care Management (ICM) and key
best practices , competencies, and
tools
3. Review a leadership best practice to
lead transformational change and
clearly communicate Home Health
as value added partner .
© 2014 Sutter Health
What is the Sutter Center for Integrated
Care (SCIC)?
SCIC supports health care organizations, leaders and clinicians through
the provision of educational programs, consultation, best practice
tools, and model hardwiring of the Integrated Care Model (ICM).
SCIC team seeks to transform healthcare delivery nationwide by
guiding the way for those seeking to achieve better health, better care,
and lower costs for individuals and populations.
Those trained include: hospital executives, case managers, home
health and hospice clinicians, care navigators/managers for hospitals
and insurers, telehealth nurses, social workers, pharmacists, therapists,
and physicians
© 2014 Sutter Health
Meet the Team
Beth Hennessey, RN, MSN
Executive Director
Paula Suter, RN, BSN, MA
Clinical Director
Jennifer Pearce, MPA
Health Literacy
Program Manager
© 2014 Sutter Health
Sutter Health at a Glance
One Sutter:
Patient Experience
Operational Excellence
Market Growth
Future Innovation
•
•
•
•
5,000+ physicians
55,000+ employees
24 acute care hospitals
Home Health, Home Infusion,
Hospice, DME
• Long-term care services
• Health care research, development
and dissemination program
© 2014 Sutter Health
5
Sutter Center for Integrated Care (CIC):
Facts About Who We Serve
Sutter CIC
SCAH
Northern California
28 Locations
• 11 Home Health
• 7 Hospices
• 2 Infusion
• 2 HME
• 1 Private Duty &
Geriatric Care Management
1,800 Employees
770 Volunteers
20,000 Average Daily Census
Sutter Health: Transitions of Care,
Complex Case Management, Advanced
Illness Management, PCMH, Patient
Experience, Population Health
Outside SCAH/SH:
7000+ Providers (49 States and
3 Countries: US, Canada & Singapore)
© 2014 Sutter Health
Urgency for Change
 STAR
 CoP
revisions
 Value Based
Payments
© 2014 Sutter Health
Star Ratings:
Pay Close Attention to Patient Experience
Patient Satisfaction –
Did you like what I did?
Versus
Patient Experience –
Did we do what you expected
/what met your needs?
© 2014 Sutter Health
8
New COP’s and ICM Practices/ Tools
COP
ICM Tool
Continuous, integrated care process based
on a patient-centered assessment
Risk assessment at referral/intake, Stoplight
tools, Med Risk tool, High Risk med teaching
tools, Personal Health record- “Always event”
Patient-centered, interdisciplinary
approach that recognizes the contributions
of various skilled professionals
Weekly case conferencing, Personal goal listed in
EMR, case conf discussion of goals, use of
SBAR template, SMART action plans
Outcome-oriented, data-driven quality
assessment and performance improvement
program
Metric tracking bi-weekly, client friendly med list,
ARC program as an example of an improvement
Eliminate the focus on administrative
process requirements that lack adequate
consensus or evidence
OASIS not completed at first visit for high risk
TOC patients, High alert medication teaching
Safeguard patient rights
Universal precautions approach to HL, Clientfriendly Medication list
© 2014 Sutter Health
Medicare Payments Will
Significantly Change: Bold Goals
Are Set
1) Alternative Payment Models
( ACOs & bundled payments)
30% by 2016
50% by 2018
2) Tied to quality or value
85% by 2016
90% by 2018
© 2014 Sutter Health
Living in Two Worlds at the Same
Time is Challenging
Value Based Population
Reimbursement
Fee for Service
Urgency for change to survive and thrive in both worlds calls providers to …
consistently provide exceptional high quality care for ALL patients
© 2014 Sutter Health
Evolving “World” of Payment Reform:
Impacting “Transitions of Care”
FFS World
Penalties
World
Value
Based
World
• Decrease acute care length of stay
• Decrease acute care length of stay
• Avoid readmissions e.g.: HF, MI, COPD,
pneumonia
• Focus on quality and patient experience
outcomes across providers, settings and time,
starting with high risk patients
• Better health, better care, lower cost
© 2014 Sutter Health
Integrated Care Management (ICM):
Where it started
Journey Towards
Excellence In
Homecare &
Healthcare:
Improving Experience
and Outcomes
of Care
© 2014 Sutter Health
The Right Thing to Do:
IOM Quality Chasm Report
• Current healthcare systems
cannot do the job
• Trying harder will not work
• Changing care systems
will work
• Make the right thing to do
the easy thing to do
© 2014 Sutter Health
The Right Thing to Do:
IOM Quality Chasm Report
ALL health care providers should pursue six major aims:
1)
2)
3)
4)
5)
6)
Safe
Effective
Patient Centered
Timely
Efficient
Equitable
“Providing care that is respectful of
and responsive to individual patient
preferences, needs, & values &
ensuring patient values guide all
clinical decisions.”
“ A New Health System for the 21st Century” (IOM, 2001)
© 2014 Sutter Health
15
Integrated Care Model (ICM):
What is it?
• A person-centered care
delivery model
• Based on Wagner’s Care Model
• Integrates care transitions
best practices
• Integrates health literate care
 All patients
 All providers
 All settings
© 2014 Sutter Health
Integrated Care Management (ICM):
A Care Delivery Model for Improved Outcomes
Person-Centered
Evidence-Based
Coordinated Care
- Care with dignity and
respect
- Clinical best practices
- Seamless transitions
across providers,
settings and time
- Patient Engagement:
- Values, needs and
preferences drive care
Self-management
support
- Patient as partner
Health literate care
- Meaningful and timely
information exchange
Improved outcomes leading to better health, better care and lower cost
© 2014 Sutter Health
Patients Values, Needs and
Preferences Guide All Care
“We think our job is to ensure health and survival.
But really it is larger than that.
It is to enable well-being.
And well-being is about the reasons one wishes to
be alive […] those reasons matter all along the
way.”
Atul Gawande, MD, MPH,
Author of Being Mortal: Medicine
and What Matters in the End
© 2014 Sutter Health
Person-Centered Care
Person-Centered
- Care with dignity and
respect
- Value, needs and
preferences drive care
- Patient as partner
Goal Before:
Manage signs and symptoms
of HF exacerbation, low
sodium diet, and fluid
restrictions adhered to by ----
Goal Now:
Able to join ROMEO
(Retired Old Men Eating
Out) group for lunch once a
week
© 2014 Sutter Health
Person-Centered Care
Person Centered
- Care with dignity and
respect
- Values, needs, &
preferences drive care
- Patient as partner
Goal Before:
Safely ambulate 100 feet
with or without assistive
devices by time end of
episode.
Goal Now:
Be able to walk on my own
to the activity center in the
next month.
© 2014 Sutter Health
Asking questions to
understand persons
preferences
These are some
things you can
work on that will
help you return
to gardening.
Lets go over
these options
together.
What would you
like to work on?
© 2014 Sutter Health
Use Shared Decision Making Approach to
Goal Setting
Walk 15 minutes each day
Starting tomorrow
Walk around my house for 15 minutes
after lunch daily for the next week
I may feel too tired to do it
“I would
like to
exercise”
Ask my husband to encourage me
Will improve my enegy level so I can
work in my garden again
March 2nd
© 2014 Sutter Health
Power Point Template 3
22
Quality of Life
Tools
As a persons condition
changes, their needs
and preferences
change.
Shared decision making
with patient and
caregivers is facilitated
with person-centered
health literate tools.
© 2014 Sutter Health
Evidence-Based Care
Step 3
Leads to
Empowerment
Promotes
Engagement
Evidence-Based
- Clinical best practices
Step 2
Start with
Plain
Language
- Patient Engagement:
Self-management
support
Step 1
Health literate care
Source: Blue Shield California Foundation.
(2012). Empowerment and engagement among
low-income Californians: Enhancing patientcentered care.
© 2014 Sutter Health
Patient Engagement is
“The Right Thing To Do”
Evidence reveals that patients who are
actively involved in their health and healthcare:
 Achieve better clinical
outcomes
 Have lower healthcare costs
 Are more satisfied with
their care experience
© 2014 Sutter Health
How Can You Start Engaging Patients?
The Cycle of Patient Engagement
Leads to
Empowerment
Promotes
Engagement
Start with Plain
Language
Source: Blue Shield California Foundation.
(2012). Empowerment and engagement
among low-income Californians: Enhancing
patient-centered care.
© 2014 Sutter Health
This Approach is Appropriate for All
Individuals Regardless of:
Reading ability
Education level
Universal
Precaution
Approach
Socio-
economic status
Source: Smith, Sandra A. (2001). Patient Education and Literacy in Labus, A. & Lauber, A.
(Eds.) Preventive Medicine and Patient Education. Philadelphia: WB Saunders, 266-290.
© 2014 Sutter Health
To Improve Understanding and
Engagement
Use a universal
precautions approach
to health literacy with
verbal
and
written materials
© 2014 Sutter Health
Universal Precautions
Oral Communication Self Assessment
Found in AHRQ
Universal
Precautions
Tool Kit
© 2014 Sutter Health
Enhancing Provider Competencies:
Make “the right thing to do, the easy thing to do”
© 2014 Sutter Health
30
Power Point Template 3
Verify Understanding
Teach-Back Competency Check List
You get to hear in the
patients own words :
• their understanding
• what is important
• how to best “connect”
new information
© 2014 Sutter Health
To Improve Understanding and
Engagement
Use a universal
precautions approach
to health literacy with
verbal
and
written materials
© 2014 Sutter Health
Evidence: Easy-to-read is Preferred!
College educated readers’response to health
information written at 5th grade level:
Recall of key messages
Satisfaction
Sources: Smith SA. Information giving: Effects on birth outcomes and patient satisfaction. Int Electronic J Health Educ 1998:;3:135-145. Online at
http://www.beginningsguides.net/content/images/stories/info-giving.pdf
© 2014 Sutter Health
33
Health literate
stoplight tool with
universal precaution
approach applied
ClearMark Award of Distinction
Center for Plain Language
Washington, D.C.
© 2014 Sutter Health
Moving toward Health Literate Care:
Stoplight form before
• Third person
• Zones drive
navigation
• Graphic does not
support text
• Font, layout, graphics
not consistent with
health literacy
principles
© 2014 Sutter Health
Stoplight after:
supports patient
and family engagement
• First person
• Patient daily assessment
drives navigation
• Font, layout, graphics
consistent with health literacy
and plain language principles
• Supports patient and
caregiver engagement
• Supports teach back with
content ready for “chunk and
check”
© 2014 Sutter Health
36
Universal Precautions Approach in
Action: Patient Friendly Medicine List
Medication
and Route
Dose
Frequency
Reason
Instructions
Font size
increased
to 14 pt
© 2014 Sutter Health
37
Coordinated Care
There and Home Again
Safely (AMA)
Joint Commission
7 Foundations
Coleman, Naylor, RED,
Boost
Taking
the Best
of the
Best
Coordinated Care
- Seamless transitions
across providers,
settings and time
- Meaningful and timely
information exchange
© 2014 Sutter Health
ICM Alignment with TJC Foundations For
Safe Transitions
TJC Foundation
ICM Practice/ Tool/competency
Patient/ family action/
engagement
Universal precautions approach to HL, id of pt
goals and preferences through open-ended
questions and reflective listening, teach-back
Early identification for “at risk”
patients
Look for common barriers: low self rating of
health, depression, low literacy, cognitive deficits,
lack of social support, etc.
Transitions planning
Protocols to guide care delivery for high risk pts
Medication management
Thorough medication reconciliation, medication
risk assessment, assistance with medication
adherence
Multidisciplinary collaboration
and transfer of information
Broad use of SBAR in provider and patient
communication, team review of high risk patients
Leadership support
Creating a learning environment and reviewing
© 2014 Sutter Health
readmissions for improving practice
39
Person-Centered Care “Always Event”:
Starting in Hospital
“I have four areas we need to focus on to help prepare
you and your family for discharge, but before we start
on my list can you tell me what you are the most
concerned or worried about when you leave here
and go home?”
Then transitions of care focus areas ….
1. Medication Management Post-Discharge
2. Early Follow-up
3. Symptom Management
4. Personal Health record
© 2014 Sutter Health
Person-Centered Care “Always Event”:
Starting in Hospital
Open ended questions in
hospital and continued in the
home
•
What are you most concerned about
at this time?
•
What would you like to have happen
as a result of our care?
•
How would you like to feel?
•
What is one thing that is most
important to you that you want to be
able to do again?
Feeling lonely as I live alone.
© 2014 Sutter Health
Risk for Re-admission:
IHI Two Question Rubric
High Risk
Criteria
A
• 2 or more
hospitalizations in
past year
Criteria
B
• Low confidence
with self-care, or
fails teach-back
© 2014 Sutter Health
Person Centered Assesment Tool
Personal assessment of health,
“In general would you say your health is… poor (1)
fair (2) good (3) very good (4) excellent (5) ?”
© 2014 Sutter Health
Single Item Self-Rating and One Year Event
Rates
Source: DeSalvo, et.al., Health Services Research, August 2005
© 2014 Sutter Health
ICM Transitions of Care:
9 “Touch-Points” in First 2 Weeks
Week 1
•Home Care Coordinator
in-hospital patient visit
•Patient Assessments:
Risks for readmission
•Patient Concerns/ Goals
•Stoplight teaching
•MD Follow-up appt
•PHR
3 home
visits or
virtual visits
Week 2
• Focus on patient
engagement, med
management,
barriers and
confidence-building
Remote
monitoring
Home visits
Pre-discharge
•1st visit w/in 24 hrs
•2nd visit w/in 72 hrs by
same clinician
•3rd visit same week
•Focus on patient
concerns, med rec, signs
& symptoms, MD f/u,
personal health record
Remote
monitoring
• Remote monitoring
with focus on patient
engagement & selfmgt support
• Remote monitoring to
detect signs of
exacerbation and build
confidence in SMS
Additional
interventions
• Case conference
• Patient –friendly med list
• Medication Management and
adherence
• SBAR communication
Home
visits
continue
based
on need
© 2014 Sutter Health
High Alert Medication
Stoplight Tools
A recent study found that four
agents were responsible for
2/3 of all drug related
hospitalizations:
1. Plavix
2. Coumadin
3. Insulin
4. Oral Hypoglycemics
Source: Budnitz, et al. NEJM, Nov 24, 2011.
© 2014 Sutter Health
46
Health Literate Tools:
Across Providers and Settings
© 2014 Sutter Health
Cohesive Care Delivery Promotes
Efficiency, Safety, and Access
© 2014 Sutter Health
SBAR for Patients in PHR
© 2014 Sutter Health
What “key lesson” would I share with
Home Health Leaders ….
Source: Vocera
Experience
© 2014 Sutter Health
Innovation Network
50
Accelerators for Execution and Committment
Leadership buy-in and commitment to
transforming care to be person-centered care
Process to ensure hardwiring best practices
Outcome metric tracking to demonstrate value
Success stories in all case conferences,
leadership & management meetings, and in
employee news letter “Clinical Connect”
Clear communication to stakeholders about the
value add of Home Care : Elevator speech
© 2014 Sutter Health
51
Leadership but-in and commitment to
person-centered care
• Tie to organizational
strategic objectives with
focus on the patient and
employee experience
• Identify ALWAYS event
• Track progress over
time to maintain focus
• Engage all employees
in the value of providing
person centered - care
© 2014 Sutter Health
52
Communicating ALWAYS event to
Providers
Infographic
•Featured at the 2015
Sutter Health Management
Symposium
• In plain language
describes how to engage
patients with every
encounter
•Applies to all staff in all
settings
© 2014 Sutter Health
53
ALWAYS Event Incorporated into Standard
Work Across System
A
I
D
E
54
T
ACKNOWLEDGE
“Hello Mrs. House, I am Georgia, the homecare nurse from Sutter Care at
Home. We spoke on the phone yesterday about my visit this morning.
INTRODUCE
“Your nursing case manager, John, was not able to visit today, but he gave
me an update about your wound, and after my visit today I’ll let him know
how the new treatment is going for you”
DURATION
“I think my visit will be about 45 minutes; is that going to work for your
schedule?
EXPLANATION
“In addition to doing the wound care, I’d like to review your medications
with you to make sure our list of medications is up to date and see if you
have any questions or concerns regarding your medications. Before we
get started, what questions or concerns do you have? I want to make
sure we take time for what is most important to you.”
THANK
“Thank you Mrs. House, I will be giving John an update on how good your
wound looked today. Do you have any questions for me or for me to pass
© 2014 Sutter Health
along to John? I have time.
Communicating
Value-Add
• Have an elevator speech
ready
• Know your statistics
• Understand the strategic
objectives of new payment
models and which your
partners are considering
• Embed information about
how your agency will help
meet strategic objectives
© 2014 Sutter Health
Home Health:
Experience as High Value/ Low Cost Provider
Experience caring
for complex
patients
Demonstrated
improvement in
outcomes
Lowest cost post
acute provider
• 4 out of 5 HH pts have 3 or more chronic diseases
• 62% have incomes < 25K/yr
• 60% are older than age 75
• 65% improvement in breathing
• 89% improvement in wound healing
• 68% report less pain
• 8K less on average than all other PAC settings
• Home is the venue of choice for care amoung older
Americans
Source: Lee, t and Schiller J. HHN, Feb. 2015
© 2014 Sutter Health
56
Know Your Numbers
10%
Your Agency
Your State
© 2014 Sutter Health
Home Care as a Value Added Partner
ACROSS Healthcare Continuum
Valued Hospital
Partner
Valued Physician
Practice Partner
Valued Home &
Community Partner
© 2014 Sutter Health
“Life is a pond.
We are all pebbles.
Never underestimate the
difference one pebble
can make.”
Hardwiring Excellence.
Quint Studer
© 2014 Sutter Health
What questions do you have,
I have time?
Contact Information
Beth Hennessey, RN,BSN,MSN
Executive Director Sutter Center for Integrated Care
[email protected]
© 2014 Sutter Health