NYSPFP- Readmission Collaborative Domain II - Kick-off … · NYSPFP- Readmission Collaborative Domain II ... • If weight does not return to baseline, ... NYSPFP- Readmission Collaborative

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

NYSPFP- Readmission Collaborative Domain II - Kick-off Webinar Improving Care Transitions Between Hospitals and SNFs

February 28, 2017

NYS PARTNERSHIP FOR PATIENTS

AgendaTopic Speaker Welcome/ Overview Karline Roberts, NYSPFP

NYSPFP Readmission Collaborative Karline Roberts, NYSPFP • Goals, Measurement

IPRO Readmission Project Sara Butterfield, RN, BSN, IPRO Donna DeGarmo, RN, MSN, Bassett Healthcare Network Laurie Neander, RN, MS, Bassett Healthcare Network Diane Judson, RN, BSHA, Wingate Healthcare

Next Steps Karline Roberts, NYSPFP • Preparing for In- person Meeting • Capabilities Assessment

Calendar of Events Karline Roberts, NYSPFP

Question and Answer Forum All participants

February 28, 2017


NYSPFP Readmissions Initiative Overview

o Domain I: Patient- and caregiver-centric discharge processes

o Domain II: Improving care transitions between the acute care setting and skilled nursing facilities (SNFs) o Objectives: To assist New York State hospitals inreducing their readmission rates by improving thetransitions of care between acute care providers andSNFs

o Goal: CMS goal of reducing readmissions by 12% from a 2014 baseline

February 28, 2017


Approach

o Identify hospital and SNF partners with high readmission rates among shared patients

o Identify readmission champions and interdisciplinary team members in hospitals and SNFs

o Establish recurrent face-to-face collaborative meetings

February 28, 2017


Why the Collaborative Approach? o Systematic approach to quality improvement whereby health care organizations come together to: o Identify, test, and measure evidence-based practiceinnovations

o Share experience to accelerate learning and disseminate innovations

o Create a framework for sustaining improvement

February 28, 2017


NYSPFP Support NYSPFP support will include: o Facilitation of regional collaborative meetings o Hands-on quality improvement support o Assessment tools to identify gaps in current practice o Action planning assistance to drive improvement o Ongoing activities to inform, educate, train, and share

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Benefits of Participating o Support in addressing challenging areas in the transitions of care process

o Resolve outstanding inter-facility issues o Avoid Medicare Reimbursement Reductions:

o Value Based Purchasing o Hospital Readmission Reduction (HRR) Program

February 28, 2017


Hospital Readmissions Reduction (HRR) Program

o Part of Affordable Care Act o Program links what hospitals are paid to the quality of the care they provide - not just quantity of the services provides

o The HRR Program provides financial incentives to hospitals to reduce costly and unnecessary hospital readmissions

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The Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP) o What is it?

o The program rewards skilled nursing facilities with incentive payments forthe quality of care they give to people with Medicare.

o When does it start? o Fiscal year 2019 for 2017 calendar year data

o Why is it important? o It promotes better clinical outcomes o Data to be publically reported starting Oct. 2017 on Nursing Home

Compare https://www.medicare.gov/nursinghomecompare/search.html o How will the program work?

o Participating facilities will be paid for their services based on the qualityof care, not just quantity of the services they provide in a givenperformance period.

o Measure o 30-day all cause unexpected potentially preventable readmission rate

February 28, 2017

https://www.medicare.gov/nursinghomecompare/search.html


NYSPFP Readmissions Measurement Strategy

o Overall Outcome Measure o 30 day potentially preventable readmission rate (PPR) o All Condition, All Cause Readmissions Rate o Medicare, All Cause Readmission Rate

o Overall Process Measure o HCAHPS: “Care Transitions” and “Discharge Information” scores

o Aligns with patient/family engagement efforts o No manual data entry o Provides meaningful and actionable data

o Domain II Measures o Medicare SNF readmission rate will be analyzed as databecomes available

o Process and outcome measures within each collaborative will be determined by the collaborative teams

February 28, 2017


Website Resources https://www.nyspfp.org/Members/Initiatives/Readmissions/Overview.aspx

February 28, 2017

https://www.nyspfp.org/Members/Initiatives/Readmissions/Overview.aspx

Transitional Care Partnerships: Aligning Forces for Improved Communication & Care Coordination Across the Healthcare Continuum

IPRO Coordination of Care Initiative

Sara Butterfield RN, BSN, CPHQ, CCM Senior Director, Healthcare Quality Improvement

February 28, 2017


in collaboration with IPRO

1

Source: CMS FFS Medicare Claims Data (In hospital deaths and transfers to another acute facility were not counted)


NYS MFFS 30-Day Readmissions by Discharge Disposition CY 2015

All NYS Hospital Aggregate

2


Approach o Regional cross-setting community coalitions

● Hospitals, Home Health, Nursing Homes, Assisted Living Facilities, Physician Practices, Hospice, RHIO, Office for Aging, County-based services, community service providers, EMS, Community Pharmacies, Key Stakeholders

o Community Based Root Cause Analysis

o Adoption of Evidence Based Interventions

o Assistance in monitoring & measuring impact

o Building collaborative partnerships to support sustainability

3


Approach

o Identify common goals & shared missions acrosssettings

o Identify cultural & procedural differences across settings o Each partner has a unique perspective to identify &address issues associated with failed transitions

o Deal with one or two problems at a time, beginning with the easier issues

o Move out of the silo(s)

4


Building Capacity o Cross-Setting Collaboration is key to success!

o All healthcare settings, community service providers andcommunity partners who have a stake in improving caretransitions need to be involved in Coalition efforts to impact readmission drivers: Hospitals Home health SNF’s Hospice High Volume Physician Offices EMS Community Based Organizations Federal Qualified Health Centers Area Aging and Human Service Providers Medical Homes Assisted Living

5


The True Key to Success: Building Capacity

Communication Collaboration Partnerships


Bassett Healthcare Network

Laurie Neander RN, MS President / At Home Care

Donna D. Anderson, RN, MSN, CENP Senior Director for Care Management

Transition Partnerships



to Improve Quality Care for

OUR Patients



Adopt a Standardized Risk Assessment Tool

Adopt a Standardized Risk Assessment Tool

Institute for Healthcare Improvement: How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations http://0104.nccdn.net/1_5/1fe/228/023/VNAABP_IHI-Risk-Assessment.pdf

http://0104.nccdn.net/1_5/1fe/228/023/VNAABP_IHI-Risk-Assessment.pdf

NYS PARTNERSHIP FOR PATIENTSAdopt a Risk Management Strategy

Adopt a Risk Management Strategy

Institute for Healthcare Improvement: How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations http://0104.nccdn.net/1_5/1fe/228/023/VNAABP_IHI-Risk-Assessment.pdf


http://0104.nccdn.net/1_5/1fe/228/023/VNAABP_IHI-Risk-Assessment.pdf


Know Your Data; Understand Your Risk

SHP Risk of Hospitalization Alert Risk for Hospitalization: You SHP State (NY) SHP National

Patients that triggered the SHP Risk of Alert Triggered Alert Triggered & Alert Alert Alert Alert

Hospitalizations Alert Hospitalized Triggered Triggered & Triggered Triggered &

# % # % Hospitalized SOC/ROC Hospitalized

Moderate Risk 69 36.1% 19 27.5% 22.1% 35.1% 23.6% 35.7%

High Risk 19 9.9% 9 47.4% 7.1% 57.4% 9.8% 54.4%

All at Risk 88 46.1% 28 31.8% 29.2% 40.6% 33.5% 41.2%



Disease Management Pathways Supported by Telehealth Technology: The Underpinning of A High-Risk Strategy

• Evidence based (American College Cardiology; AHA; ADA; COPD GoldStandard, etc.)

• Define patient specific biometric data ranges-actual vs. self-report • Patient Activation: real time data facilitates an understanding of the relationship

between unhealthy behaviors and poor health – teach self care • Identify a defined set of patient-centered services and interventions to reduce risk

of ED or ACH

Example: • Diuretic Standing Order: If weight gain is ≥ 2-3 lbs. over 24 hours OR a 5 lb. or

> increase over 7 days: • Instruct patient/caregiver to increase daily prescribed dose of oral diuretic by 50%

x 48 hours. • If weight does not return to baseline, notify physician for additional orders.



Patient: ______________________________________________________ D.O.B.: _______________ Primary or Secondary Diagnoses: Heart Failure: � Yes � No High Risk HF Date Patient Admitted to Hospital: ___________ Date Patient for Admission to AHC: _____________

1. Refer and admit patient to At Home Care, Inc. Heart Failure Disease Management Pathway Management2. Diuretic Standing Order: If weight gain is ≥ 2-3 lbs. over 24 hours OR a 5 lb. or > increase over 7 days:

• Instruct patient/caregiver to increase daily prescribed dose of oral diuretic by 50% x 48 hours. Pathway• If weight does not return to baseline, notify physician for additional orders.

3. Home Health Services 60-Day Multidisciplinary Visit Plan: Service Visit Schedule Over A 60 day period Registered Professional Nurse Week # 1 Admit patient to AHC and follow with 2-3 direct in home visits; for a

total of up to 8 visits over 60 days ; * Up to (2) PRN nursing visits for assessment /intervention

Remote Telehealth Visits 5-7 days per week over a 60-day period, minimum Physical Therapy Evaluation LifeLine with Reminders Install Personal Emergency Response System (initial 60-days funded by AHC) Clinical Dietician 1-2 visits – direct or remote telehealth Other (specify)

4. MONITORING PLAN If for two or more consecutive visits (direct in-home or remote visit) the patient exhibits the following, and/ or is symptomatic, the physician will be consulted: Vital Data Standardized Parameters Please specify if other (range)

prescribed Heart Rate < 50 or > 120 / minute

Blood Pressure Systolic: < 90 or > 180 Diastolic: < 40 or > 100

Temperature > 100.5 ‘

Weight Gain > 2-3 lbs. / 24 hours OR 5 lbs. over 7 days

Glucometer reading Monitor weekly; < 60 or > 300

Monitoring Frequency: _________/ day Glucose < _________ or > __________

SPO2 < 88%

__________________________________ ______________________ Prescribing Physician Date

__________________________________ ______________________ Transition Partnerships

Cc: Primary Care Physician □ ______ Date


Challenges…and, Opportunity • Health and IT system silos effective use of information technologies is key • Understanding data – including what matters to patients (loss of work, loss of

independence, etc.) • Enabler to reengineer care processes. To understand effective coordination of

longitudinal care and services across all care settings and across all patient conditions

• Level of risk and most appropriate response – cost and care efficient for the full cycle of care

• Supported by a risk stratification assessment, home health care providers design collaborative transitions’ programs to coordinate with primary care/ health home, navigation, remote monitoring technology, care managers …. And, in lieu of ED or ACH, referral of high risk individuals to a traditional Medicare Certified home health program

• A work in progress – knowledge continues to evolve

2/27/2017 Transition Partnerships


Collaborative Care Patient Centered Care Redesigned Delivery of Care Quality-Adjusted Care Cost-Adjusted Car


Wingate Healthcare

Diane Judson, RN Regional Director of Network Integration Post Acute Services



A Transitional Care Model Provider integration moving toward:

Value Based Care Readmission Reduction

& Consistent Patient Engagement


One Year - 2 Pilot Programs Hospital/SNF/VNS/PCP Areas of Focus: ▪ Organization Capabilities/Process mapping ▪ Communication system development:

→ Provider to Provider → Emergency Room utilization → Hospital Units to SNF Units → Primary and Specialty Care providers → Community Based Providers

Goals: ▪ Care Paths/Risk Stratification ▪ Patient/Caregiver identification, engagement, education and support


Transitional Care Interdisciplinary Team

○ SNF RN Care Manager (new)

○ Hospital Case Managers

○ Admission Liaisons

○ Specialty Care/Hospitalists

○ Community Based Care Managers/Providers

○ Primary Care Physicians:

○ ACOs/Independent/Small practices


Blended Models Implemented

▪ Greater New York Hospital Association IMPACT(Readmission Reduction Collaborative)

▪ Geisinger Transitional Care Model

▪ INTERACT

▪ Harold Freeman Care Navigation

▪ Coleman/Naylor


Key Elements

• Care Management Integration • Physician/Care Manager Engagement• Capabilities Enhancement

• Communication systems: • Warm handoffs • Medication reconciliation • Parallel care paths • Sustained partnerships


How well did the pilots work?

• Improved quality of care ○ Communication Systems Design ○ Increased clinical capabilities related to plans of care

• Improved physician satisfaction with care○ Primary Care referral and involvement

• Improved patient/family satisfaction ○ Would you recommend? Increased: 78% → 96%

• Reduced Caregiver strain ○ Early engagement in care planning ○ Ongoing communication/education/support


Most importantly….

• Readmission reduction – Skilled Nursing facility

• from 28%/month to 9%/month within 3 months of implementation

– PCP Group • reported 48% reduction within 3 months of implementation

– LOS in SNF reduced from average of 60 -100 days to 7-21 days – VNS partnership in readmission reduction (blended participants)

▪ SNF placement within 30 days post hospital discharge ▪ Coordinated ER utilization and discharge

Next Steps


Step I: Building Relationships o Obtain Leadership support o Identify readmission champion and interdisciplinary team members o Complete contact form o Hospital to work with NYSPFP to confirm SNF partners and invite team to meetings

February 28, 2017


Step 2: Assessing Current Practices and Clinical Capabilities

o Capabilities Survey o Nursing Home Capabilities Survey/Checklist

o To assist hospital emergency rooms, hospitalists, and case managers with decisions about hospital admissions or return to the nursing home

o Hospital Emergency Department (ED) CapabilitiesSurvey/Checklisto To assess the current workflow and practice in the ED to better inform nursing homes

o NYSPFP Participants: Complete the survey o NYSPFP staff will review and aggregate the information to inform of the next steps of the collaborative

February 28, 2017


Calendar of Events 2017 o Watch for NYSPFP announcements and dates for upcoming 2017 events: o April/May

o Launch of hospital site in-person sessions o Action planning and goal setting

o June/July o Follow-up coaching calls

o September o Idealized Model Process Mapping Webinar

o October/November o Hospital Site in-person session to tailor process mapping with“idealized practices”

o December o ED/Observation Webinar

February 28, 2017


Understand Hospital-SNF Data and Issues

o Analyze your high readmissions by DRG o Compare discharge DRG to readmission DRG

o Conduct audits o Consider interviewing 5 patients who are readmitted to explore issues

o What are the top reasons for the readmissions

February 28, 2017


Roadmap to Success o Participate fully – make significant improvementstogether o Commit to improvements and to staff education

o Maintain communication with partners o Maintain reliable contact lists

o Understand each other’s regulatory/site specific issues. o The hospital approach does not equal the nursing homeapproach

o Open communication between facilities o Understand community resources available o Understand or develop innovative best practices o Involve the patient, family, and health care advocate

February 28, 2017


Develop an AIM Statement and Action PlanAdministrative Champion Team Lead________________

Lead Physician Nurse Lead

Data Lead Other Team Member(s) ________________

AIM STATEMENT

Consider each process change or key strategy below, and complete the worksheet components for implementing them. Add other strategies as appropriate for your hospital.

Process Change/Key

Strategy*

List Next Steps (How will you implement process

change/key strategy?)

Resources/Stakeholders available/needed? (Which Depts/Staff

will be involved?) Owner(s)

CompletionDate(If Not in

Place)

Measurement Strategy (What data will be used to monitor progress/track impact of changes?)

February 28, 2017

Question and Answer

Documents

NYSPFP- Readmission Collaborative Domain II - Kick-off … · NYSPFP- Readmission Collaborative Domain II ... • If weight does not return to baseline, ... NYSPFP- Readmission Collaborative