collaboration key to making outcome based pathways and … · 2013. 10. 17. · spo training spo...
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Collaboration Key to Making Outcome Based Pathways
and Reimbursement a Reality Yvonne Ashford (Central CCAC)
Valerie Armstrong (North Simcoe Muskoka CCAC)
Tina Hamilton(Saint Elizabeth Health Care)
OACCAC Knowledge and Inspiration Conference
June 20th, 2013
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Supporting Structural and Cultural Change
Kotter’s 8-Stage Process
1. Establish a sense of urgency
2. Create the guiding coalition
3. Develop a vision and strategy
4. Communicate the change vision
5. Empower employees for broad based action
6. Generate short term wins
7. Consolidate gains and producing more change
8. Anchor new approaches in the culture
Improving Care Experiences
• Patient outcomes drive care delivery
• Care decisions made by patient and care professional closest to patient
• Care based on evidence-informed best practice
• Payment for quality (outcomes)
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Establishing a Sense of Urgency
Planning
4
Creating a guiding coalition
Service Provider and CCAC Joint Team
Cross-functional teams NSM and Central CCAC Consolidated project plans developed with SPOs & CCACs
Joint CCAC Project Team
Central CCAC Champlain CCAC North Simcoe Muskoka CCAC
Local Service Provider Internal Project Team
Cross-functional team from CCAC including frontline staff
Local CCAC Internal Project Team
Cross-functional team from CCAC including frontline staff
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Planned Activity
Central CCAC NSM CCAC
Pathways Wound Wound / Orthopaedic
Description All new wounds All populations
All new wounds/joint replacements Short Stay population
Provider Partners
1. Bayshore 2. Closing the Gap 3. Paramed 4. Revera 5. Saint Elizabeth 6. Spectrum 7. SRT Med-Staff 8. VHA Home 9. Calea
Wound: 1. Bayshore 2. Closing the Gap 3. Saint Elizabeth
Orthopaedic: 1. Revera 2. Closing the Gap
Start Date CHRIS changes – Oct. 25 Business change – Nov. 26
CHRIS changes - Oct. 25 Business change - Nov. 26
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Developing a vision and strategy
Planning
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CCAC
Deployment and
Testing (IT/IS)
CCAC
Contracts
CCAC
Education and
Training
CCAC
Business Process
Program Design
CCAC
Client Service
Governance
OA &CCAC
Project
Planning
CCAC
Engagement and
Communication
CCAC
Evaluation
Measurement
Reporting
WORK
BREAKDOWN
STRUCURE
SPO
Training
SPO
Business
Process
SPO
Communication
SPO
Billing
Process
SPO
Evaluation &
reporting
Detailed schedule
outlining activities
for all parties involved
CCAC
Finance
Communicating the change vision
CCAC/SPOs Joint Planning
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VSM/Process Mapping Session
• Reviewed current state
• Identified “What will change” and “What remains the same”
• Mapped future state
• Completed gap analysis
• Demonstrated CHRIS and HPG interaction
Outcome:
• Joint action plan
• Business rules
• Revised process maps
Educational Tool Kit
1. Business process scenarios
2. Business rules document
3. Process maps
4. Q&As
5. Presentations
6. Change management material
7. User Guides – HPG / CHP
8. Guidelines for completing reports
9. Pathways
10. Video for HPG / CHP use
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Educational Tool Kit
Change Management Resources
• Model for change analysis
• Change management exercises
• Train the trainer
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Educational Tool Kit
Business process scenarios
• All known scenarios
• Communication
• SPO & CCAC actions
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Scenario and technology testing
• Testing scenarios with CHP & CHRIS
• SPO & CCAC
Educational Tool Kit
Video for HPG / CHP use
Recorded instruction video
Accessible to all stakeholders
Easy to understand
Standardized instruction
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Lessons Learned Planning
• Define Scope Early
• Risk analysis key
• Set the Stage
• Consolidated contracts, IT readiness, aligning caseloads
• Scenario Development and Testing
• Define workarounds, identify improvement opportunities
• Collaborative Approach
• Involve frontline early and often, involve cross-functional
• Resource Intensive
• Identify consistent lead, local and SPO steering committees
• Process Redesign
• Core standard processes, decisions impact local and SPOs
• Communication
• Internally and often, key messages across stakeholders
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Implementation Strategies & Challenges
14 Empowering employees for broad based action
Implementation Strategies
CCAC
Management support for initial OBPs – confirmation of processes prior to sending out initial offers
Regular team huddles to review and provide real-time information
All managers were knowledgeable of model and available to support staff
Manager most involved to be on call initially
Ensure staff on all shifts are knowledgeable of processes
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Empowering employees for broad based action
Implementation Strategies
Service Providers
Initial interval reports reviewed and submitted with support
Ensure IT and support staff knowledgeable and be available
Resource experts available to support a Coordination staff – real time
Internal steering committee to guide decision making
Ensure all staff on all shifts are knowledgeable of processes
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Empowering employees for broad based action
Implementation Strategies CCAC and SPOs
1. Regular check-ins with CCAC and SPOs (first two weeks)
• Real-time problem-solving and decision-making
2. Identification of one contact person at CCAC and SPO
• For communication and escalation
3. Continue with internal committees – the “new norm”
• CCAC and SPO internal committee
• Joint CCAC/SPO committee
• CCAC and OACCAC
• Weekly provincial meetings
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Post-Implementation Lessons Learned and Impacts
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Consolidating gains & producing more change
Anchoring new approaches in the culture
Impact on Clinical Processes
Focus on Outcomes
• Communication more focused on outcomes and less about visits
• Focus on “Clinical Management” by SPOs well received
• Shift from teach, reduce and discharge to ensuring wound is healed prior to discharge
• SPOs have more autonomy with clinical judgement – with some controls internally
SPOs monitoring patients/frequencies and best practice
• Consistency being seen
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Impact on Clinical Processes
Shift in SPO thinking
• Holistic and consideration of other services to meet gaps
• e.g. ET Nurse consults - earlier escalation to prevent delays
Some SPOs – additional work
• Lack of system integration and duplicate effort
• Increased time for orientation
Physician Practices
Challenges with physician practices
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Impact on Internal Operations
Scalability
• Model and business rules must be scalable to other populations (i.e.. Palliative, etc.) = sustainable
• Consideration of multi-disciplinary pathways
Works well with Short Stay population
• More complex, more challenging
• FFS and OBP processes complex
Shift in care coordinator thinking
• Focus on patient and patient outcomes versus frequencies
OBP reporting
• More succinct and clinically based
• Method of reporting remains a challenge - Paper
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Impact on Technology
Lack of integration between SPO systems & CHRIS
• Duplicate entry and effort for CCAC and SPO
Workarounds until enhancements made
• Increased time and effort for staff
Tracking of enhancements and bugs
• Ongoing tracking informs improvements
Early scenario testing using CHP / HPG
• Completed early to confirm processes and limitations
• Reduces re-work
• Ensure billing codes are accurate
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Impact on Financial Processes
Revenue Reconciliation Challenges
• Not well understood or possible
• Organizational risks for CCACs and SPOs
• More intensive financial auditing processes - CCAC and SPO – new auditing processes defined
Financial risk during POC
• Best practices reports shared with SPO
Reimbursement Model
• Impact not fully understood
• Organizational risks for CCACs and SPOs
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Impact on Financial Processes
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Central CCAC
Impact on Patients
Standard approach to wound care and hips/knees
• Promotes best practice
• Focus on outcomes
Simplified referrals
• Less patient time required for completion
Reduced variation among care coordinators and SPOs
• Consistency in provider / agency
• Consistency in care coordinator
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Active Short Stay Clients with an Authorized OBP
(as of May 28, 2013)
On May 28, 2013:
• 1674 active Short Stay clients
• 19.77% (n=331) had an OB pathway currently authorized
Of the 331 clients:
• 74.3% (n=246) OB-W pathway
• 25.7% (n=85) OB-O pathway
NSM CCAC
25.68%
74.32%
OB-O OB-W
Wound Pathway Types Authorized
(November 26, 2012 – May 28, 2013)
1130 Wound pathways authorized during this 6 month period:
• 325 assessment pathways
Remaining 805 wound pathways:
• 43.9 % Surgical Wound
• 17.9% Traumatic Wound
• 32.7% All Other - Healing
• 5.6 % Non Healing
NSM CCAC
Data Note: “Non Healing” accounts for: Maintenance Wound Initial,
Maintenance Wound Recurring, Non-Healing Wound Initial and Non-Healing
Wound Recurring authorized pathway types.
“All Other – Healing” accounts for: Arterial Leg Ulcer, Diabetic Foot Ulcer, Malignant Wound Initial, Pilonidal Sinus, Pressure Ulcer and Venous Leg Ulcer authorized pathway types.
Healable Wound Pathways Discharged – Goal Met vs.
Goal Not Met (November 26, 2012 – May 28, 2013)
478 healable wound pathways have been discharged during this six month period
• 75% (n=359) discharged: pathway completed - goal met (all outcomes have been met)
• 25% (119) discharged: pathway completed - goal not met
•NSM CCAC
Data Note: Excludes all discharged assessment and non-healing/ maintenance pathways.
0%
20%
40%
60%
80%
100%
All Other SurgicalWound
TraumaticWound
75% 68% 80% 75%
25% 32% 20% 25%
Discharge: Pathway completed - goal not met
Discharge: Pathway completed - goal met
Healable Wound Pathways Discharged - Goal not Met
• 119 Wound pathways were discharged: pathway completed – goal not met.
• 19.3% (n=23) were due to supervening events (death, hospitalization, transfer)
• 56.3% (n=67) were classified as “other”
• 24.4% (n=29) service is still active
• 7 transferred to maintenance/ non- healing pathway
•NSM CCAC
19.3%
24.4% 56.3%
Supervening Events Service is still Active Other
Average LOS (in days) per Wound Pathway
Discharged: Goal Met (November 26, 2012 – May 28, 2013)
NSM CCAC
Expected
Length of
Pathway = 60
days
Expected
Length of
Pathway = 7
days
Expected
Length of
Pathway = 60
days
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
CCAC (n= 182) CCAC (n= 171) CCAC (n=78)
Surgical Assessment Traumatic Wound
38.6
7.8
41.0
Wound (OB-W) Clients with Fee for Service
(November 26, 2012 – May 28, 2013)
• 670 clients have been authorized or previously authorized for a Wound Pathway during this six month period
• 89% (595) have a outcome based wound service authorized only
• 11% (n=75) had fee for service assigned at the same time (defined as service unrelated to wound – nursing, therapy, personal support)
NSM CCAC
Top 5 Lessons Learned
1. Collaborate early and often – between and among CCACs, providers and the OACCAC
2. Investment in resources for planning will result in effective implementation
3. Adapt your business processes to new CHRIS and HPG-CHP functionalities including some workarounds.
4. Don’t underestimate change management required – fundamental shift!
5. OBP is the “right concept” – focusing on the outcomes and shared accountability
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Outstanding care – every person, every day
Outstanding care – every person, every day