partnering to improve care coordination efforts in nj(ncta) april 15-21 cms invites you to partner...
TRANSCRIPT
NJHA Symposium Presentation 2019
Partnering To Improve Care Coordination Efforts in NJElisa Rossetti, MPH, CHESProject Coordinator
Lazara Paz-Gonzalez, MPHProject Coordinator
Who Are We?• Quality Insights is one of 14 Quality
Improvement Networks (QINs) throughout the country contracted through the Centers for Medicare and Medicaid Services (CMS) to improve the quality of care and health outcomes for Medicare beneficiaries and their communities
• The Quality Insights QIN works in five states : WV, DE, PA, LA and NJ
• Focused exclusively on quality improvement and technical assistance to reach the CMS Triple Aim goals
Healthcare Quality Strategies, Inc. (HQSI) carries out Quality Insights’ quality
improvement initiatives for NJ
Triple Aim
Care Coordination Community Coalitions• Aim to impact coordination of care by utilizing community coalitions that
unite a diverse array of providers and stakeholders with a shared vision of reducing avoidable hospital admissions and readmissions throughout our region– Coalition participation requires no formal membership; participants attend
when they are able– Meetings are generally in-person and held every two months; virtual meetings
have been held in one community • Medication safety that focuses on high-risk medications is also part of the
care coordination effort– Anticoagulants, diabetes drugs and opioids are considered high risk due to
their association with adverse drug events (ADEs) that lead to emergency department visits and hospitalizations
Vision and Goal• Our Vision
– To build a strong and sustainable community-based health care network that will provide Medicare beneficiaries with consistent, patient-centered, quality care targeted to their needs
• Coalition Goals– To reduce hospital admissions, 30-day
readmissions and adverse drug events (ADEs) for Medicare beneficiaries
– Provide a platform for collaboration among diverse providers and community stakeholders
– Support coalition participants in their efforts to achieve these goals
Care Coordination Coalitions in NJAs of 2019, Quality Insights is facilitating six active care coordination coalitions throughout New Jersey. These include:
• Atlantic-Cape*• Burlington-Camden• Central Jersey*• Greater Trenton• Lower Hudson County• Monmouth-Ocean*
* Coalition Leadership Teams established in 3 Coalitions
Laying the Groundwork• Partnerships with previous contacts and/or
collaboratives– Saint Peter’s Transitions in Care and Reducing
Readmissions Collaborative (Central Jersey)– Camden Coalition of Healthcare Providers (Burlington-
Camden)– Trenton Health Team (Greater Trenton)
Participants Sharing Common Goals• Hospitals (and New Jersey
Hospital Association)• Nursing facilities• Other community
stakeholders• Patients and families• Pharmacies• Physician practices• Social service providers
• Accountable care organizations
• Assisted living facilities• Behavioral health
providers• Dialysis facilities• Local health departments
and offices on aging• Home health agencies• Hospices
Coalition Composition: Similarities and Uniqueness• Communities primarily built to include the ZIP codes in
which most beneficiaries received their healthcare from the hospitals in the community
• There is variability in many factors, including:– Population age– Geography (urban vs. rural)– Types of participating providers and facilities– Accountable Care Organization (ACO) presence – Number of attendees
• But one common purpose: all coalition communities work towards improving quality of care and to reach coalition goals
Building Coalitions• Applied community organizing approach (process where
people who live in proximity to each other come together into an organization that acts in their shared self-interest – and to improve the conditions in their community)
• Identified Medicare providers and other key stakeholders• Reached out via emails and make calls for participation• Solicited suggestions for other organizations to invite• Clearly articulate structure, vision and goals• Held “kick-off” meeting
– Brainstorm about challenges/issues in the community (cross-setting)– Prioritize challenges to focus on– Conduct community-level root cause analysis (RCA – a systematic
process for identifying “root causes” of problems or gaps in services and developing an approach for responding to them)
Creating Common Ground – Participant Responses• When asked why they wanted to participate in the coalitions:
“Acquiring knowledge from other experts in the field and using it to the benefit of our patients”
“I would like to contribute a better understanding of how palliative care is important for the end of life stages”
“…could do nothing but benefit from meeting with peers who are trying to navigate the same challenges”
“Identify what challenges other hospitals are facing and how they handle them”
“Continued growth” “Share my experience with others”
“Because I would love to learn from others
and network”
“Assess potential collaborations or how to improve processes”
Quality Insights’ Support• Facilitation - help bring providers and other partners together • Technical assistance - provide resources and tools• Data analysis assistance - tracking and measurement of
intervention outcomes • Data reports - 30-day admission and readmission reports;
length of stay reports, ADE reports• My Quality Insights – access to portal containing tools, data
and education resources for CEUs for physicians, nurses and pharmacists [visit: www.qualityinsights-qin.org]
• Resource Materials - fact sheets, Powtoons, newsletters• Linkage between various QI initiatives
Community-Level Admissions Data Reports
Community Level Admission Graph
Medication Safety: “Big 3”• ADE Action Plan: Surveillance, Prevention,
Incentives/Oversight• Encourage communities to implement interventions to
prevent adverse drug events associated with high-risk drugs• Incorporate medication safety surveillance and error
prevention into care coordination activities– Monitoring the “Big 3” of Adverse Drug Events
• Develop/promote best practices to reduce ADEs associated with the “Big 3” through:– Surveillance, evidence-based tools, incentives, support with HIT,
recommendations• Provide ADE data reports to all participating organizations in
coalitions
Community Level ADE Report ED Visits
Community Level ADE Graph for ED Visits
Coalition Benefits• Meetings bring together providers from a
diverse array of facilities, organizations and agencies in a collaborative environment
• Create a platform to share best practices as well as challenges, and strategies as to how to meet these challenges
• Opportunity to network cross-facility that rarely exists in the healthcare world
Nuts and Bolts of Maintaining Coalitions• Active coordination efforts
– Meeting arrangements, identifying host sites, and developing agendas– Managing invitations– Continuous outreach to potential participants to optimize meeting
attendance– Maintaining participant contact information
• Gather input from coalition participants at each meeting– Provide meeting feedback forms– Solicit input for agendas for upcoming meetings– Leave time for discussion and participant announcements– Provide table for participant materials
• Involve participants – Educational presentations that address on-going efforts, strategies or
initiatives
Sustainability Efforts – Leadership Teams• Ideally, each coalition is guided by a leadership team and supported
by Quality Insights staff• Create a communal sense of ownership for the coalition • Leadership Teams participate in and host monthly leadership
meetings, as well as assist with :– Planning coalition meetings including format and content– Scheduling coalition meetings– Facilitating coalition meetings– Sharing relevant resources and updates – Recruiting new participants for the coalition
• Tasks at coalition meetings, such as:– Staffing sign-in table– Taking notes at meetings – Reporting back about leadership team meetings – Disseminating and collecting materials before and after meetings
Impacts and Value of Organizing• Over the past two years, reached out to over 2,500
individuals; attendance at meetings has been approximately 1,300
• Identified approximately 30 interventions that are supporting strategies to reduce avoidable hospitalizations or reducing ADEs
• Value in data sharing and quantitatively looking at improvement efforts and outcomes throughout each community
• Assist communities to mobilize resources and coordinate activities that improve the health of Medicare beneficiaries
Community Work: Coalition “Interventions”
Community Work: Coalition “Interventions” (cont’d)
STOP, ED Opioid Prescribing Program- CarePoint Health
Coalition Challenges• Gaps in leadership representation• Perceived “turf” issues• Competing priorities and initiatives• Broad strategies that are not “one size fits all”• Keeping attendance high and participants engaged• Impossible to set meeting schedules that fit
everyone• Sustaining working groups or committees to focus on
specific topics
Future Considerations• Innovations in reducing avoidable
hospitalizations• Looking at more interactive, electronic
strategies that are data driven and promote improved outcomes
• Stronger patient/beneficiary input• Stronger involvement of primary care
providers and physician specialists
National Care Transitions Awareness Week (NCTA) April 15-21CMS invites you to partner with them! To raise awareness and promote action on a national level during NCTA week, they need your help by committing to one or more care transition activity. For example:• Provide an educational webinar, highlighting best practices, to your
organization, community partners, or other stakeholders • Conduct a gap analysis of your current practices and commit to advancing
your practices to the next level • Reach out to existing community partners to further your partnership and
improve care coordination or identify new community partners to expand resources for patients
• Engage health IT partners to improve data transfer and communication to improve care transitions
• Incorporate or enhance patient engagement activities
What are your plans? Let us know and we will forward them to CMS [email protected] or [email protected]
Thank you
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization for West Virginia, Pennsylvania, Delaware, New Jersey and Louisiana 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. Publication number QI-NJ-C3-071718
Elisa Rossetti, MPH, CHESProgram Coordinator
Andrew Miller, MD, MPH Network Task Lead, Care Coordination
Lazara Paz-Gonzalez, MPHProgram Coordinator
Nicole Skyer-Brandwene MS, RPh, BCPS, CCPAdverse Drug Events Network Task Lead
http://www.qualityinsights-qin.org/732-238-5570