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The Playbook for Partnering with Hospitals in an Era of Outcomes-
Based Payment Reform
Kenneth H. Cohn, M.D., MBA, Facilitator CEO, HealthcareCollaboration.com
[email protected] http://healthcarecollaboration.com
978-834-6089
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Overview
• What hospitals look for in long-term care partners
• Minimizing readmissions (an introduction)
• Optimizing ecosystem management
• A ten-step guide for partnering with hospitals
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I. What Hospitals Seek in Long-Term Care Providers
• Aligned mission, vision, and values
• Commitment to quality and patient safety
• Customized, patient-focused experiences
• Risk-sharing that improves patient care
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Aligned Mission, Vision, and Values
• Find ways to participate in joint conferences and strategic planning retreats
• Use social media to build bridges
• Use more traditional types of social networking to open up doors (Board member, spouse contacts)
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Customized, Patient-Focused Experiences
• Demonstrate timely, seamless transitions
• Deliver on promises
• Target your services to hospitalists and engaged healthcare professionals who understand the value that you provide
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Risk-Sharing that Improves Patient Care
• Move from risk-shifting to sharing via common vision and operational platform
• Use similar vendors (e.g. group purchasing)
• Demonstrate ways that your niche adds value (e.g. cognitive assessment to decrease readmissions)
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Commitment to Quality and Patient Safety
• Demonstrate commitment with results and transparency
• Use stories as well as numerical data
• Measure and showcase improvement in Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) scores, (http://hcahpsonline.org/home.aspx)
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HCAHPS: An Introduction
• Standardized survey in use since 2006 to measure patients’ perspectives of hospital care to permit hospital comparisons
• Increases transparency http://www.medicare.gov/hospitalcompare/search.aspx
• Creates incentives for hospitals to improve care
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The Three HCAHPS Categories
• Composite: Nursing (1-3), Physician (5-7), Responsiveness (4,11), Pain Management (13,14), Medicines (16,17), Discharge (19,20)
• Individual: Cleanliness (8), Noise (9)
• Global: Overall Rating (21), Willingness to Recommend (22)
http://hcahpsonline.org/surveyinstrument.aspx
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II. Dealing with Re-admissions
Caveats:
• What drives 30-day readmissions may be outside of providers’ control. Track day 3-7 readmission rate
• There are better ways to improve discharge planning and care coordination than focusing on readmissions e.g. Geisinger warrantees following cardiac/ ortho surgery
• Focus on decreasing readmissions can worsen outcomes if too narrowly focused Maintain quality and safety improvement programs, especially those that build a culture of quality & safety
Joynt, KE, Jha AK. 30-day Readmissions: Truth and Consequences. [nejm.org, downloaded 4/1/12]
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Rationale for Improving Care Transitions
• 17.6% of Medicare admissions are readmissions • Estimated cost $15 billion • 80% of readmission costs deemed potentially
preventable
Moral: The setting in which care occurs is largely irrelevant for patients and their families.
The clinical outcomes matter to all of us. Patient Handoffs: Effectively Managing Care Transitions. 2009.
Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 6.
Hackbarth GM et al. 2007. Report to the Congress: Medicare Payment Policy. Washington: Medicare Payment Advisory Commission.
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Context
• Statewide 30-day hospital readmission rates vary from 13% (VT) to 24% (LA)
• Nationwide analysis of Medicare claims found that half of patients readmitted to the hospital within 30 days following discharge had no intervening physician visit
• 70% of surgical patients readmitted to the hospital within 30 days following discharge were readmitted with a medical diagnosis
• Up to 70% of patients have problems with medications within the 1st week of discharge
Naylor M et al. 2005. Opportunities for improving post-hospital home medical management among older adults. Home Healthcare Services Quarterly. 24(1):101-122.
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St. Lukes Hospital, Cedar Rapids: Case Report
Used variety of techniques to decrease readmission rate for patients with congestive heart failure (CHF), including:
– Involving family caregivers and community providers in predicting home-going needs
– Reconciling medications for discharge
– Scheduling a home-care or office visit within 48 hours of discharge
– Using Teach-Back to assess the patient’s and family’s understanding of self-care expectations
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Teach-Back
• Method to present information, requesting patients and caregivers to restate instructions in their own words as heard
• Questions used for patients with CHF included
– What is the name of your water pill?
– What amount of weight gain should you report to your doctor?
– What foods and condiments should you avoid?
– What symptoms should you report to your doctor?
Patient Handoffs: Effectively Managing Care Transitions. 2009. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 9.
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Lessons Learned
• Interventions decreased readmission rate from 12% to 3-9% per month
• Widespread variation resulted from patients near end of life but unwilling to discuss palliative care options
• Has stimulated care team to discuss end-of-life options proactively
• Palliative care practitioners included as ongoing members of care team
• Need to address cognitive issues in caregivers as well as patients
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Stop and Watch
If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift:
• Seems different than usual
• Talks or communicates less than usual
• Overall needs more help than usual
• Participated in activities less than usual
• Ate less than usual (Not because of dislike of food)
• N Drank less than usual
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Stop and Watch, II
• Weight change
• Agitated or nervous more than usual
• Tired, weak, confused, or drowsy
• Change in skin color or condition
• Help with walking, transferring, toileting more than usual
http://interact2.net/docs/Communication%20Tools/Early_Warning_Tool_(StopWatch)c.pdf
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Ten Steps to Decrease Re-admissions
• Early assessment of discharge medications and ability to comprehend discharge instructions
• Enhanced patient and caregiver instruction based on preferred learning style and understanding of condition(s)
• Timely and complete communication among physicians, nurses, and allied healthcare professionals well before date of discharge
• Telephone call from nurse within 24 hours of discharge to assess and confirm understanding of follow-up plan
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Ten Steps, II
• Post-acute follow-up within 72 hours with a nurse and/or physician for all patients at risk for readmission Bisognano M, Boutwell A. 2009. Improving transitions to reduce readmissions. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 7.
• Referral for post-acute care services as soon as likely to be needed (www.Curaspan.com)
• Sensitive, appropriate advanced care discussions and planning with patient and family
• Remote monitoring
• Streamlined, systematized transfer processes between facilities that work together frequently
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Ten Steps, III
• Improved medication management, especially with regard to anticipation, avoidance, and management of drug interactions with prescription and non-prescription medications
Bradley EH, et al. Contemporary Evidence about Hospital
Strategies for Reducing 30-day Readmissions: A National Study. J Am Coll Cardiol. 2012;60(7):607-614. doi:10.1016/j.jacc.2012.03.067.
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Readmission Summary
• Unnecessary readmissions are now seen as defects to be eliminated, much like “Never Events”
• The boundaries between physicians, hospitals, and post-acute care facilities are blurring
• Transcending silos can improve the quality and safety of patient care
• Start now and be proactive to differentiate your clinical outcomes
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III. Ecosystem Management
• If your organization is innovative, but your partners do not share in your success, your organization's success will be short-lived
• When partners in an ecosystem do well, innovation flourishes
• Population health and wellness require viable ecosystems
Adner R. The Wide Lens: A New Strategy for Innovation. NY: Penguin Books. 2012
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Ecosystem Value Blueprint I
• Who needs to adopt the innovation for your organization to be successful?
• What does your organization need to deliver?
• What inputs do you need from suppliers?
• Who stands between your organization and the end-consumer?
Adner R. The Wide Lens: A New Strategy for Innovation. NY: Penguin Books. 2012, 85-87.
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Ecosystem Value Blueprint II
• What needs to happen for your intermediaries to move your innovation to consumers?
• Identify the risks in your ecosystem that your intermediaries, complementors, and suppliers must bear
• For those partners whose status is not green-lighted, work to understand the reason and to identify a viable solution
• Update your blueprint at least monthly or more rapidly depending on the pace of change
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IV. Ten-Step Approach to Partnering with Hospitals
• Reach out to one (or two) hospital(s) where you have a relationship(s)
• Connect at multiple levels: case mgr./ DC planner, utilization review, hospitalist, nurse mgr., C-suite, Board
• Partner on pilot projects that produce wins for hospital, assisted living community, and residents (e.g. reducing readmissions within the first week after transfer, web-based discharge planning)
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Partnering with Hospitals III
• Make it easy for your strategic partners to know you
– Hotline or designated connection number
– Informative, interactive website: about us, history, awards & recognition, comments from residents and patients (video)
– Thought leadership: blog, newsletter, water-cooler links to your facility that add value, repurposing content
– Social media, esp. LinkedIn
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Partnering with Hospitals III
• Demonstrate support at highest levels at kick-off of new pilot project
– Set stretch goals
– Use plan, do study, act (PDSA) framework
– Limit planning to 30 days, execution to 120-day cycles
– Make deadlines public
– Use a dashboard to highlight barriers to progress (red-green light)
– Summarize goals, actions, learning, and next steps on Intranet to aid others in your organization
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Partnering with Hospitals IV
• Strengthen your network(s) by attending local, regional, and national conferences with hospital leaders (eg. ACHE Congress March 24-27, 2014 or ACHE cluster seminars approved for NAB credit, http://ache.org/NAB )
• Form an interdisciplinary group that meets quarterly to move from us vs. them to we
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Partnering with Hospitals V
• Provide value: V= Quality/ Price – Focus on quality, as measured by people you
serve – Use checklists to improve safety
http://www.nejm.org/doi/pdf/10.1056/NEJMsa0810119 http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/ DesktopPDF/English/booklet_Eng_desktop.pdf
– Eliminate waste Quality = Appropriateness x (Outcome + Service)/ Waste
[email protected], www.VirginiaMasonInstitute.org 206-341-1654
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Some Sources of Waste
• Duplicate laboratory testing and imaging
• Time searching for frequently used items
• Rework from not doing something correctly the first time
• Unnecessary patient transfers
• Arbitrary individual caretaker variation
• Fighting fires rather than preventing them
National Priorities Partnership, http://nationalprioritiespartnership.org/aboutnpp.aspx
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Partnering with Hospitals VI
• Give the HCAHPS survey to your residents twice annually and publish results on your Intranet:
(http://hcahpsonline.org/surveyinstrument.aspx)
– After a year, publish the results on your Internet and in your annual report
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Partnering with Hospitals VII
• Celebrate all successes publicly in person and on Intranet and Internet
– Present results at local, regional, and national meetings
– Use abstract deadlines to sustain momentum
– View speed bumps as learning
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Conclusion
• We encounter different perspectives as a result of our training, care models, professional organizations, and the people we serve
• The pace of change and the need to balance the interests of different stakeholders make conflict inevitable
• Well-managed constructive conflict is a challenging but rewarding journey that can be a source of innovative, transformative ideas
• Long-term relationships can become a core competency, with competitive advantage accruing to those who do it well
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Thanks
• Maribeth Bersani, [email protected] Senior Vice President Public Policy, ALFA 703-562-1180
• Dr. Jennifer Daley, [email protected]
• Neal Peyser, [email protected] President Healthcare Continuum Advisors, 708-829-7054
• Ron Tamol, [email protected] VP Southern Region, COMS Interactive LLC 704-661-150004-661-1500
• Stephanie Handelson, Eric Bartkowiak, Kristie Kronk, Loriann Putzier