C Y H dl M P ti t? Wh tCan You Handle My Patient? What Case Managers Need to Know

2:00 – 3:30 pmR S jRowena StajerJill SchuylerPresbyterian Community Hospital

Can You Handle My Patient?

Presented by: Jill Schuyler, LCSWRicki Stajer, RN, MA, CPHQ

444 beds, non profit

Payer Mix:

- 30% Medicare- 10% Medi-Cal- 6% Uninsured- 54% HMO/PPO

Presentation Objectives• Demonstrate understanding of the

increased complexities involved inincreased complexities involved in transitioning patients through care settings

• Identify the core characteristics of an interdisciplinary team care management model

• Understand the role of the post-acute provider in ensuring smooth transitions forprovider in ensuring smooth transitions for patients

• Learn how to partner more effectively with hospital case managers

Care Management Department

RN and LVN case managers LCSW and MSW Social Workers Care Management clerks

Care Management Team Model • Utilization review• Care coordination• Psychosocial support• Discharge activities

Why is This Important to You?

• Two years we’ve been focused onTwo years we ve been focused on changing our model of collaboration

• We have learned how to truly collaborate within our own organization and now

• We are building a new model of• We are building a new model of collaboration with our post-acute care providers

New Model of Collaboration?

Reactive, not proactive• Couldn’t anticipate patient’s needs at discharge• We weren’t functioning in a multi-disciplinary fashion• Care team members were working in silos

• PT/OT/ST, nursing, case management, physicians, ancillary services (radiology, cardiology, etc)

Prioritization was done from individual department needs and therefore coordination of care based on the patients’ needs was impossible

We were not able to ‘pace the case’ • The case was pacing us and we couldn’t keep up!

Desired Outcomes Improved care planning & coordination for the

patient

Improved communication & collaboration amongst Improved communication & collaboration amongst all care team members

Focused planning based on patient needs

Improved patient satisfaction & clinical outcomes

Improved operational efficiencies

Decreased length of stay

How Did We Implement These Rounds?

Literature search to find the evidenced best practice

Collaborated with nursing leadership

Developed the framework for rounds

Created tools• Purpose• Program Description • Program Goals• Roles and Responsibilities of ownership

• Nurses, case managers, social workers

• Standardized Scripts - Case managers, nurses, social workers

Care Coordination RoundsKey Components

Coordinate all the care the patient needs • To get better and go home• To get better and go home

• To go the next appropriate level of care safely & timely

Safety Net• Platform to escalating patient care situations to

other forums• Complex care conferences

• Ethics Committee

• Legal intervention

Care Coordination RoundsKey Components (cont.)

Goals for the care coordination rounds • Patient• Patient

• Length of stay

• Discharge plan

Team members develop & understand the ‘plan for the day’ as well as what is needed to complete the ‘plan for the stay’the plan for the stay

Nursing ‘Plan for the Day’ KZander

Relieve symptoms

Advance diet, mobility and knowledge

Talk and work with MDs & disciplines

Expedite tests & proceduresExpedite tests & procedures

Coordinate care to complete the care plan for the day

Social Worker’s ‘Plan for the Way’ KZander

Patient and family engagement

Impact of the hospitalization, diagnosis & recovery

Identifying decisions & determining if the patient and family is making those decisionspatient and family is making those decisions

Identifying funding and resource needs

Care Manager’s ‘Plan for the Stay’ KZander

Leading rounds to set priorities & timeframes

Facilitating actual coordination of care

Using best practice guidelines to plan for expected length of stay & outcomes (Milliman Guidelines)

Validating if the patient is at the appropriate level of carecare

Anticipating the next level of care & what is needed to move to that level

Were We Successful? YES!

R d i i i ?• Reduce omissions in care?

• Reduce redundancies?

• Save time?

• Were the rounds worth the time?

Were We Successful? (cont.) CMs, SWs and nurses report:• ‘Know’ their patients bettero e pa e s be e• Able to prioritize their work more efficiently• Collaborate to contact MDs and get questions answered

in a more timely manner• Identify the need for family conferences earlier• Partner more effectively in solving complex coordination

issues• Nurse managers report that their nurses really know

th i ti t ll th t th f d btheir patients well; that they prepare for rounds by reviewing lab results, physician notes, consultant reports and diagnostic findings first thing in the day

• Data shows a clear reduction in length of stay

Reduction in Medicare Length of Stay

Medicare Length of Stay

4 2

4.4

4.6

4.8

5.0

5.2

5.4

5.6Ave

rage

LOS

Implementation of

Care Coordination Rounds

4.0

4.2

FY 2006 FY 2007 FY 2008 FY 2009 YTD Feb-10

Fiscal years

Lessons Learned Plan Thoughtfully! Collaborate Constantly!

Ti t th f t d t d l h i• Time at the front end to develop a comprehensive program will save confusion during implementation

• Communication and leadership are skills that require teaching and mentoring

Get buy in from all disciplines including physicians• Get buy-in from all disciplines, including physicians. You are changing culture!

It’s an evolving process that requires continuous mentoring

Developing Partnerships: Transitions of Care

• Why are partnerships between hospitals andWhy are partnerships between hospitals and post-acute settings important?

1. National Data: – 1 in 5 (20%) Medicare patients are readmitted

within 30 days• 75% have been found to be preventable

$17 4 billion in a 2004 CMS study– $17.4 billion in a 2004 CMS study– Preventable readmissions may affect

reimbursement for both hospitals and post-acute providers

Reducing Hospital-SNF 30 Day Readmissions, The 2009 Continuum of Care Project

Case Management Monthly. January 2010

Importance of Partnerships

2. Barriers between hospitals and ppost-acute care setting

a. Incomplete, limited and even inaccurate information at time of transfer• SNFs definitely have limited access toSNFs definitely have limited access to

complete necessary patient information

• Patients come to hospitals from SNFs alone with limited information

Importance of Partnershipsb. Lack of understanding on each

provider’s side regarding the others work flow• Gaps in communication

• Lack of knowledge of the impact on the other provider’s ability to care for the patient

• Lack of trust• Lack of trust • See each other in old, historical contexts, not

as partners both working towards the same goals for their patients

Case Examples of Hospital and Post – Acute Provider Partnerships

Case Example 1:

• 33-yr-old uninsured female with multiple sclerosis• She needed aggressive physical therapy• Social issues and her father was her IHSS worker• We completed all paperwork for her Medi-Cal

application• Developed a letter of agreement with SNFDeveloped a letter of agreement with SNF• 6 months later approved for Medi-Cal hospital

was reimbursed for 3 months of care from SNF

Case Example 2:

• 62-yr-old uninsured female with massive CVAmassive CVA

• Trach and vent dependent• Very difficult placement• Worked with family completed all

paperwork for Medi-Cal application• Developed letter of agreement with a sub

t l tacute placement• Patient was moved to appropriate level of

care

Consequences of Transition Barriers

7 possible consequences identified by7 possible consequences identified by both SNF and hospitals– Increased medical costs– Prolonged patient stay– Rehospitalization– Patient adverse events

M di ti i t ti– Medication interactions– Increased pharmacy costs– Patient falls

Components of Successful Partnerships

• Team approach in developing the D/C PlanTeam approach in developing the D/C Plan– Hospital, post-acute staff, patient & family

together• Effective Communication Processes

– Standardized hand-offs• Holistic approach to understanding patient

needs– Patient & family centered planning

• Clinical, psychosocial, family dynamics– Advance Directives, long term plan including end of life

“Success in reducing readmissions lies in effectively partnering to not only achieve better outcomes but also toachieve better outcomes but also to reduce the fragmentation and lack of support that so often comes with transitions between providers and care settings.”

Amy Berman, Program Officer, The John A. Harford Foundation

Partnership at the System Level

How do we develop long term successful p gworking relationships together?

• Align goals and objectives

• Strive to understand each others’ needs

• Recognize that there is value in helping each other; for our patients and ourselves

Aligning Goals & Objectives

Why?Why?

• Health Care Reform & the proposed changes in reimbursement is naturally aligning acute & post-acute providers

B tt f ti t h• Better for our patients who are more complex and require more services

Aligning Goals & Objectives

How?• Identify what we have in common

– Development of specialized programs• Hospital: Joint Programs to reduce length of stay &

increase patient outcomes• SNF: Focused programs for specialized therapy for

Total Joint patients• Hospital: Palliative Care Program• SNF: Provides Hospice beds• SNF: Provides Hospice beds• Hospital: Uninsured patients with post-acute needs• SNF: Negotiates Letter of Agreement

Understanding Each Other’s Needs

Why? Id tif th i ti f• Identify the gaps in continuum of care between us to improve patient care – Each of us only knows their own paradigm of

providing health care – Putting the pictures together gives us an

opportunity to improve our communities’ healthcare infrastructures

• Increasing the chances of successful transitions for all patients and

• Improving our financial and clinical outcomes together

Understanding Each Other’s Needs

How? Pl d C ll b ti• Planned Collaboration– Routine continuum of care meetings

• Statistics and analysis– Admission rates

» Payor, diagnoses, length of stay– Readmission rates – Emergency Department visitsEmergency Department visits– Individual case discussion

» What worked well? What didn’t?– Infection rates– Fall rates

Understanding Each Other’s Needs

• Discuss Strategic Initiativesg– Hospitals want to decrease preventable

readmissions and prevent financial penalties– post-acute care settings want to increase the

average daily census – Top 3 DRGs for patients returning to a

hospital from a SNF are:• Cardiac, respiratory and infection-relatedCardiac, respiratory and infection related

• Reasons for returns are found in D/C & follow-up processes, care capacity & quality in SNF, patient’s disease progression TREO Solutions, Perspectives June 2010

Value in Helping Each Other

Why? TREO S l ti “ i b t li i• TREO Solutions: “reimbursement policies are driving changes in long term care….growth of short stay admissions & overall clinical complexity of all SNF residents...” June, 2010.

• Rehab Perspectives: “Chasing census is an adrenaline-fueled roller-coaster ride - &adrenaline fueled roller coaster ride & unfortunately it’s not all that effective. Building census…is a rock solid, ongoing strategy. Martha Schram, President, Aegis Therapies. Fall, 2005.

Value in Helping Each Other

How?New Face of CollaborationNew Face of Collaboration

– Move from case to case collaboration to long term strategic planning together

• Analyze our shared patient population within the community

• Identify the 3 – 5 top patient conditions that need the greatest support across the continuum

Value in Helping Each Other– Develop agreed upon plans and tools

• Tools: – Standardized hand-off processes when patients areStandardized hand off processes when patients are

moving from either type of facility to the other– Access into electronic medical record systems as

appropriate• Plans:

– Developing strategies for each care setting related to specific DRGs in support of continuity of care

» Starting and then building on family education» Developing processes to maximize POLST and Advance

Di ti i f tiDirectives information» Supporting and continuing end of life discussions » Developing long term discharge plans together» Sharing information with the acute and post-acute

physicians

So…Can You Handle My Patient?

• Well now you know what acute• Well, now you know what acute hospitals are looking for…– Robust willingness to collaborate on

individual cases,

– Work together analyzing data and fi di t iti d thfinding opportunities, and then

– Partner and develop long term strategic plans

When We Become Community Based Partners

• We will meet our own organizational goals• We will meet our own organizational goals

• We will improve our patient’s quality of life by – Decreasing medication events,

– Increasing understanding of how this episode of care impacts them and their families and p

– Ensuring smooth transitions

Jill S h l

Thank you.Jill Schuylerjschuyler@pih.net(562) 698-0811 x12956

Rowena Stajerrstajer@pih.netj p(562) 698-0811 x12780

Presbyterian Intercommunity Hospital

Questions