care navigation affinity group session one · 2020. 9. 2. · care navigation affinity group...
TRANSCRIPT
Care Navigation Affinity Group
Session One
September 28, 2017
Comprehensive Care for Joint Replacement Model
Audio available through device speakers OR by dialing (800)832-0736
Conference Room:*4934891#Access Code: 092817#
Welcome
Harold Bailey, MSHSALearning and Diffusion Group
Center for Medicare & Medicaid Innovation
Hilarea Amthauer, MPH, BSN, RNCJR Learning System Team
The Lewin Group
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Alicia Goroski, MPHCJR Learning System Team
The Lewin Group
Webinar Agenda
• Welcome & Logistics
• Overview of the CJR Driver Diagram
• Introduction to the Care Navigation Driver Diagram
• Presentation: Eric Lowe, Community Hospital East
• Questions & Discussion
• Announcements & Reminders
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Meeting Logistics
• All telephone lines are muted and will be unmuted during the discussion session
• We encourage comments and reactions via Chat throughout the presentation
• Participate!– Chat– Polls– Telephone (During Open Discussion)– Post-Event Survey
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Introduction to Adobe Connect
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Download Available Resources
Closed Captioning
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To Ask Questions
or Send Messages
To View the Video
To Dial In Via
Telephone
To Raise Your Hand To Enlarge the Presentation
Introduction to Adobe Connect (Cont.)
• Use the Chat pod to submit any questions or comments
• Please use “@” if your question/comment is directed to a specific presenter
• Submit your question/comment by clicking the chat bubble icon
• Please share in Chat now:– Name– Organization– What you hope to learn from this
Affinity Group
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Care Navigation Affinity Group Goals
Convene on a monthly basis to:– Share care navigation and care coordination
tools and resources– Discuss successful strategies, challenges, and
lessons learned– Learn from each other
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Overview of the CJR Driver Diagram
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Introduction to the Care Navigation Driver Diagram: Primary Driver #1
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Introduction to the Care Navigation Driver Diagram: Primary Driver #2
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Poll 1
Are you using any change concepts or tactics in your care coordination/care navigation program that are not currently included in the driver diagram? [Select one option]• Yes (please share in Chat)• No• Maybe (I need to take a closer look at the Driver
Diagram)
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Interview with Eric Lowe, RN
Community Health Network Joint Care Coordinator
Community Health Network
• 5 hospitals– Indianapolis, IN
• (3 locations) in CJR – Anderson, IN– Kokomo, IN
• 1500+ Total Joints per year
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Community Hospital East
• East side of Indianapolis, IN• 7 employed physicians & 2 independent• Employed hospitalist group
– Pre-op clinic and rounding • 300+ total joints per year
– 93 CJR episodes YTD• 18 of those fractures
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Indianapolis Market
• MSA # 26900– Indianapolis, Carmel, Anderson– 24 CCNs
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Joint Care Coordinators (JCC)
• 5 total – 2 at North– 1 at East– 1 at Kokomo– 1 at South
• All are Registered Nurses• Various Backgrounds
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A JCCs’ Typical Day
• Pre-operative education on future patients
• Rounding on current patients
• Following-up on discharged patients
• Tracking various outcome measures
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Patient Interaction
• Prior to surgery– Multi-disciplinary education class (2 hrs)
• How to prepare for surgery• Exercises • What to expect after surgery• Discharge planning
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Patient Interaction (2)
• While in the hospital– Daily rounding
• PT & OT – Functional outcomes
• Case Management– Discharge barriers
• Patients– Satisfaction– Discharge planning
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Patient Interaction (3)
• After discharged– SNF
• JCC follows up with the SNF on POD#7– Home
• Home PT sees the patient 3 x week for 3 weeks– Reunion Dinner
• All patients• 3-4 months after discharge
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Post-Acute Interaction
• Home Health– Standing meeting every 6 weeks
• Review cases– Including episodic data
• Review barriers• Discuss opportunities• Refine orders
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Post-Acute Interaction (2)
• SNF– Quarterly meeting with preferred providers
• Review cases– Including episodic data
• Review barriers• Discuss opportunities• Refine orders
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Collaboration
• JCCs– Monthly
• JCCs, MDs, & Executive leadership– Quarterly
• Post-Acute Team– Every 6 weeks
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Pre-Op Assessments
• RAPT (Risk Assessment Prediction Tool) – Surgeon’s office
• Patient Reported Outcomes– Pre-op Clinic
• NSQIP Surgical Risk Calculator– Pre-op Clinic
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RAPT Article Screenshots
NSQIP Surgical Risk Calculator
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Suggestions for Care Navigators
• We’re all in this together– CJR Connect– Other MSA’s in your region– Webinars– Summits– Surgeons– Patients
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Questions & Discussion
• What questions do you have for Eric?• Did you hear anything today that you would be able to
implement with your CJR patients?• What tools or resources do you use to assess and
measure care coordination, patient engagement/activation, and/or navigator touchpoints?
• Do you stratify services or touchpoints based on risk score?
• As the care navigator, do you tailor your interactions based on risk score?
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Poll 2
Which of the following tactics does your organization use to coordinate care and facilitate communication and collaboration with post-acute providers and community organizations? [Select all that apply]• Host regular meetings with PAC providers (quarterly, monthly). • Share data with PAC providers to better monitor and track patients.• Cultivate and support primary care, specialty provider, and post-acute care
co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
• Collaborate to revise care protocols (e.g., expected LOS, timing and frequency of rehab, what to do in an emergency, etc.).
• Cultivate relationships and increase awareness of community-based services for patients as they transition back into the community.
• Other (please specify in chat).
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Announcements & Reminders
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Continue Discussion on CJR Connect
• Request to join the “Care Navigation” groupo Go to the “Groups” tab on CJR Connecto Click on the green plus sign to join the “Care Navigation”
group • Post a comment in the group, share resources with your peers,
or just respond to others!• To request a CJR Connect account, go to:
https://app.innovation.cms.gov/CJRConnect/CommunityLoginand click “New User? Click Here”
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Upcoming CJR Learning System Events
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If you have any questions about these events, send an email to [email protected]
Reminders
• If you have any questions related to the Affinity Group, send them to [email protected]
• Send any technical or programmatic questions to [email protected]
• Please take a few minutes to complete the Post-Event Survey
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