LEARNING SESSION NUMBER IJanuary 29th & 30th, 20148:00 AM – 4:15 PM

The Riley Center at Southwestern Seminary1701 W. Boyce Avenue, Fort Worth, Texas 76115Room 150

Care Transitions and Patient Navigation Learning Collaborative

January 29th, 2014

Learning Session Welcome and Introductions

Aubrie Augustus, RN, BSN, MHA; Senior VP Network Quality, JPS Health Network and

Administrative Director, Learning Collaborative

Agenda8:30-8:40 Welcome and Introductions

8:40-8:50 Learning Session Overview

8:50-9:00 The Case for Improvement in Care Transitions and Patient Navigation in Region 10

9:00-9:10 Intersection Between the Learning Collaborative and DSRIP

9:10-9:20 Introduce Story Board Gallery Walk 9:20-9:30 Break

Agenda

9:30-10:15 Storyboard Gallery Walk: Meet the other Provider Teams

10:15-10:40 Model for Improvement, Part 1 Aim Statements, Monthly Measures, Run Charts

10:40-11:10 Team Meeting#1: Revise Aim Statement, Data Collecting Planning

11:10-noon The Model for Improvement, Part 2: The Plan- Do-Study-Act Testing Cycle Noon-1:00 pm Lunch

1:00-1:20 Overview of Change Package for Care Transitions: What do we know that works?

Agenda1:20-2:00 Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide our Work

2:00-3:15 Introduction to Motivational Interviewing to Behavior Change

3:15-3:25 Break

3:25-3:55 Team Meeting 2 Planning for High Impact Change

3:55-4:10 Teams Share Their Plans for Action Period 1

4:10 Evaluation

4:15 Adjourn

Learning Session Overview

Gillian Franklin, M.D., MPHClinical Effectiveness & Integration Specialist

Project Manager & Performance Improvement Specialist, Learning Collaborative

Learning Collaborative Model (Breakthrough Series Model)

Learning Session Overview

The Learning Session

Goals And Objectives

Goal: Participants will learn about the Model for Improvement .

Objective: Participants will understand the various aspects of the Model for Improvement and their functions.

Instructional Objective: Participants will work on parts of the Model for Improvement (Plan-Do-Study-Act Testing Cycle) to test change.

Learning OutcomesModel for Improvement

Full engagement as early adopters

Strategies Process Improvement NOT Research

Elements “Best Practice” Changes Learning Collaborative Change Methodology Aim Statements; PDSA Testing Cycle; Monthly Measures; Run Charts etc.

Action Period 1

Inquiry-driven

Formative Feedback

» Knowledge

»New skills

» Immediate changes

» Steal Shamelessly

» Share Relentlessly

The Take Away

Wait, Wait Don’t Tell Me!!!

What is a proven way to test potential changes

without disrupting your organization’s day-to-day

operations?

Answer

Model for Improvement&

Plan-Do-Study-Act Cycle

The Case for Improvement :Care Transitions and Patient Navigation

Elizabeth Carter, MDSenior Vice President for Population Health

Director, Care Transitions Learning Collaborative

The Case for Improvement

Inadequate case coordination including care transitions responsible for $25-45 Billion in wasteful spending

– “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful”

IOM report“Crossing the Quality Chasm”

Medicare Cost Per Beneficiary and 30 Day Readmission by State

All Cause 30 Day Readmission Rates

» Sickle cell anemia- 31.9%» Gangrene- 31.6%» Hepatitis- 30.9%» Disease of white blood

cells-30.6%» Chronic renal failure-

27.4%

Conditions with Highest Readmission Rates

The Case for Improvement

Root Causes per Robert Wood Johnson:• Hospital computers don’t interface to community providers-

less reliable hand-off• Current payment policies may create disincentives for

hospitals to invest in care transitions• Medicaid low payment incentivizes NH to send patient back

to the hospital to qualify for a more generous Medicare payment rate

• Half of Medicare patients admitted within 30 days have not been seen by a physician in the interim

Reducing Readmissions for Value-Based Healthcare

Texas in the 4th quartile» Medicare 30 day readmission» NH admissions and readmissions» Home health admissions

Texas in 3rd quartile» Admissions for Pedi asthma» Asthmatics with ED visit» Medicare admission for ACS

Avoidable Hospital Use and Costs

Affordable Care Act

Carrot

» Oct 2012, increase in Medicare payment if achieve or exceed performance (help at home, warning signs/symptoms, discharge instructions)

» Medical Home- pay providers for care transition services

» Demonstration projects- Monthly payments or per beneficiary per month for transitions processes/coordination

Stick

» Oct, 2012 reduced payments 1% readmission for CHF, AMI, pneumonia exceed target

» Transparent Physician level quality data

The Intersection of DSRIP and the Learning Collaborative

Mallory JohnsonManager RHP 10

Regional plans should recognize the importance of learning collaboratives in supporting continuous quality improvement, RHPs will provide opportunities and requirements for shared learning among the approved DSRIP projects in the region.

Learning collaboratives should strongly be associated with Performing Provider’s projects and demonstrate a commitment to collaborative learning that is designed to accelerate progress and mid-course correction to achieve the goals of the projects and to make significant improvement in the Category 3 outcome measures and the Category 4 population health reporting measures.

According to the PFM…. Our Learning Collaboratives should…

The continuation of the journey we have all been on together!

Over the last two years we have all experienced together…

What does the Learning Collaborative mean to Region 10 DSRIP Projects?

Shared Learning & New

Experiences

Newly fostered relationships

and collaboration

Regional commitment to

improve care across the

continuum

• A networking opportunity to learn how other similar projects are doing and best practices occurring in our community

• Focus on specific issues where multiple providers will collaborate to see improvement for all

• An opportunity to bring performance improvement practices (CQI) to your projects

• Recognition that it’s not just about the milestones, but the broader impact of participation in the Waiver, willingness to collaborate with peers, and show improvement at the individual, regional, and state levels

What can the Learning Collaborative mean to your DSRIP Projects?

Best practices CollaborationPerformance Improvement

Practices

Regional Impact

TEAM ME

Storyboard Gallery Walk Hunter Gatewood, MSW, LCSW

Break

Storyboard Gallery Walk: Meet the Other Provider Teams

Model for Improvement: Part 1 Aim Statements, Monthly Measures, Run Charts

Hunter Gatewood, MSW, LCSW

Team Meeting #1: Revise Aim Statement, Data Collection Planning

The Model for Improvement, Part 2: The Plan, Do-Study-Act Testing Cycle Hunter

Gatewood, MSW, LCSW

Lunch

Overview of Change PacketWhat do we know that works for Care

Transitions and Patient Navigation

Acute Phase

Acute Care Episode

Population At Risk Secondary

Prevention

Trajectory 1 (T1)Relatively healthy

adult with onset of new chronic illness

Trajectory 2 (T2)Adult with multiple chronic conditions

Trajectory 3 (T3)Adults at end of life

Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of an episode of illness and sets forth a vision to guide ongoing and future efforts.

Post Acute/ Rehab Phase

Context for Transitional Care

IHI’s Blueprint for Improving Transitions and Reducing Avoidable Re-hospitalizations

Transition from Hospital to Home• Enhanced

Assessment• Teaching and

Learning• Real-time Handover

Communications• Follow-up Care

Arranged

Post-Acute Care Activated• MD Follow-up Visit• Home Health Care

(as needed)• Social Services (as

needed) or

• Skilled Nursing Facility Services

Alternative or Supplemental Care for High-Risk Patients*• Hospice/

Palliative Care• Transitional Care

Models• Intensive Care

Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)

• Additional Cost for these Services

Improved Transitions and Coordination of Care

Reduction in Avoidable Re-hospitalizations

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

Patient and Family Engagement

What do we know that works?What do patients want?

Very helpful interventions• Speaking with a pharmacist about their medications especially true

if patient had low literacy• Receiving a phone call 1-4 days after discharge– receiving these two interventions made them more comfortable

with talking to their outpatient provider after discharge

.

Courtney Cawthon, Sheena Walia, et al (2012) Improving Care Transitions: The Patient Perspective, Journal of Health Communication: International Perspectives, 17:sup3 312-324

Change Concepts

• Optimum Hospital Discharge Planning and Process• Deliver Timely Access to Care• Prior to the First Post-Hospital PCP: Prepare Patient

and clinical team• During the First Post-Hospital PCP visit: Assess

Patient and Initiate New Care Plan• At the conclusion of the First PCP Visit:

Communicate and coordinate ongoing care plan

Navigation

Navigation is often necessary because of the fragmented and complex health care system

New accreditation standard for navigation process to address health care disparities and barriers to care by the American College of Surgeons’ commission on Cancer

Multiple approaches to problem-solve, educate, define next steps

What Works? Systematic Review

36 randomized, controlled trials of Inpatient to Outpatient Hand-offs• Multiple components ( 94% of trials)• Significant improvement in outcomes (69% of trials)• Strategies before and after discharge (>50% of trials)• Transition managers employed (72% of trials)

– Care coordination– Patient education– Assessment of social and functional needs

Hesselink G et al. Improving Patient handovers from hospital to primary care: A Systematic Review. Ann Intern Med 2012 Sept 18; 157-417

Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide Our

Work

Scott Walters, PhDUniversity of North Texas Health Science Center

School of Public Health

Introduction to Motivational Interviewing to Behavior Change

Break

Team Meeting #2: Planning for High-Impact Change, Drafting a PDSA Test

Teams Share Their Plans for Action Period 1

Evaluation

Adjourn