ASPIREtoKnockoutPneumoniaReadmissionsDesigning&DeliveringWhole-PersonTransitionalCare
AmyE.Boutwell,MD,MPPNCHAKnockoutPneumoniaCampaign- Webinar2
April5,2018
PurposeoftheKnockoutPneumoniaReadmissionsSeries
Thisseriesistosupportyourworktoreducepneumoniareadmissions
ØWewillfocusonconnectingconceptstoaction
ØWewillfocusonhigh-leveragestrategies toreducereadmissions
ØWewillfocusonimplementation coaching
Thebestuseofyourtimeistousethistimetoactivelyadvanceyourpneumoniareadmissionwork
ØComewithquestions,challenges,cases,data,ideasforimprovement
ØInviteyourcross-continuumpartnerstoattend
ØEmailuswithquestionsorissuestodiscussonthenextwebinar
ASPIREtoReduceReadmissions
basetemplates.com
https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html
ASPIREFramework
“Design”
“Deliver”
Reduce Pneumonia
Readmissions
Design
Deliver
ü .
ü .
KnockoutPneumoniaReadmissionsSeries
Webinar ASPIREtoKnockoutPneumoniaReadmissions Resources
March1 Knowyourdata,understandrootcauses • ASPIREGuide,Section1• ASPIRETools1and2
April5 Alignwithrelatedeffortsandresources,identifygaps • ASPIREGuide,Section2• ASPIRETools3,4
May3 Designaportfolioofstrategiesandoperationaldashboard • ASPIREGuide,Section3• ASPIRETools5,6,7
June7 Activelycollaborateacrossthecontinuum • ASPIREGuide,Section4,5• ASPIRETools9,11,12
August2 Delivereffectivepost-dischargetransitionalcare • ASPIREGuide,Section6• ASPIRETool13
September6 Self-assessmentandpreparationforin-personsession • Self-assessmenttool• Supportrequestform
October16 KnockoutPneumoniaReadmissionsin-personsession • 30dayactionplan• 90dayactionplan
November1 KnockoutPneumoniaReadmissions:SuccessStoriesPart1 • Wewelcomevolunteers
December6 KnockoutPneumoniaReadmissions:SuccessStoriesPart2 • Wewelcomevolunteers
ObjectivesforthisSession
• Knowwhattransitionalcarepractices,processes,tools,servicesalreadyexistinyourhospital
• Knowwhattransitionalcareservicesandsupportsareinplaceinthepost-acuteandambulatorysettings
• Know whatservicesandsupportsareavailableinthecommunity,includingbehavioralhealth,social,andsupportiveservices
Reflectiononyourpastmonthofreadmissionwork
Whatdidyoulearninthepastmonthaboutyourpneumoniareadmissionpatterns?
• What is your hospital’s PNA readmission rate? • How many PNA discharges do you have per day? • How many PNA patients are d/c to home per day? To SNF? • What is your PNA d/c to SNF readmission rate? • What % of your PNA readmissions return < 7 days of discharge?
Whatdidyoulearninthepastmonthaboutwhy yourpneumoniapatientsreturntothehospital?
https://www.youtube.com/watch?v=5uS6hBh1Qtg
WhatdidMrs.MacDonaldneed?
• Reminder• Clarification• Repetition• Support• Confidence• Point of Contact• Home Visit
Isthiswhatyouareprovidingtoyourpatients?
Whatdidyoulearninthepastmonthaboutwhy yourpneumoniapatientsreturntothehospital?
Segmentyourpneumoniapopulation,byrootcause:RootCause Response
Endoflifetrajectory Familymeeting,GoalsofcareReferraltohospice
Recurrentaspiration GoalsofcareEDcareplanAlternatives(admittoSNF)
Abx-Assoc.Diarrhea Anticipatorypathway(whattodoif..)Treatandreturn(SNF,homecare)Alternatives(admittoSNF)
HighINR2/2abx Titration,closefollowupdurationoftherapy
Forgot,confused,worried Post-dischargecallstoclarify,reinforce“Callmefirst”instructions
Lackself-efficacy In-personnavigation,in-homefollowup
Nowthatweknowpatternsandrootcauses,whatarewegoingtodoaboutit?
Especiallyifyoudon’thaveamagicwand….
“Werunthecarecoordinatorpilot;IthinknursingisworkingwithITongettingahigh-riskflagintherecord.Idon’tknow
howthatiscoming.…”
InventoryHospital-BasedEfforts&Resources
• Readmissionreductionactivitieshaveproliferatedovertime
• Someeffortsmayhavedevelopedinisolationfromoneanother– Notallwouldnecessarilyincludepneumoniaintheirtargetpopulation
• Resourcesorassetsmayexistthatcouldbeleveraged– Readmissionflags,highriskflagsinEMR(dotheyincludePNA?)– Post-dischargefollowupcalls(dotheyincludePNA?)– Centralizedappointmentscheduling(dotheyincludePNA?)– Pharmacistsorpharmacytechnicians(reviewforPNApatients?)– ACO,bundledpaymentteams(dotheytargetPNA?)
HospitalInventoryTool
Usethistoolto:
•Identifyreadmissionreductioneffortsacrossdepartments
•Identifywhethereffortsarecoordinated
•Identifywhetherthereisduplication
•Identifygaps– inadministrativesupport
•Identifygaps– inclinicianengagement
•Getspecific– whichpatientgroups(dx,services,program)getwhat?canweaddantorallPNApatientstothatservice?
“Youdon’tunderstand,therearejustnoresourcesinthecommunity”
InventoryCommunityEfforts&Resources
• Post-acuteandcommunityprovidersmayofferservicesandsupportshospitalstaffareunawareof
– PMCHpost-dischargecalls,transitionalcaremanagement– Front-loadedhomevisits– SNFtohometransitionalcarephonecalls,arrangingappointments,inhomeservices
• Healthplansmayofferhighriskpatientscaremanagement– NJWellcare:“advocacyteam”– SCallMCOs:transitionalcareteamstodopre-dischargeinpersonvisit
• Resourcesorassetsmayexistthatcouldbeleveraged– Communitybasedcaremanagement– Behavioralhealthclinicswithpeers,advocates,groups,transportation– Volunteer,faith-based,elderserviceandsocialserviceagencies
CommunityInventoryTool
Use this tool to identify:
• Peersupports?
• Navigators?
• Medical-legaladvocates?
• Seniorservices?
• Faithbasedorcommunityvolunteers?
• Formalpartnerships?
• Informalarrangements?
• Optimizingavailableresources?
• Islinkageaseasyasitneedstobe?
• Gapsinservicesandsupports?
MedicaidManagedCareOrganizations(MCOs)
MCOscanassistwith:– IdentifyPCP– HomeNursing– Medicationadherence– Dischargeplanningfromalllevelsofcare– DiseaseManagement– ComplexCaseManagement– Coordinationofservices
• Examples:– Transitionalcarestaff– Complexcaremanagers– Behavioralhealthcaremanagers– Mobilizeresourcestomeetbasichealth-relatedneeds
AdultDayHealthCare
• AdultDayServicesprovidesanorganizedprograminacommunitygroupsettingtopromotesocial,physicalandemotionalwellbeing.Theseprogramsofferavarietyofactivitiesdesignedtomeettheneedsandinterestsofeacholderadultwhoreceivescare.
• InterdisciplinaryTeamconsistingofa:CenterDirector,RegisteredNurse,LicensedSocialWorker,Dietician,CNA,GNA,CMA,andTherapeuticRecreationalDirector.
• Services:IndividualizedCarePlans,DailyNurseAssessments,PT,OT,medicationadministration,woundcare.
• Ifyouhavequestionsaboutadultdayservicescontact:ThelocalDepartmentofSocialServicesTheAreaAgencyonAging
https://www.ncdhhs.gov/assistance/adult-services/adult-day-services
BonSecoursBaltimoreHealthSystem
InternalInventory• PeerrecoverycoachesintheED• OutcomesManagement• SocialWork• BehavioralHealthProgram• Clinicsprovidepost-discharge
followup<7-10daysforanyone• IT:ACOpatientsflagged• IT:UseCRISPfornotifications
What’sneedednext:• Carecoordinationmodelforhighriskpatients• Createcareplansforhighutilizers• Integratemedicalandbehavioralhealthcareclinicalinformation• Continuetoinnovatetomeetneedofpatients
CommunityInventory• HealthEnterpriseZone• TheCoordinatingCenter• HomelessOutreachProgram• TransitionalHousingProviders• HomeHealthAgencies• SkilledNursingFacilities• BaltimoreAreaAgencyonAging• CollaborationwUMMidtown
Source:presentationtoHSCRCCareCoordinationworkgroup,Dec2014
ReflectonFindingstoDate
• Whichinternalhospital-basedprocessesorresourcescouldbemobilizedtobetterserveourpneumoniapatients(pallcare,pharmacist,SW,ToC)?
• Whatprocessesorservicesexistwithpostacutepartners,andaretheybeingappliedtoourpneumoniapatients(warmhandoffs,circleback,virtualco-management,SNFMD/PAs,EDtreatandreturnpathways)?
• Whatservicesexistinambulatorycareandaretheybeingdeliveredtoourpneumoniapatients(realtimenotificationofPCP,timelypostdischargecontact,transitionalcaremanagement,PCMHcaremanagement)?
• Whatservicesexistinthecommunitythatcanbetteraddressourpneumoniapatients’needsforsupportiveservices,check-ins,contact,reassurance?
Recommendations
1. Develop arunninglistoftherootcausesofPNAreadmissions
2. Developaworkinglistofstrategiestoaddressthoserootcauses
3. Knowifyouhavehospital-basedservicesthatcanaddressthoserootcauses
4. AskyourSNFs,HomeHealth,andPCPpracticesiftheyhaveenhancedsupportsandservices– knowwhattheydo,forwhom,andwhetherthisappliestopneumoniapatientsaswell
5. Learnmoreaboutthecommunityservicesandsupportsthatexistthatcouldbemobilizedforyourpneumoniapatients
Thankyouforyourcommitmenttoreducingreadmissions
AmyE.Boutwell,MD,MPPPresident,CollaborativeHealthcareStrategiesAdvisor,NCHAPneumoniaKnockoutCampaignAmy@CollaborativeHealthcareStrategies.com
617-710-5785
ContactUs
KarenSouthard,RN,MHAVicePresident,QualityandClinicalPerformance
TrishVandersea,MPAProgramDirector