Transcript 1:15-2:30PM Breakout Peg Bradke and Rebecca Steinfield or IHI`s

MA STAAR Fall Learning Session
Engaging Front-Line Staff and Your
Cross Continuum Team
1:15-2:30PM Breakout
Peg Bradke and Rebecca Steinfield
Hospitals
• Perform an
enhanced
assessment of
post-hospital needs
• Provide effective
teaching and
facilitate enhanced
learning
• Ensure posthospital care followup
• 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
IHI’s Roadmap for Improving
Transitions and Reducing Avoidable
Rehospitalizations
Post-Acute Care
Transition from Activated
Hospital to Home • MD Follow-up Visit
Supplemental Care
for High-Risk
Patients *
• Transitional Care
Models
• Enhanced
• Home Health Care • Intensive Care
Assessment
(as needed)
Management (e.g.
• Teaching and
Patient-Centered
• Social Services (as
Learning
Medical Homes, HF
needed)
• Real-time Handover
Clinics, Evercare)
or
Communications
* Additional Costs
• Follow-up Care
• Skilled Nursing
for these Services
Arranged
Facility Services
• Hospice/Palliative
Care
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
Vision for Cross-Continuum Teams
Understanding mutual interdependencies,
the hospital-based teams co-design care
processes with their cross-continuum care
partners and collaborate to solve problems
to improve the transition out of the hospital
and reception into community settings of
care.
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Cross-Continuum
Improvement Teams
• One of the most transformational changes in the STAAR
Collaborative
• Reinforces that readmissions are not solely a hospital problem
• Need for involvement at two levels:
1) at the executive level to remove barriers and develop overall
strategies for ensuring care coordination
2) at the front-lines -- power of “senders” and “receivers”
co-redesigning processes to improve transitions of care
• New competencies in partnering across care settings will be a
great foundation integrated care delivery models (e.g. bundled
payment models, ACOs)
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Starting your Cross-Continuum Team
IHI How-to Guide, Page 6
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Starting your Cross-Continuum Team
IHI How-to Guide, Page 8
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CCT Membership Recommendation
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Executive Sponsor
Day-to-day Leader
Patients and family members
Hospital clinicians and staff
Supporting staff (QI, IT, Finance, etc.)
Palliative Care
Payors
Clinical and administrative staff and/or leaders from the community
─ Skilled nursing facilities
─ Office practice settings
─ Home health
─ Community or Public Health Services
─ Area Agencies on Aging
 Consider those that are part of your system but also
 those outside of your organization/system
General Recommendations for
CCTs
• Meet regularly to facilitate bi-directional communications and
collaboration, assess progress, remove barriers to progress and
support the improvement of the front-line teams in all clinical
settings.
• Have members from the cross-continuum team visit each other’s
sites (including accompanying a nurse on a home visit) to observe
patient care processes during transitions.
• Complete periodic diagnostic reviews of patients that have been
readmitted.
• Complete a gap analysis of your settings --Where to you have
work going with the key changes currently?
• Add patients and family members to the cross-continuum team to
enhance the focus on the patient’s experience and to harvest their
suggestions for improving care processes.
Frontline Engagement
Tips from Steve Spear
• Allow the frontline team interests to
determine where to start.
What have you found?
How have you used observation to move test of
change?
• Solve a problem that really matters …
When you start to score gains, your staff
to take notice.
• Don’t think too much but do a lot. That’s
where the real learning takes place.
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make
that will result in improvement?
Act
Plan
Study
Do
Setting Aims
Establishing Measures
Selecting Changes
*2001 Associates in Process Improvement
Discussion Questions for
Frontline Engagement
• What stories have you used to enhance
the work and move you process?
• In what way are you using data or
measure results to engage your staff?
• What are your barriers to engaging your
frontline?
• What are your successes in engaging
frontline staff and spreading your
successful practices?
CCT’s Role in Performing an Enhanced
Assessment of Post-Hospital Needs
• On admission, how can hospital clinicians and
staff get timely and relevant information from
community providers (e.g. medication lists,
comprehensive care plans, insights about the
patient’s ability to provide self-care, advanced
directives).
• Other emerging best practices?
CCT’s Role in Providing Effective Teaching
and Facilitating Learning
• Develop and utilize universal patient-friendly
education materials for common clinical
conditions in all health care settings in a
community.
• Ensure that all health care providers in the
community are competent in effectively teaching
and facilitating learning for patients and family
caregivers utilizing health literacy principles.
• Other emerging best practices?
CCT’s Role in Providing Real-Time
Handover Communications
• Hospital team members and community providers
co-design real-time handover communications
(including preferred format, mode of
communication and specific information about the
patient’s status).
• Consider adopting a universal format for patient
care plans (with information about medications,
diet, treatments, signs and symptoms that require
medical attention and plans for follow-up).
• Other emerging best practices?
CCT’s Role in Ensuring
Post-Hospital Care Follow-Up
• Determine who is the best clinical provider (from
the patient’s perspective) to complete follow-up
phone calls.
• Collaborate with payers and post-acute care
providers to determine eligibility for intensive
care management and best clinical provider for
various patient populations (Care Transitions
Intervention, APN Transitional Care, HF Clinic,
Patient-Centered Medical Home, Evercare, etc.).
• Other emerging best practices?
CCT’s Role: Review Data
• Patient experience data
─ Communication with patients (Q 3,7)
─ Discharge preparation (Q 19,20)
• 30-day all-cause readmission rates for:
─ All conditions
─ Conditions of interest
• Rehospitalization rates if available
• Days between discharge and readmission
• Readmission into Observation status
• Patients readmitted within 30 days who had an office visit
before return to hospital
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What is one new
thing you learned
today that you would
like to test?