Coordination of Care Initiative Cuyuna/Riverwood Community Community Meeting March 28, 2019
Download meeting agenda and slide handout: • Agenda • Presentation 2
Welcome & Introductions 3
Meeting Agenda and Objectives • Discuss care coordination efforts across Minnesota and share community scorecard report • Learn how the East Metro CoC community Mental Health workgroup created a comprehensive three- episode behavioral health video training series for care providers and family caregivers • Participate in discussion on how the videos and training can be used across health care settings 4
Coordination of Care Initiative Update 5
Coordination of Care Initiative Goals • Improve quality of care for Medicare beneficiaries who transition among care settings • Reduce 30-day hospital readmission rates and admission by 20% by 2019 • Increase the number of days at home • Establish sustainable, transferrable transition practices across the spectrum of care 6
Coordination of Care Communities 7
Success Stories Webinar Series This six-webinar series highlights the innovative work the Lake Superior QIN COC partners have done across care settings and in the community to improve transitions of care and reduce readmissions. Successful Strategies for Sustained Home-based Innovative Strategies Community Improvement to Prevent Readmissions Tuesday, January 22, 2019, 12 – 1:00pm – More Tuesday, April 23, 2019, 12 – 1:00pm – More Changing the Culture: Improving At Your Service: Benefits of Home Recognition and Management of Sepsis Health Agencies Working with their QIN Thursday, May 30, 2019, 12 – 1:00pm – Register Tuesday, February 26, 2019, 12 – 1:00pm – More Achieving Community Goals by Partnering Using Data to Drive Community with Aging and Disability Resource Centers Quality Improvement Efforts Tuesday, June 25, 2019, 12 – 1:00pm – Register Tuesday, March 26, 2018, 12 – 1:00pm – More Download the webinar series flier. 8
Other Upcoming Event LSQIN Webinar - Trauma and Its Impact on Behavioral Health Concerns in Primary Care - Thursday, April 11, 2019, 12 – 1:00 p.m. – Register 9
Featured Tool - Mora Community 10
Home Health Gap Collaborative Tools 11
Community Scorecard 12
The Community 13
Admissions (community) 14
Admissions (comparative) 15
Admissions (vs. goal) 16
Number of Fewer Admissions Needed to Meet Goal • This community had 786 admissions in the most recent 12 months (Q4 2017 – Q3 2018). • Needed to be at 873 admissions for final measurement (Q4 2017 – Q3 2018), which was surpassed by 87 admissions! • Congratulations! This community has achieved the CMS goal! 17
Readmissions (community) 18
Readmissions (comparative) 19
Readmissions (vs. goal) 20
Number of Readmissions Needed to Meet Goal • This community had 112 readmissions in the most recent 12 months (Q4 2017 – Q3 2018). • Needed to be at 125 readmissions for final measurement (Q4 2017 – Q3 2018), which was surpassed by 87 readmissions! • Congratulations! This community has achieved the CMS goal! 21
Next Community Meeting Date and time of the next community meeting is to be determined. Stay tuned for an announcement from Stratis Health. 22
Featured Presentation — Mental Health Video Training Series and Tools Dean Neumann, APR Community Relations Director HealthEast Care System St . Joseph’s Hospital Mental Health and Substance Use Services 23
Post-Acute Care Mental Health Training Series Stratis Health / Cuyuna-Riverwood Coordination of Care Quarterly Meeting March 28, 2019
Presenter and Objectives Dean Neumann, Community Relations Director St . Joseph’s Hospital Mental Health and Substance Use Services Objectives: • Understand why the series was developed • Understand how best to use the videos and written teaching aids • Understand the timing and sequence of the information
Background Lake Superior East Metro Coordination of Care Committee presentation • Providers voice concern about caring for persons with intense mental illness September symptoms 2017 • Identify training needs, Workgroup experts, content and Formed format Video • Stratis Health Grant Series
Target Audiences For care providers and caregivers – especially those without formal clinical training programs • Assisted living direct care staff • Family caregivers • Home care nursing staff • Home care chore staff • Nursing facility nursing assistants • Residential care staff
Training Goals • Boost understanding of older adult mental health • Equip providers and caregivers with techniques to prevent and de-escalate behavioral crises that may lead to unnecessary hospitalization • Improve behavioral / mental health outcomes for older adults • Encourage more education and training 3/25/2019 CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates
Advisory Group • Michelle Wincell O’Leary – Touchstone Mental Health • Patti Cullen – Care Providers of Minnesota • Peter Thelen – Andrew Residence • Dean Neumann – St. Joseph’s Hospital • Kay King – NAMI Minnesota • Aira Wandamacher – CareChoice Cooperative • Janelle Shearer – Stratis Health • Nancy Miller – Stratis Health • Jane Gendron – Stratis Health • Teresa Lewis – MN DHS • Julie Apold – Leading Age Minnesota • Barb Jeroski - HealthStar Home Health • Leslie Brown – Tealwood Senior Living 3/25/2019 CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates
Older Adult Mental Health Basics Video #1 in a series
Prevention & De-escalation Video #2 in a series
Person-centered care and collaboration Video #3 in a series
Facilitator Guide
Video Quiz Two Methods • Fill-in during viewing – “open book test” • Provide quiz after viewing Answer Checking • Self-score after taking the quiz • Facilitator scores Time codes listed in answer sheet for each quiz question
Fact Sheet • Hand out separately or • Post on bulletin boards / provider common areas
Action Checklist • Pocket-size reminder card • Carry and apply during daily work
Sample Plans and Templates • Geriatric Depression Screening Tool • Sample Crisis Prevention Plan • Person-centered Care Plan Template
Overview of Three Videos Older Adult Mental Health Basics Explain common mental illness disorder categories – share the compelling statistics - address the fear and inadequacy many providers and caregivers feel – confront stigma and derogatory labels – express hope and treatment can be effective – convey how you as a care provider or family caregiver - can support – provide resources for more help. Crisis Prevention & De-escalation Describe common behaviors and triggers likely to cause behavioral events – Suggest prevention tips to reduce behaviors - Demonstrate “right way / wrong way” de - escalation scenarios - how to apply new learning after an event – offer additional resources . Person-centered care & collaboration Importance of individual behavioral care plan - creative solutions to diminish / redirect behaviors - when to consult with outside professionals for behavioral assessments / evaluations – offer additional resources
Video Training Series Locations https://www.lsqin.org/initiatives/ behavioralhealth/ http://www.stratishealth.org
Video Highlights
What Worked? • Sponsoring organization • Phenomenal workgroup • Longer planning period yielded better content • Excellent video production company • On-camera talent and location shooting
Unforeseen Challenges • Longer planning period than anticipated • Search for funding • Prioritizing topics, content and experts • Balancing clinical focus with audience health literacy • Cost constraints
Advice For Similar Projects • Find a good project manager • Timeline takes longer when you’re doing something new • Be “over - inclusive” to insure key stakeholder buy -in • Volunteers have limited time – trade-off between time and budget • Everyone brings strengths to the table • Some will be disappointed • Be willing to be a long-term champion • Some may do more work than others • Don’t’ get paralyzed - Just “Do It”
Contact Dean Neumann – St. Joseph’s Hospital Director of Community Relations Email: deneumann@healtheast.org Phone: 651-232-3921
Community Discussion How can the videos and training be used in various health care settings? 45
Contact Information Nancy R. Miller, Stratis Health nmiller@stratishealth.org 952-853-8528 or 877-787-2847 46
This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C3-19-32 032519
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