Community Partnerships Part 2Partnering with Home Health to improve Care Coordination and

Lower Readmissions

Eve Esslinger - eesslinger@wvmi.org

Objectives• At the completion of this webinar, the participant will be

able:– Identify and select tools and resources from the HHQI

Cross Setting 1 BPIP to bridge gaps in patient care between care settings.

– Describe how to advance communication between providers

– Recognize the benefits of using health coaching as a tool to strengthen and support a care transition program.

www.homehealthquality.org

BPIP Contents• Introduction• Leadership

– Tools, Ideas, Focus Section, Checklists, Organizational Culture, Ideas for working with physicians

• Tools– Primary (in the BPIP)– Associated Resources– Weblinks

• Discipline Checklists

"The early bird might get the worm, but the second mouse gets the cheese."–Unknown

Discipline Tracks

Cross Setting I: Care Transitions

• Improved Care Transitions: – Improved patient

satisfaction– Less adverse drug events– More efficient health

care providers– Fewer hospital

readmissions

Home Health Compare• How often patients had to be admitted to

the hospital (End Result Outcome Measure) – Georgia: 27% National 27%

Evidence-based practice

• Evidence-based clinical decision making– External evidence from research, theories,

opinion leaders, expert panels– Clinical expertise– Patient preferences and values

Melnyk and Fineout-Overholt, 2011, p. 4

Care Transitions Models

• Transitional Care Model• Care Transitions Program: Care

Transitions Intervention• Project Red• Project BOOST

Planning Approach

• Know your community of providers• Be prepared to speak a common language• Consider innovative approaches to

improving care across settings

"Give me six hours to chop down a tree and I will spend the first four sharpening the axe."-Abraham Lincoln

How to improve?

• Organizational Commitment• Just Culture

– Learning from errors or potential errors• Ongoing staff education• Identify opportunities

– Learning how to reduce hospitalizations by examining patient hospitalizations or rehospitalizations is a step toward improvement.

Improving Communication

• Between disciplines• Between other providers• With patient/caregiver/family

“Examine what is said, not who speaks.”--Proverb

“It is greed to do all the talking but not to want to listen at all.” --Democritus

Applying Best Practice Interventions as a Community

Develop relationships with your referral stream• Where do your patients come from and where do

they go next?• Develop standard referral, communication and

transfer processes• Develop mechanisms for accountability to those

processes• Explore web-based sharing instruments to drive

improvement (Brock, 2010, HHQI Cross Setting (CS) I BPIP: Focus Section)

How to locate?

How to locate?

Care Transitions Tools

How to locate?

How to locate?

How to locate?

Coaching

• Health Coach/Navigator: – Clinician acts as a health coach through active

listening, working for the patient’s agenda, and identifying patient beliefs and values to activate a patient’s own motivation for change and adherence to treatment.

(Huffman, 2007)

Insights

Coaching: Telephone support• Customer: My keyboard is not working anymore.• Tech support: Are you sure it's plugged into the

computer?• Customer: No. I can't get behind the computer.• Tech support: Pick up your keyboard and walk 10 paces

back.• Customer: OK• Tech support: Did the keyboard come with you?• Customer: Yes• Tech support: That means the keyboard is not plugged in.

Six Telephone Coaching Tips• Schedule the call• Work from an agreed upon agenda• Use active listening skills to enhance call

effectiveness• Location, location, location• Call just because…• Avoid using a speaker phone(Huffman, 2010, HHQI CS I BPIP: Focus Section)

Telephone Support

• Adopt evidence-based models• Assess strengths and what you can add to

community based strategies• Understand value-based strategies• Build a community of practice• Develop relationships with your referral system• Review readmissions with those partners(Brock, 2010, HHQI CSI BPIP: Focus Section)

What a motivated provider can do:

Care Transitions: Insights

Care Transitions Tools

How to locate?

Teach Back

“The only way to know for sure whether patients understand is by asking. One technique to do just that is the “teach-back,” in which providers ask patients to state in their own words (i.e. teach back) key concepts, decisions, or instructions just discussed.”

Helen Osborne, M.Ed., OTR/L President of Health Literacy Consulting

Teach BackNurse

PracticeExercise

Care Transitions Tool: SBAR

Focus Section

• Pages 13-38• Coaching• Motivational

interviewing• Updates on

national and state care transitions projects

To-Do List – Week 1

• To do by week 1:– Download the BPIP– Break it apart (e.g., circulate discipline tracks)– Know your readmission rate (and by hospital)– Evaluate hospitalizations and ED visits through

record reviews and staff discussion

"Great things are not done by impulse, but by a series of small things brought together." Vincent Van Gogh

To-Do List - Wk. 2 • To do by week 2:

– Ask staff for input on care transitions• Include barriers and solutions• Use staff meetings, post-it boards, etc

• Plan immediate adoption some tools/practices– SBAR, Teach Back– Patients see PCP within 7 days of hospital

discharge– Medication Reconciliation

To-Do List – Wk. 2 continued• Analyze every:

– Hospitalization– ED visit– Medication

discrepancy• Reach out to other

providers• Evaluate Transitions

models• Staff Education

References• Barlow, J., Wright, C., Sheasby, J., Turner, A, & Hainsworth, J. (2002). Self-management

approaches for people with chronic conditions: A review. Patient Education and Counseling, 48, 177-187.

• Hernandez, A.F., Greiner, M.A., Fonarow, G.C., Hammill, B.G., Heidenreich, P.A., Yancy, C.W., Peterson, E.D., and Curtis, L.H. (2010). Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. The Journal of the American Medical Association, 303,1716-1722.

• Home Health Quality Improvement, Cross Setting I BPIP, October 2010• Huffman, M., (2007). Health Coaching: A New and Exciting Technique to Enhance

Patient Self-management and Improve Outcomes. Home Healthcare Nurse, 25, 271-276.

• Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. The New England Journal of Medicine, 360, 1418-1428.

• Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins

www.homehealthquality.org

hhqi@wvmi.org

This material was prepared by the West Virginia Medical Institute, the Quality Improvement Organization supporting the Home Health Quality Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy.

Publication Number: 10SOW-WV-HH-BK-061912. App. 6/2012.