southeast michigan “see you in 7” - gdahc · 2012-11-13 · agenda welcome and introductions...

Southeast Michigan “See You in 7” Hospital Collaborative

Welcome!

Session 7

November 13, 2012 at 8 am

Providence Hospital Medical Building

Thank You to our Planning Team

MaryAnne Elma, MPH Shilpa Patel Alice Betz Cec Montoye, RN, MSN Joy Pollard, PhD, RN, CCRN, ACNP-BC Janice Norville, MSN, MSBA, RN Sandra Oliver McNeil, DNP, ACNP-BC, AACC Celeste Williams, MD David Lanfear, MD Devorah Rich, Ph.D. Lisa Mason Annie Ervin, MPP

American College of Cardiology (ACC) ACC Michigan Chapter of the ACC St. Joseph Mercy Health System Ann Arbor Trinity Health, St. Joseph Mercy Oakland University of Michigan Wayne State University Henry Ford Hospital Henry Ford Hospital UAW Retiree Medical Benefits Trust Greater Detroit Area Health Council Greater Detroit Area Health Council

Thank You!

Agenda

Welcome and Introductions

What to Expect: “See You in 7” Testing Interventions Phase and Beyond

Michigan Chapter of the ACC Annual Meeting “See You in 7” Poster

Roundtable Discussion of Quarterly Progress Reports

Hospital & Home Health Care Collaboration to Improve the Early Follow-up Process

• Residential Home Health

• ST Mary Mercy Livonia

Closing

Southeast Michigan “See You in 7”

Hospital Collaborative: What to Expect Focus Methods/Tools Meetings

Pre-Implementation May - July

ACC Online Initial Assessment; ACC “See You in 7” Toolkit; Selection of “See You in 7” Process Measures; Analysis of where hospital is, where it should be, and how to get there

Kickoff Meeting; 2 Conference Calls/Webinars

Test Intervention Aug - Jan

Plan for Improvement; Pre-Implementation Data Submission; Collaborative hospitals to share best practices, barriers; Quarterly Progress Reports

2 Quarterly Meetings; 4 Conference Calls/Webinars

Evaluation Feb - April

Data collected will be evaluated; Lessons learned to be shared; Quarterly Progress Report Post-Implementation Data Submission

2 Conference Calls/Webinars; 1 Quarterly Meeting

Walk In With: Initial Assessment

Results

Walk Out With: Understanding of

how to use the "See You in 7" Toolkit and of the structure and purpose of

the Collaborative

Walk In With: Final decision on choice of process

measures (DOC A)

Walk Out With: Understanding of why Collaborative

Hospitals need improvement on selected measures

Walk In With: Results of gap analysis

(DOC B)


where hospitals are on achieving process measures,

where they should be, and how they plan to get there

Pre-Implementation Phase: Selecting "See You in 7" Process Measures and Performing Gap Analysis

Session

1 In-Person

May 21, 2012

3:00PM - 6:30PM

June 19, 2012 July 17, 2012

Session

2 Webinar

Session

3 Webinar

Walk In With: Results of Pre-Intervention Data

Request (DOC C) and Plan For Improvement

(DOC D)


Hospital’s “See You in 7” Interventions; partnering with

follow-up care providers

Walk In With: Identification of

early barriers


Collaborative Hospitals' barriers to implementing

process measures

Walk In With: Quarterly Progress Report

(DOC E)


Hospitals’ challenges, lessons learned, and next steps

Testing Intervention Phase: Implementing Interventions Related to Selected Process Measures

Sept. 20, 2012 Oct. 17, 2012 Aug. 22, 2012

Session

5 Webinar

Session

4 In-Person

Session

6 Webinar

Quarterly Progress Report (DOC F)

Testing Intervention Assessing Progress and Restructuring Interventions Phase

Session 7

In-Person

Dec. 13, 2012 Jan. 17, 2013 Nov. 13, 2012

Session 10

In-Person

Feb. 14, 2012 March 14, 2013 April 17, 2013

Evaluation: Successes and Lessons Learned

Quarterly Progress Report (DOC G)

Post-Intervention Data Request (DOC C)

Session 8

Webinar

Session 9

Webinar

Session 11

Webinar

Session 12

In-Person

Round-Table Discussion: Quarterly Progress Reports


SY7 Process

Measure

Hospi-

tal SY7 Strategies

Identifying HF

patients prior to

D/C

GCH Outcomes management provides daily list of patients w/ up to date diagnosis, & medical records is performing concurrent

coding that helps update patient information

HFM Evaluate current sources of CHF patients and seek best match with final coded CHF

MM RN initiates EMR HF D/C instructions upon admission if patient identified as HF

1-2 dedicated staff review all admitted patients charts daily for presence of current HF Diagnosis or history of past HF history

1 staff member completes compliance audits on initiation of HF instruction into EMR by RN on all admits & discharges daily

1 dedicated staff member completes compliance audits for congruency of Med Rec and D/C Instructions post D/C on all

identified HF patients daily.

Results sent to Patient Care Services Director, who develops status report sent to CNO & CEO every 2 wks

SJMO Pilot with 2 home care agencies for follow up CHF care; Case manager identifies CHF patient and refers to one of 2 home

care agencies; Patient is then seen before discharge and within 24 hours of discharge at home for medication reconciliation

and assessment. Pilot will continue through December

Daily rounds on all units involved in pilot (3) and use of a CHF checklist to capture all the necessary core measures for best

practice; similar checklist is used on the other hospital units

SJP Utilize Boost tool to ID high-risk patients

NP facilitates appt. prior to D/C

Utilize Health Connect for appt.

Multidisciplinary rounds 2d/week reviewing &/or conducting in depth review of readmits w/in 30 and/or pts at high risk for

readmission

VAAA Care coordinator RN’s (4) for each Medicine service will ID patients upon admission and notify PCP and HF team members if

their patients are hospitalized

Scheduling &

documenting f/up

visit w/ a

cardiologist or PCP

that takes place

w/in 7 days after

D/C

GCH Developed team of nurses responsible for education & ensuring the patient has a physician appt w/in 7 days and make f/u

calls to see if patient saw PCP

BGP Home care nurse w/experience in HF employed to work in hospital to make f/u appt. before D/C

MM Multidisciplinary Discharge Pathway implemented (source for all D/C planning information)

HUCS call the physician office to schedule the appointment

Appt. information placed on D/C instructions when appt. can be scheduled prior to D/C

SJMO The RN makes the appointment for the patient before discharge

VAAA HF order set will include HF post-discharge clinic order

Providing patient

w/ documentation

of the scheduled

appt.

BGP D/C f/u appt. card is given to each HF patient prior to D/C and included in HF folder containing teaching information

GCH Development of Hospital to Home Discharge Brochure

Development of Appt./Questionnaire tool

VAAA Identify patients early in hospitalization; Place HF post-discharge clinic order in standard order sets

SY7 Process

Measure

Hospi-

tal

SY7 Strategies

Identifying &

addressing

barriers to

keeping appt.

CHMC Compile list of transportation resources used by CHF team &physician offices

Make first f/u appointments for all HF patients; ensure first appointment falls w/in 7 days of D/C

Incorporate discussion of barriers, including transportation, into D/C instructions conversation between CHF NPs and patient-

Involve family in discussion when possible

HFM Meet and interview CHF patients who were discharged home upon readmission

Identify via interview, patients that did not make their 7 days follow up appointment

Provide alternative (resident clinic) to patients if they indicate that they have a busy physician who will not be able to see them

within 7 days

SJMAA HF Coordinator finished orientation (w/scripting suggestions) & started working w/ all HF patients

Largest PCP practice hired complex case managers and SJMAA coordinating hand off w/ them

SJMO Home care agencies are addressing all issues: non-compliance, transportation problems, lack of understanding etc

Working to

ensure that

the patient

arrives at the

appt. w/in 7

days of D/C

BGP Audit consisting of f/u phone call to patient to be conducted by nurses after scheduled appt.

CHMC Evaluating instituting a post-discharge f/u call for all HF D/C; Clarify for patients the need for appointment w/in 7 days

MM Script for the f/u phone calls initiated. RNs on units make calls along with APN support from Disease Management/HF Clinic

SJMAA HF clinic tracking “no-shows” & calling them to reschedule

HF coordinator calls patient to determine if patient kept appointment

Largest PCP practice hired complex case managers & SJMAA are coordinating a hand off w/ them

SJP W/ Ascension MI Alpha project, Providence establishing clinic for CHF patients--NP will provide the first f/u appointment w/

Health Connect making next appointment w/ PCP and cardiologist

Making the

D/C summary

available to

the f/u health

care provider

CHMC Review process of faxing to f/u care providers to ensure that all necessary copies are sent timely

Reinforce w/ patients the need to bring D/C instructions/med list to appointment

MM HUC informs office staff that the discharge summary & instructions are available on web portal in the medical record for on-staff

physicians

SJMO The summary is available in our system and/or faxed to the attending physician upon request

SJP Formalize work group to ID key areas of information that are helpful to PCP (form in final stage)

Home Health / Hospital Collaboration to Improve Early Follow-Up


© 2012 Residential Home Health. All rights reserved. Proprietary and Confidential. For Residential Home Health use only.

Hospital & Home Health Collaboration to Improve Care Transitions & Reduce Post-Acute Risk

November 13, 2012

20 | © 2012 Residential Home Health. All rights reserved. Proprietary and Confidential. For Residential Home Health use only.

Residential’s Team

+ Mr. Mike Lewis, Chairman & CEO, Residential Home Health, Residential Hospice and Healthy Living Medical Supply

+ Mr. David Curtis, President, Residential Home Health

+ Ms. Melissa Hess, RN, Regional Director – Southeast Michigan

+ Ms. Meg Galvin-Board, Regional Director – Mid-Michigan

+ Mr. Travis Schmidt, Regional Director – Southeast Michigan

+ Ms. Letty Azar, Vice-President, Corporate Development


Growth in U.S. Population – Age 65+

10,000 U.S. citizens become eligible for Medicare each day.

Greater capacity and capability needed to care for

geriatrics with complex chronic conditions.

40

72

0

10

20

30

40

50

60

70

80

Americans - Age 65+ - Millions

2010 2030

Source: U.S. Census Bureau


Post-Acute Care Challenges Today

Hospitals

Nursing Facilities

Physicians Patient Home

Typical Home Health

Typical Hospice

Typical Medicare Post-Acute Patient

• Multiple conditions • Numerous physicians • Poly-pharmacy • Caregiver support • Family resources ($)

Key Care Mgmt Issues • Poor care coordination • Misaligned incentives • Poor communication, disconnected EMRs • Under-utilization of post-acute services • Timely PCP access

• Lack of evidenced-based clinical programs • Lack of clinical capacity to respond timely • Lack of technology to manage utilization/cost • Lack of resources for care transition & service coordination

Medicare patients now see an average of seven

physicians, including five specialists from four different practices.

A typical PCP coordinated with an average of 229 other physicians in 117

different practices just for Medicare patients.


Effective 10.01.12!

Penalties & Hold-Backs to Hospitals Payors are targeting inefficiencies and improved management of care transitions in the current FFS reimbursement structure:

Hospitals Need to More Actively Manage Post-Acute Care Networks as Scope of Penalties and Hold-Backs Will Increase

3. Re-Admission Penalties

Up to 3% by FY 2015

2. Value-Based Purchasing Up to 2% by FY 2017

1. Related DRG Re-Admission No-Pay

5% of CMS Reimbursement

on the table!


Typical Hospital Medicare Acute/Post-Acute Transition & Risk Exposure

Source: Health Market Resources, Inc, 2010 Medicare Claims Data, Jencks et. al.

30-Day Re-Admit Exposure

Typical U.S.

Hospital Avg. LOS 5 days

~$12K Claim

20% of Discharges

50+% of Discharges

20% of Discharges

2% of Discharges

8% of Discharges

Home with No Post-Acute Services

Home with Home Health Services Avg. LOS 90 days

Facility – ECF/SNF Avg. LOS 20 days

Hospice Avg. LOS 90 days

Other

H

It’s no longer just about a discharge. What’s your 30-day post-acute plan?

~55% of Medicare patients readmit within one year.


Residential Home Health is the Most Preferred Home Care Company in Michigan

Home Care Agency

Physicians who refer to agency

Residential Home Health 2,262

Great Lakes Home Health 1,479

Beaumont Home Care 1,185

Henry Ford Home Health Care 1,180

Gentiva Health Services 998

McLaren Visiting Nurse & Hospice 938

St John Home Care 876

Visiting Nurse Assoc of SE MI 862

The Medical Team 831

Family Home Health Services 682

Home Care Agency

SNFs who refer to agency

Residential Home Health 149

Great Lakes Home Health 118



The Medical Team 77

Henry Ford Home Health Care 64

Visiting Nurse Assoc of SE MI 64

Beaumont Home Care 60

Pinnacle Senior Care 60

Home Care Agency

Hospitals who refer to agency

Residential Home Health 79


Great Lakes Home Health 58

McLaren Visiting Nurse & Hospice 57

Pinnacle Senior Care 50


Henry Ford Home Health Care 39

Mercy Amicare Home Healthcare 39

Beaumont Home Care 37

Heartland Home Care LLC 37

Source: Health Market Sciences, Inc, 2010 Medicare Claims Data


Current Primary Hospital Customers


Current Primary SNF Customers

Premier Homes


Residential’s Leadership in Compliance and Clinical Controls – Seven Principles per OIG

1. Standards & Procedures

+ Code of Conduct, annual attestation by all employees, culture

2. Oversight

+ Compliance officer with CHC certification, executive committee

3. Education & Training

+ Annual review and testing, on-line curriculum and on-going updates

4. Auditing & Monitoring

+ External audits for all companies, HIPAA audit, EMR in-place for full audit trail, distribution of responsibilities for control

5. Reporting

+ Compliance hotline, national health law firm as counsel

6. Enforcement & Discipline

+ Code of conduct/policy manual

7. Response & Prevention

+ All reported issues documented and reviewed


5 Core Elements of Optimal Hospital-to-Home Transition

1. Hospital Bed-Side Transitional Nurse Liaison from Home Care with Care Transition Certification

2. Transitional Nurse Liaison to Follow Patients in SNFs

3. Comprehensive Telehealth Program with Daily Vital Sign Monitoring

4. Comprehensive Nursing & Therapy Home Care Program

5. Comprehensive On-Going Utilization Management Program to Monitor Care Plan


Disciplined Utilization & Care Management Framework

Intake RN

Patient Physician(s)

Referral

RHH Patient

Nursing/Therapy Supervisors

RHH In-Home Clinical Team

SOC Info

Direct Care

Direct Care

Service Coordination

Care Coordination

Care Coordination

Utilization Management

Episode Optimization

Wound Care, Telehealth &

High-Risk Team

Triage

Regulatory Compliance/Fiscal Intermediary

Medicare QIO

Beneficiary Review

Oversight & Audit

Beneficiary Dispute


Best-in-Class Integrated Technology Platform

Field Point-of-Care

Office Work Flow Manager

Patient Satisfaction

Wound Care

Clinical Outcomes

Operations Data Warehouse

Physician Portal

TeleHealth

Pharmacy Mgmt

CRM & Service Automation


Fully-Integrated Clinical Technology Platform

Using Homecare Homebase since 2005;

leading home health and hospice EMR

All clinicians use tablet for documentation at point-of-care

Data warehouse for outcomes management and reporting by physician, hospital, SNF, etc.

Physician web-portal for electronic management and oversight of home health care plans Workflow and

reporting allows for tight management of utilization and protocols


Residential’s Telehealth Program

Patient

Physicians Field Clinicians Nursing, Therapy

& Social Work

Reduced 30-Day Unplanned Readmissions 12% All Cause/ 6% CHF

TeleHealth

Daily monitoring of weight, BP, oxygen

saturation, heart rate and other health status questions

RHH Office Triage by Cardiac Nurses

Coordinate Consulting

Coaching for Behavior Modification Diet, Medications, Symptom Mgmt

Telehealth is provided with no cost to patient or physician, and no incremental reimbursement

from CMS/other payors.


Residential’s Telehealth Program

+ Residential has the largest program in the state of Michigan with a census of up to 300 patients and over 350,000 patient days on telehealth

+ 60% reduction in hospitalizations for patients with heart failure compared to usual care (NEHI, January, 2009); consistent with RHH results

100% of Telehealth

Patients Report in On Daily Basis

(By 11 am)

Up to 300 patients

~40% Require

Triage by RN

Education, MD Coordination,

Additional Visit

10% Prevented Readmit in 24 Hours


Acute Care Level of Availability

After hours care not handled by third-party answering service, but an RN with full access to all patient records

No IVR, automated call handling at main office

Every patient receives President’s cell phone number upon admission


Operational Scope and Scale

RHH admits patients seven days per week across 25 counties in Michigan and 9 counties in Illinois with Care

Transition/Service Coordination Team of ~40 FTE Professionals

Care Transitions and Coaching

Catherine A. Ponder, RN, BSN

Certified Care Transitions Coach and Trainer

38

Objectives

1. Benefits of adopting a Care Transitions Coaching model to reduce avoidable

readmission’s using a patient –centered model:

• Lower readmission rates

• Synergistic Health care team approach

• Empowering patients and caregivers

• Patient learns self-management of their healthcare

2. What makes the model unique

3. Coaching techniques and tools that facilitate self management

4. Demonstrate the value and efficacy of the Care Transitions Coaching model

5. Value of the home visit

6. Value of coaching the patient to identify their personal goal

39

About Us

• 304 bed not-for-profit teaching

hospital in Livonia, SE Michigan

– Part of Saint Joseph Mercy

Health System

– Member of Trinity Health

• Senior Service Strategic Plan

– First Senior ER in the state

of Michigan

– NICHE

• Private practice physician model

• 63% of patients over age 65

• Each year reinvests funds to

improve the health of the

community as part of its

Community Benefit Ministry

40

Care Transitions Intervention

“For age is opportunity no less than youth

itself, though in another dress, and as the

evening twilight fades away the sky is filled

with stars, invisible by day.”

- Henry Wadsworth Longfellow

Development of ST Mary Mercy Livonia

Program

41

• CEO identifies Care Transitions Intervention

(CTI) by Dr Eric Coleman to reduce avoidable

readmissions

• Supported by Service Line Administrator Senior

Services/Case Management and Case

Management

• November 2010: 4 Coaches trained and certified

in the Coleman model

Development

42

• Utilizing a readmission risk prediction

model, targeted patients were identified as

“intermediate risk” with diagnosis of HF,

PN, or COPD

• 2012 added acute MI and frequent

readmissions

43

• Educated key stake holders and

organization leaders

Development

Home Visit Field Trip!

44

45

Physician and Administration Support

Development

46

• Identified Physician and case management

champions

47

“I am so happy to have Dr. Yousuf visit me in my home.”

- Mrs. Virginia Matson

Primary Care Physician Support

Development

48

• Used stake holders input for creation of

patient centered tools and materials

Development

49

• Developed educational brochures and

communication tools for PCP and

patient/caregiver engagement

Development

50

• Developed action plan for readmissions

occurring during program enrollment

Development

51

• Using scripting techniques “next level of

care” to increase enrollment

• Developed best practice for coaching the

patients “where they are” and what is

important to them

52

• Lead Coach Trained in Colorado as a

Certified Trainer

Development

CTI Outcomes

Outcomes

53

Outcomes

• Lower readmission rates in patients who receive

a CTI Coach

• Positive feedback from patients, caregivers and

healthcare providers

• CTI identified as recommended intervention by

Heart Failure Collaborative

• Forging a synergistic team approach with

healthcare providers in the hospital and

community minimizing role confusion and

supporting a smooth care transition for patients

and their care givers 54

55

• Partnered with The Senior Alliance (AAA1-

C) in successful application for Affordable

Care Act Section 3026 demonstration

project funding

• Added on-site TSA Coach and developed

team approach for higher risk patients.

• Created Community Transition Improvement

Coalition to increase engagement of all

downstream providers

Synergistic Team approach

Partnerships!

56

Planning for a smooth transition throughout the continuum of healthcare

57

What Makes the Model

Unique

Medical Model

58

Patient

instructed by

Healthcare

providers and

caregivers

Patient Centered Model

59

Patient

supported as

an equal and

valuable

partner in their

healthcare

60

“This is my garden…my sanctuary. This is what

is important to me.”

- Miss S.

Based on Personal Goals

“What is Important to Me”

Built On Trust

61

• Patients

• Care givers

• Health care providers

62

How it Works

How it Works

63

• The Care Transitions Program is based on the Intervention by Dr. Eric Coleman of the University of Colorado

• Empowers patients and care givers to take a more active role in their health care.

• Skill transfer to patient • Consists of a 30-day enrollment focusing on

the four pillars

www.caretransitions.org

How it Works

64

• Guided by the personal goal, Coach uses “Show me / Tell me” techniques leading the patient to self-management of their healthcare focusing on:

• Medication self-management

• Patient-centered Personal Health Care Record

• PCP follow-up appointments and transportation

• Knowledge of red flags and how to respond

Patients Receive

65

• In-hospital visit • Home visit • Follow-up phone calls • Tools

Medication Management

66

67

Data informs….

68

Lower readmission rates for patients enrolled in CTI

with a coach

69

Data

• Overview (through April 2012)

– Encountered 550 patients

– Interested 511 (93% of Encountered pts)

– Enrolled 417 (82% of Interested / 76% of encountered)

• 72% of enrolled patients have successfully

completed the 30-day program

• 9.1% have been readmitted

– Average risk score of readmitted patients 7

– Risk Score range: 5-9

70

Stories Motivate…

71

Value of the Personal Goal

72

Value of the Personal Goal

“I had a beautiful

garden that

summer which I

was very proud of

and Dr. DeSouza

had all the

tomatoes he

could eat- which

was the real

goal.”

- Mr. DeMatteis

73

Patient Quotes and Goals

“Finish my book!” (80 y/o)

“This is it! I don’t know if there will be a next time.” (75 y/o)

“I knew I was sick when I could no longer run to first base… I was

82 years old. I had been playing baseball since I was 5 years

old.”(85 y/o)

“My secret is: Golf and driving! My last hole-in-one was at age 71!”

(94 y/o)

“To take care of my wife… she is my precious gem!” (Married 60 years)

“Stay independent and happy!” (92 y/o)

“Own my 40th Cadillac and celebrate life with my family!”(86 y/o)

“Get back to the Senior Center… I am in charge of Bingo!” (83 y/o)

74

More Quotes and Goals

“Plant my garden!” (82 y/o)

“Eat pumpkin pie … with ice cream.” (88 y/o)

“Adjust to my new normal.” (80 y/o)

“Walk my daughter down the aisle.” (78 y/o)

“Get well enough and stay well enough to get to dialysis…

It is my Life Line!” (79 y/o)

“To keep walking… so I guess I will use the walker, but I did not need one before!” (89 y/o)

“To continue to learn new things!” (83 y/o)

“To dance at my granddaughter’s wedding.” 89 y/o, granddaughter 2 y/o)

“I take one day at a time. I enjoy helping people and having

purpose… that makes me feel good. I am content at my age.”

(93 y/o)

Data informs. Stories motivate.

-Paul Conlon, Senior Vice President

Clinical Quality and Patient Safety

Trinity Health

75

Connectedness, Self-Care and Creativity

76

The Power of the Story!

77

Your Questions and Your Stories…

78

“Healthcare reform tells us what we must do and

our hearts tell us what we should do”

Catherine A. Ponder

[email protected]

734-679-7666

“The miracle is not that we do this work, but that we are happy to do it”

-Mother Teresa

mailto:[email protected]



Thank you!

Session 8: Webinar on Thurs, Dec. 13, 2012 from 8:00AM - 9:00AM

Quarterly Progress Reports Due Jan. 7, 2013

Southeast Michigan “See You in 7” Hospital Collaborative:

southeast michigan “see you in 7” - gdahc · 2012-11-13 · agenda welcome and introductions...

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