d8/e8: the triple aim & beyond-partnering with...
TRANSCRIPT
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D8/E8: The Triple Aim & Beyond-Partnering with Payers-Increasing Trust, Building Infrastructure, & Rethinking Partnerships
Iva Tatum, RN CCM CLNC
Manager of Case Management
Community Care Managed Healthcare Plans of OK
This presenter has nothing to disclose.
Orlando, Florida
IHI Summit
March 20 – 22, 2016
Session Objectives
Understand the approaches taken by payers to successfully engage with providers and communities to improve delivery of care and patient outcomes and the keys to effective collaboration among the stakeholdersOutline what payers can offer to provider practices to enable them to thrive in a value-based payment model, as well as the components of the Triple Aim that can be achieved in partnerships of payers with providers and their staffProvide data to support the momentum that fosters patient-centered care and effectively implement intervention bundlesIdentify innovative resources for population management and care coordination and tools to build community partnerships and relate success stories from providers engaged in value-based programs
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Provider owned health plan – Tulsa, Oklahoma
Serving over 400,000 lives, predominately in NE Oklahoma
Owned by St. Francis Hospital and St. John Health System
Each system with employed medical group
“Integrated System”
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Where do you start?4
For everything there is a beginning……..
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Americans are Living Longer6
Centers for Disease Control (CDC) www.cdc.gov
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The 2014 State of the States Health Report reports the following statistics.
Oklahoma ranks 44th in overall health status compared to other states in
the nation.
Oklahoma has the
1. 12th highest rate of death due to cancer in
the nation.
2. 3rd highest rate of death due to heart
disease in the nation.
3. 4th highest rate of death due to stroke in
the nation.
4. Highest rate of death due to chronic lower
respiratory disease in the nation.
5. 4th highest rate of death due to diabetes in
the nation.
PAYERS as PARTNERS
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PAYERS
PatientTTH
SNFCommunity
ResourcesFHP
My
Health
ACOCPCCommunity
Collaborative
What are the puzzle
pieces in utilizing
cutting edge
practices
to execute optimal
healthcare???
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Initiatives, Interventions & Outreaches
• CPC• Community Collaborative• ACO• TTH• My Health• SNF• Community Resources• PAM• FHP
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1. Individuals come to the hospital at the right time. (By way of prevention and education, members learn to come earlier in their symptoms before something becomes an acute emergency. It’s much more expensive to treat acute cases in the ER.)
1. Individuals come to the hospital at the right time. (By way of prevention and education, members learn to come earlier in their symptoms before something becomes an acute emergency. It’s much more expensive to treat acute cases in the ER.)
2. Individuals come through the right door. (Members get information about how to access primary care facilities and doctors, avoiding the ER if possible to keep costs lower.)
2. Individuals come through the right door. (Members get information about how to access primary care facilities and doctors, avoiding the ER if possible to keep costs lower.)
3. Individuals come ready to be treated: Education reduces anxiety, they understand their benefits & financial options, & they understand their medications.
3. Individuals come ready to be treated: Education reduces anxiety, they understand their benefits & financial options, & they understand their medications.
4. Individuals to understand the importance of a support
system: As payers & providers empowering those we serve to identify their support system is an extremely important part of recovery – especially support after the patient is released from an inpatient stay.
4. Individuals to understand the importance of a support
system: As payers & providers empowering those we serve to identify their support system is an extremely important part of recovery – especially support after the patient is released from an inpatient stay.
Find the Right Door
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CPCI - Principles
• Shared decision making
• Protocol driven evidence-based medicine
• Advanced access
• Integrated behavioral health
• Integrated pharmacy services
• Self management support
• Strong care management support
• Change in payment methodologies
• “Build the airplane while we’re flying it”
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SNF Focus areas for 2015
Communication and
Coordination of Care
Patient Engagement
Smooth Transitions
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Skilled Nursing Care
• Dedicated “SNFist” teams rounding 2X/week
• Dedicated nursing staff that rounds at facilities
• Quarterly joint meetings with all contracted facilities –support, education & data sharing
• Sponsored symposia and webinars – IHI webinar on eradication of C diff
• Yearly quality projects –mimic 100K lives campaign
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Communication
� Standardized Admission Packet Checklist
� RTA—Return to Acute Audit Tool� Quarterly SNF Collaborative
meetings to provide data and education
� Weekly onsite rounding by SNF nurse and physician
� Availability of SW for unusual discharge needs
� Communication with HH agencies & DME providers at time of DC
� Communication with PCP office to transition back into the community & set up F/U office visits
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Patient Education
� Teach back technique
� Health Literacy
� Interpreters, when necessary
� Input from pts and caregivers
� Unified materials across the continuum of care
� Educate pt regarding diagnosis, self-care mgmt and importance of follow-up
� Listen before we teach – ask open ended questions
� Goal for pt: Take action when you notice a change in your health
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Do You Know What the Patient WANTS?
(1) What is the person’s understanding of their health or condition?
(2) What are their goals if their health worsens
(3) What are their fears?
(4) What are the trade-offs they are willing to make and not willing to make?
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Dr. Gawande’s Four Questions?
Is What you see What they see?
Perception is Key…..Feedback provided to
facilities through patient survey data to allow them to view their facility through the eyes of their patients.
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Patient Activation Measure® (PAM®)
The PAM survey reliably predicts future ER visits, hospital admissions and readmissions, medication adherence and more.
• PAM activation levels are mapped to hundreds of consumer health characteristics – motivators, attitudes, behaviors and outcomes – for dozens of health conditions.
• Take Individuals from Disengaged to Activated
• PAM identifies where an individual falls within four different levels of activation. This gives providers and health coaches insight to more effectively support each individual.
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http://www.insigniahealth.com/products/pam-survey
Diagnosis of
serious illnessDeath
Palliative Care—
What are the Patient’s Goals?
Life Prolonging TherapyPalliative CarePalliative Care
Curative Medical CareH
O
S
P
I
C
E
B
E
R
E
A
V
E
M
E
N
T
World Health Organization, 1990
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Interventions to Reduce Readmissions
Patient education
Discharge planning
Medication reconciliation
Appointment scheduled prior to discharge
Timely follow-up
Timely PCP communication
Follow-up telephone call
Patient hotline
Home visit
Transition coach
Patient-centered discharge instructions
Provider continuity
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Admission Packet Checklist22
SNF Collaborative
Admission Packet checklist.
Both area hospitals management teams have been educated on the information
needed to assess a member for admission to SNF level of care. The 5 items on the
checklist below are key components on what is needed for a SNF facility to
evaluate for a SNF level of care placement.
1. Face sheet with the patients demographics
2. Physicians order—The order needs to indicate they are discharging to a SNF
level of care.
3. Current Medication list—preferably to include the last dose received
4. Current Physical Therapy notes.
5. H & P
The information should be current for review. You should not be reviewing a
patient on Monday to accept them on Friday, by Friday they may be able to go
home with home health. When they arrive at your facility they should have hard
scripts for all medications requiring them. Please notify me if this continues to be
an issue.
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RTA Audit Tool23
Community Collaborative Meetings
Goals� To pilot and report on the use of standardized processes of care.
� To discuss best practices and review the feasibility of adapting community wide standards of care for the following high risk patient groups.� CHF and atrial fibrillation
� Pneumonia
� COPD
� Strokes
� To share and evaluate effective interventions that have been piloted at area facilities and healthcare agencies.
� To education participants on area community services available as well as educational opportunities to benefit your staff.
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Transition to Home TTH
• Coleman model – University of Colorado
• Focused on patient coaching – encouraging active patient involvement in health care
• Focused diagnoses – Atrial fibrillation, CHF, COPD, Pneumonia, AMI/CABG
• Decreased readmission rate – 35% at one year
• Now have added TTH from SNF
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TTH—Transition to Home
This is a FREE service to help patients:• Recover.
• Understand and manage their medications better.
• Help prevent them from being readmitted to the hospital.
• Make a plan for their follow-up appointment with their primary care team.
• Maintain the good care they received in the hospital after they get home.
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A home visit by a Transitional Care Nurse.
A booklet to keep questions, logs, and any
healthcare information they would like to
share with their Dr.
A Health information card designed to
help them manage their health
conditions.
Three follow-up calls from a Transitional Care Nurse who
provides support during the transition
from the health care facility to home.
What’s Included
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Medication
self-
management
Medication
self-
management
Use of a
patient-
centered
health
record that
helps guide
patients
through the
care process
Use of a
patient-
centered
health
record that
helps guide
patients
through the
care process
Primary
care
provider
and
specialist
follow-up
Primary
care
provider
and
specialist
follow-up
Patient
understanding
of "red flag"
indicators of
worsening
conditions
and
appropriate
next steps
Patient
understanding
of "red flag"
indicators of
worsening
conditions
and
appropriate
next steps
Patient
Centered
Goals
Patient
Centered
Goals
Faith Health Partners
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Faith Health Partners
Patterned after Congregational Health Network –Memphis, TN
Health systems working with local faith-based congregations to improve health awareness (education), empowering (training of embedded workers in the churches) and resources (programs from hospitals in the churches)
Support from the church post-discharge
In TN, decrease of readmissions by as much as 50% in vulnerable populations
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How to enroll:
Registration form
Member Card
Plans and Purposes of Faith-Health Partners
� Improve Health Outcomes
� Increase Satisfaction with Healthcare
Services
� Decrease Admissions and Readmissions
� Decrease Healthcare Costs
� Health Education and Advocacy
� Voluntary Care-giving
� Congregational Liaison
� Increase communication with doctors to
decrease need for emergency services
� Coordination of Volunteers
� Reconnect the Homebound or Homeless
� Health and Community Resource
Assessments
� Faith leaders help design program for their
congregation
� Training for specific disease processes
� Training on accessing appropriate levels of
care, and navigating the healthcare
systems
� Hospital Visitations
� Assisting members at discharge and after
returning home
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My Health Access Network
• Tulsa, OK is a Beacon Community
• Received a $12M grant to start a health information exchange
• Data comes from all NE OK hospitals, most primary care groups, labs.
• ADT feed – admission, discharge, transfers – which allows embedded care managers to quickly provide telephonic follow-up and minimize risk of readmission
• Heavily involved in building and maintaining infrastructure – our CEO is the immediate past chairman of the board
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Welcome to MyHealth.
MyHealth Access Network links more than 4,000 providers and their patients in a community-wide health information system that will help providers better monitor and improve care to:
Reduce health care costs associated with redundant testing, hospital admissions,and emergency department visitsImprove care coordination during transitions between health care settingsImprove patients’ experience and ability to take control of their own healthImprove quality care for the state of Oklahoma and its nearly 4 million patientsBring community leaders and organizations together to utilize health information in meaningful ways to improve community care
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Patient
Centered
My Health Access--Who We Serve
• Think of MyHealth as a “health care public utility”.
• MyHealth Access Network is a health information network that provides secure, online access to a comprehensive view of patients’ health care records for providers, including specialists, hospitals, ancillary care providers, etc.
• Members of MyHealth Access Network can share medical records, perform referrals, obtain lab and pharmacy data electronically, submit reportable data to the Oklahoma Health Department and share data between electronic medical records (EMR).
• By participating in the MyHealth network, a complete picture of patient medical care-from test results and allergies to X-rays-is available with the click of a mouse.
• This secure data also makes it possible fore MyHealth to generate snapshots of your community’s, highlighting current statistics and possible trends.
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Data Quality Improvement
ACO Participation
• Focused on support of owner ACO
• Data management and reporting (CPC-like)
• Care management• Transition to Home• Skilled nursing support• Care transition support –
especially ER, which mimics CPC-like functions of embedded care managers
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Oklahoma Health Initiatives
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HICNOLast
NameFirst Name DOB Address City State Zip Phone 1
Patient
Type123456789A Duck Donald 10/05/51 NAOR NAOR NAOR NAOR (918)-000-000 E
101112134D Duck Daisy 07/27/59 209 E Daffodil Lane DEWEY OK 71245 (918)-000-000 I
151617182A Wreck Ima 01/26/48 6703 W Storey AVE Tulsa OK 71245 (918)-000-000 E
162025169D Blessing Ura 07/18/45 1704 Crossover DR BARTLESVILLE OK 71245 (918)-000-000 E
Date of
Admission
Date of
DischargeDischarge Status
Medical
CenterACO Attributed Group
ACO
Attributed
Provider
Follow Up
Provider 1
Provider Name
1Date 1
Follow Up
Provider 2
F/U Phone
CallDate Nurse
Person
Providing
Informatio
n
Reason for hospitalization MedicationsNew
Medications
Identified
Need for
Medication
Management
Identified Need
in obtaining
Medication
Fall Risk
Completed 1/5/2016 Caregiver ^SWELLING, LIP New Rx Added ABX No No No falls
Completed 1/5/2016 Beneficiary R TKA New Rx Added PAIN MED, ABX No No No falls
Wrong # 1/5/2016
Not Entered
Yet Encounter for general adult medical exam Not Entered Yet Not Entered Yet Not Entered Yet Not Entered Yet
Completed 1/5/2016 Beneficiary ^HEADACHE No Changes No No No falls
Additional
Notes
ACO participation
Seniors Services
Adult, Senior, and Disability Services
Infants, Children, Youth and Parent Services
Questions—Call Karie Graybill, SW
Community Resources
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Community Resources
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Community Resources
2-1-1
• 2-1-1 is a free, confidential call from any phone
• www.211oklahomahelpline.org/resources/findhelp.h
tm
• Available 24 hours a day, every day
• Available for every county in Oklahoma
• For health and social services information, financial
assistance, housing, counseling, health care and
information on free and low-cost services offered by
hundreds of agencies
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•••• Food Pantries
•••• Clothing
•••• Furniture
•••• Food Pantries
•••• Clothing
•••• Furniture
•••• Utility Assistance
•••• Gasoline
•••• Car Repairs
•••• Utility Assistance
•••• Gasoline
•••• Car Repairs
•••• Household Supplies
•••• Personal Care Products
•••• Prescriptions
•••• Household Supplies
•••• Personal Care Products
•••• Prescriptions
•••• Help with rent and mortgage
•••• Eviction notices
•••• Help with rent and mortgage
•••• Eviction notices
•••• Free Medical and Legal Clinics
•••• Shelters
•••• Free Medical and Legal Clinics
•••• Shelters
Tulsa Healthy Start
Case Management offers
• Assistance with prenatal care
• Access to well-baby visits
• Childhood immunizations
• Referrals to WIC services
• Family planning assistance
• Links to social services for jobs, child care,
housing, and education
Purpose: The purpose of Healthy Start is to
reduce infant mortality by providing healthy
messages and support for the entire family. It
also seeks to ensure continuity of care for
women and children.
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QUESTIONS????47
FOR ALL YOU DO FOR ALL THE PATIENTS YOU SERVE!!!