calverthealth cares program...calvert memorial hospital is a 74 bed independent, not-for-profit,...
TRANSCRIPT
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CalvertHealth CARES Program
Making a PACCT to CARE
Leveraging Community Resources to Educate, Engage and Empower Patients
Karen Twigg, BSN, RN, CMCN
Welcome! Nurses: This session has been approved for 1.0 contact hours.
Hospice & Palliative Care Network of Maryland is an approved provider of continuing nursing education
by the Maryland Nurses Association, an accredited approver by the American Nurses Credentialing
Center’s Commission on Accreditation.
Social Workers: The Maryland Board of Social Work Examiners certifies that this program meets the
criteria for 1.0 credit hours of Category I continuing education for social workers in Maryland.
MNA/ANCC does not endorse or approve any commercial products.
I have no conflict of interest to report
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Objectives
• Identify key community resources, create a platform for meaningful engagement and mobilize an effective winning team
• Recognize opportunities to engage and empower patients to become advocates for their own care.
• Combine quality improvement resources with Health Care Reform expectations to proactively develop sustainable solutions that are supported by organizational leadership.
Calvert Memorial Hospital is a 74 bed independent, not-for-profit, community hospital.
Located in beautiful Prince Frederick, MD, CMH provides general medical / surgical,
psychiatric and post-acute skilled & rehab care.
Founded in 1919, CMH has been taking care of Southern Maryland families for almost 100 years.
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• In FY 2016: – 41,928 patients visited our emergency room
– We had 5,092 inpatient admissions and 3,449 observation stays
– Our physicians performed 1,017 inpatient and 8,074 outpatient surgeries
• There are 228 active and consulting physicians representing over 40 different specialties
• Approximately 1,200 dedicated employees help CMH provide the very best for our patients, with more than 200 volunteers helping to add those "special touches"
• In addition to our main hospital campus, 4 satellite medical office buildings ensure that quality care is no more than 15 minutes from anywhere in Calvert County
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Discharge Planning Model • Case Managers:
– Inpatient Units: Telemetry, MedSurg, ICU, OB – Emergency Department – Psychiatric Unit
• RN role vs SW role • Weekdays, weekends, evenings • Multi-disciplinary rounds • Palliative Care Program • EMA and Adfinitas – Physician Champions • Curaspan Discharge Central / Ride Central • Bridging transition from acute to post-acute
How are we doing it? Through patient,
caregiver, community and team collaboration.
CalvertHealth CARES!!
Collaborative Activation of Resources and Empowerment Services
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Partners in Accountable Care
Collaboration and Transitions (PACCT & Super PACCT)
• community coalition of over 30 local agencies and health care providers
• focused on optimizing patient outcomes through improved care
coordination, collaboration and communication
• targeted improvement of transitions between the hospital and home
(medical home, hospice, skilled nursing, retirement community, etc.)
Since October 2013, PACCT members have created a forum for sharing
best practices, increasing awareness of housing options for seniors, and
creating solutions to improve patient outcomes and patient experience.
Committee
Purpose
Strategies:
2) Improve networking between community partners
3) Enhance information / strategy sharing
5) Optimize engagement with / use of community resources
6) Optimize use of technology
8) Brand our collaborative and publicize what we are doing / why / outcomes
1) Reduction in all cause readmission rate to < 8% (in Maryland intra and inter hospital rate)
2) Reduction in nursing home readmission rate to < 14%
3) Reduction in Medicaid readmission rate to < 12%
4) Reduction in Medicare patient readmission rate to < 12%
5) Reduction in avoidable hospital based utilization (PQI) < 4%
Revised 10/19/17
Key Result
Measures:
9) Leverage our collective to increase our access to resources and capabilities and explore ways to
share risks and benefits ($)
PACCT's purpose is to facilitate and promote collaboration between our community health care
partners, with the goal of eliminating care fragmentation, while fostering an environment of
collegiality, networking and resource sharing focused on enhancing our efficiency and effectiveness in
optimizing patient outcomes.
1) Improve the patient centered experience by ensuring patient's receive the right care in the right
setting, as evidenced by the reduction of avoidable admissions, all cause readmissions, emergency
department visits and outpatient observations stays at CalvertHealth Medical Center and in the
Southern Maryland region.
2) Improve synergy (consistency, efficiency, and effectiveness) of patient centered disease specific
care planning, education and medication management provided by our community health care
partners.
7) Explore incentivization methods to engage PACCT members and community providers; ex.:
lunches, communication, networking, professional growth
4) Mobilize CalvertHealth CARES Program; including Transitions to Home, Project Phoenix,
Medication Therapy Management
1) Improve patient engagement: develop motivational interviewing initiative & begin targeted
synchronization of education - same tools / different methods
3) Improve communication flow and patient centered care coordination between our community
health care partners, as evidenced by the development and implementation of post-acute pathways
and protocols. Target initiative: Mental health pathway that navigates a specific population.
Goals /
Key Result
Areas:
PACCT Charter
Partners in Accountable Care Collaboration and Transitions
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CARES
Together, We Can Cross the Bridge to Wellness
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CalvertHealth CARES Target Population for CMS, HSCRC and TLC-MD
PF CARES Clinic PF CARES Clinic
This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network-Quality Improvement Organization for
Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy. HQI|11SOW|20170125-164747
• Initiative CalvertHealth’s CARES is a free “community benefit”
program which takes a multi-faceted approach to meet the post-discharge needs of patients by assisting patients at moderate to high risk for readmission or emergency department overuse.
• Team Physician, Nurse, Social Worker, Pharmacist
• Target Population Bridging the gap for patients who:
▪ Are unable to schedule a follow up physician appointment within 5 days post- discharge from ED, observation stay or inpatient admission
▪ Lack a primary care provider
▪ Can’t afford essential medications and/or those who need assistance managing multiple medications
▪ Need assistance securing transportation to health care appointments
▪ Can benefit from access to an array of post-acute care resources
Interventions Phone calls, patient portal, community outreach, active listening with coaching, home visits, CARES clinic, financial guidance and assistance
It’s all about the relationship…..
Consistency, Collaboration, Communication = TRUST
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CalvertHealth CARES Philosophy
• P atience
• E ngagement
• R espect
• K indness
CalvertHealth CARES Program Overview • Transitions to Home (T2H)
• Coaching calls and home visits
• Medication therapy management calls and home visits
• Readmission interviews and chart reviews
• Targeted diagnosis interviews and chart reviews (PAU’s)
• Nurse, social worker, pharmacist – and soon, community health worker
• Oversight and post-clinic diagnostic testing and PCP follow up provided by Medical Director
• Monday – Friday 8AM – 5PM (staggered staffing)
• CARES Clinic • Coaching, assessment, medication therapy management, bridging
medical care, education, resource linkage, financial guidance for health care management, linkage to PCP, health insurance enrollment
• Physician, nurse, pharmacist, social worker
• Monday , Tuesday, Thursday 8AM – 1PM (Prince Frederick Urgent Care Center)
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Medication Assistance Program (MAP) Transportation Assistance Program (TAP)
▪ Utilizes the financial assistance programs provided through CMH to help patients pay for essential medications, medical supplies or transportation to medical appointments when financial resources and assistive programs do not meet their needs
Patient Portal ▪ Provides patients secure internet access to their hospital medical record and services, such as reviewing lab results, scheduling appointments and paying hospital bills
CARES Grand Rounds ▪ Community focused committee, serving in an advisory capacity to facilitate identification of potential solutions to care challenges and gaps for high utilization group (HUG) patients
▪ Focus will be on:
- provision of safe, quality patient care in an optimal setting
- awareness, education and accessibility of CalvertHealth and community-based programs and resources
- community support and guidance in developing and implementing multi-faceted care plans
Medication Reconciliation and Medication Therapy Management (MTM)
What brings our patients into our hospitals?
• Medication-related problems: result in 5-10% of hospital admissions
….. 60% of these were avoidable!
• Adverse drug events: the 3rd leading preventable cause of death in the United States
• Medication errors: administration of and missed doses
• Non-adherence: due to cost, access, life style barriers
• Lack of or miscommunication: at admission, during care provision, patient education, transitions of care
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Medication Therapy Management (MTM)
• Medical care provided by pharmacists
• Goal is to optimize drug therapy and improve therapeutic outcomes for patients • Includes:
- performing a comprehensive medication review
- formulating a medication treatment plan
- monitoring efficacy and safety of medication therapy
- enhancing medication adherence through patient empowerment and education - documenting and communicating MTM services to prescribers in order to maintain comprehensive patient care
Mr. X and the Blueberries • 49 year old male with history of high blood pressure, chronic alcohol abuse with
liver impact, reflux, Barrett’s esophagus, obesity, medication non-compliance, depression
• Challenges - hadn’t seen Primary Care Provider (PCP) in > 1yr. due to financial issues
- not following medication regime
- unemployed due to severe joint pain and swelling
• Referred to Discharge CARES Clinic post-inpatient discharge
• Saw nurse / physician / pharmacist / social worker at 4 weekly visits over 1 month (12+ hrs. of intervention, including follow-up phone calls) March through April 2015
• Opportunities - high blood pressure and reflux, not taking meds correctly
- Ibuprofen and alcohol overuse due to pain
- Financial management, needs insurance
- Prior elevated uric acid level obtained from remote lab (gout)
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Patient Primary Goal: Return to work as a mason
• Plan - Modify medication regime, adding gout medication, replacing Ibuprofen with Acetaminophen, and changed prescriptions so that all medications are now once a day in the AM with breakfast (went from 7 to 11 meds, but patient’s cost actually less)
- Use MAP to help patient pay for medications until he returns to work / gets MA
- Coach on medication compliance improvement and alcohol use reduction
- Add B-complex vitamin and ½ cup of blueberries daily (anti-oxidants)
- Complete paperwork for Hospital Presumptive Eligibility (temporary MA)
- Start simple exercise program, begin with walking
• 3rd Visit - Blood pressure improved from180/100 to 130/85
- Alcohol use self-reported as occasional
- Joint pain improved to degree Mr. X worked several days the previous week
- Clinic MD contacted PCP who agreed to see patient
- Mr. X reports he is feeling better and his family has been supportive of changes
needed. “It is easy to manage these new medications since they are all once a day.
The bad news is I have to fight my family for my blueberries!”
Surprise visit! Mr. X popped into the Clinic about 1 month later, after walking there from home (about 2 miles), to thank everyone for their help and to share his continued success with them.
Outcomes by the numbers
• 3 ED visits and 1 observation stay in the 3 months before being seen in the clinic
• 2 ED visits in the 5 months prior to that
• 0 ED visits / hospital stays during his time attending the clinic
• 0 ED visits / hospital stays in the 10 months after he was transitioned from the clinic
• Patient compliant with seeing his PCP
• In the 2 years following his last clinic visit, he has had 2 ED visits and 2 hospital stays
Sustaining the Win
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Huddles, Hand-offs and Supplies, Oh My! ▪ Weekly Team Planning Meetings
▪ Briefing and Debriefing Huddles
▪ Warm Hand-offs
▪ Supplies
Project Phoenix Behavioral Health Case Manager
▪ Partnership between CalvertHealth Medical Center and the Calvert County Health Department, launched August 2015
▪ Targets patients needing mental health and substance abuse services
▪ Provides care management coaching and medication management guidance via phone calls and in person coaching sessions with a social work case manager
▪ Readmission RCA patient interviews and chart reviews
▪ Originally funded by a Maryland Community Health Resources Commission grant awarded to the Calvert County Health Department
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0%
5%
10%
15%
20%
25%
Aggregate
Medicare
Nursing Home
All Cause Aggregate
Target < 9%
Non-Risk Adjusted
All Cause, Intra-hospital, Non-risk Adjusted
Readmission Reduction Trends
FY 2014 – FYTD 2018
3/2015 Opened CARES Clinic 2 days / wk at PF
8/2016 Increased CARES Clinic to 3 days / wk at PF
2/2017 Opened CARES Clinic 2 days / wk at Solomons
10/2017 Closed CARES Clinic at Solomons / Increased CARES clinic to 3 days / wk @ PF
FYTD’18 CARES Clinic aggregate average admissions & readmissions combined rate = 2.5%
FY’18 aggregate average, risk adjusted readmission rate = 8.68%
Program Return on Investment Due to Improvements in:
▪ Health care spend per beneficiary - through reduced utilization and readmissions
▪ Safer patient environment - through reduced exposure to hospital associated conditions due to reduced hospital utilization
▪ Overall patient health - through provision of services in the patient home, care coaching, referrals to partnering service providers and discharge CARES clinic services …..
Through state incentive programs and grant opportunities (HSCRC and Rural Maryland Prosperity Investment Fund)
CalvertHealth Medical Center has been awarded ≈ $2.6M over the past 4 years
The CalvertHealth CARES Program has received state and national recognition as a best practice
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Mr. Z – It Takes a Village • 54 year old male with history of peripheral vascular disease
with ischemic left foot ulcer, complicated by cellulitis and abscess. Also has history of high blood pressure, hyperlipidemia, previous alcohol and tobacco use. 1 ED visit and 1 inpatient admission in 3 months
• Challenges - hadn’t seen Primary Care Provider (PCP) in > 2yrs. due to financial issues
- not following medication regime
- no insurance / no photo ID
- homeless
• Referred to Discharge CARES Clinic + MAP for wound care supplies and medications
Mr. Z – It Takes a Village
• Saw CARES Team for 16 visits over 4 months
• Collaborators: Vascular Clinic, Southern Maryland Community Network, On Our Own of Calvert (socialization / transportation)
• Goals - obtain insurance within 1 month of 1st clinic visit (met)
- find housing within 1 week of 1st clinic visit (met)
- connect with mental health resources in community within 1 month of 1st clinic visit (met)
- assist with obtaining a photo ID within 3 months of 1st clinic visit (met)
- assist with obtaining a PCP, once photo ID obtained and insurance coverage active (met)
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Mr. Z – It Takes a Village
• Outcomes - 1 inpatient admission for cellulitis of left foot 2 months after last seen in clinic
How Big is Our CARES Village? • 0.4 FTE Physician
• 2.5 FTE Nurse
• 0.9 FTE Pharmacist
• 1.0 FTE Social Worker
• 1.0 FTE Coordinator / Liaison
Total = 5.8 FTE (232 man hours / week)
Supported by our PACCT membership of 30+ organizations / agencies
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CARES in Action
CARES Take Aways Put Patient at the Center and the Rest Will Follow
▪ Slow down the pace – give patients time to listen, process and formulate questions
▪ Identify the patient’s goal(s) and then build the plan upon them
▪ Rinse and repeat – the 3rd, 4th …. or 7th time may be the charm
▪ See the patient fresh each time….don’t give up – you never know when they are ready / activated to make needed lifestyle changes
▪ Consider implementing Medication Therapy Management, a group of services provided by a trained pharmacist, to gain the best medication outcomes for your patients
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Remember PERK
• Patience
• Engagement
• Respect
• Kindness
More CARES Take Aways Design Programs for Your Patients, Not Your Data
▪ Consider a patient-centered model when developing Transitions Teams, Discharge Care Clinics, Chronic Care Clinics
▪ Remember - programs are tools. Make sure your tools fit your patients needs, not your needs or what you think patients need
▪ Decrease hand-offs and enhance the strength of the relationship between the patient and your post-acute tools by crossing over staff between programs
Remember, It’s all about the relationship…..
Consistency, Collaboration, Communication = TRUST
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Measuring Our Success
30-day Inter & Intrahospital Readmissions Data Source: CRISP
FYE 18 Target
Risk Adjusted Rolling Percentage < 9.00% 8.83% 4.73% 8.05% 8.36% 8.30%
Maryland HSCRC Case Mix Index Data Source: Snapshot Program
FYE 18 Target
Case Mix Index (Excluding Deaths, Transfers, 0.894285 0.92751 0.93316 0.96604 0.95619 0.96310
Readmissions (Interhospital Non-Risk
Adjusted); Data Source: St. PaulFYE 18 Target
Readmission All Cause 7.71% 5.50% 7.03% 7.15% 7.35%Readmissions 104 80 93 105 112
Total Discharges 1349 1447 1322 1468 1524
Medicare Readmission Rate - CHMC Goal 11.24% 8.48% 9.95% 10.21% 11.45%MC Readmissions 57 49 56 58 63
Total MC Discharges 507 578 563 568 550
NH Readmits 16.79% 9.09% 13.82% 13.25% 12.90%Total NH / TCU Readmissions 23 15 21 20 20
Total NH / TCU Discharges 137 165 152 151 155
Behavioral Health Readmission Rates FYE 18 Target
Percentage 7% 5% 5.7% 6% 8.00%Readmissions 8 11 9 11 15
Total Discharges 138 173 223 173 182
FY17 Q1 FY 17 Q2 FY 17 Q3 FY 17 Q4 FY18 Q1
FY18 Q1
FY18 Q1
FY17 Q1 FY 17 Q2 FY 17 Q3 FY 17 Q4
FY17 Q1 FY 17 Q2 FY 17 Q3 FY 17 Q4
TBD
FY17 Q1 FY 17 Q2 FY 17 Q3 FY 17 Q4 FY18 Q1
< 9.00%
< 14.00%
< 13.00%
The Future
Maryland Care Redesign Programs
• Complex and Chronic Care Improvement Program (CCIP)
• Hospital Care Improvement Program (HCIP)
Physician Engagement Strategies
• Calvert CARES Program, with focus on Pharmacist & Social Worker support to key practices
• TLC-MD Coalition, with a focus on initiatives, information sharing, care planning, communication
