HOME I S T HE HUB An I nitia tive to Ac c e le ra te Pro g - PowerPoint PPT Presentation

HOME I S T HE HUB An I nitia tive to Ac c e le ra te Pro g re ss to Re duc e Re a dmissio ns in Virg inia We b ina r # 5 – Artic ula ting Yo ur Stra te g y De c e mb e r 15, 2016

HOUSE K E E PI NG • Slide s we re se nt this mo rning • We b ina r is b e ing re c o rde d • Ple a se use the “te le pho ne ” o ptio n • Audio pin pro mpt • All pa rtic ipa nts a re mute d • Ra ise yo ur ha nd • Ask a q ue stio n • Wa rm up

WE L COME AND OVE RVI E W Abraham Segres VHHA Vic e Pre side nt, Qua lity & Pa tie nt Sa fe ty a se g re s@ vhha .c o m (804) 965-1214

VI RGI NI A HOSPI T AL & HE AL T HCARE ASSOCI AT I ON An a sso c ia tio n o f 30 me mb e r he a lth syste ms re pre se nting 107 c o mmunity, psyc hia tric , re ha b ilita tio n a nd spe c ia lty ho spita ls thro ug ho ut Virg inia . Visio n T hro ug h the po we r o f c o lla b o ra tio n, the a sso c ia tio n will b e the re c o g nize d driving fo rc e b e hind ma king Virg inia the he a lthie st sta te in the na tio n b y 2020. Missio n Wo rking with o ur me mb e rs a nd o the r sta ke ho lde rs, the a sso c ia tio n will tra nsfo rm Virg inia ’ s he a lth c a re syste m to a c hie ve to p-tie r pe rfo rma nc e in sa fe ty, q ua lity, va lue , se rvic e a nd po pula tio n he a lth. T he a sso c ia tio n’ s le a de rship is fo c use d o n: princ iple d, inno va tive a nd e ffe c tive a dvo c a c y; pro mo ting initia tive s tha t impro ve he a lth c a re sa fe ty, q ua lity, va lue a nd se rvic e ; a nd a lig ning fo rc e s a mo ng he a lth c a re a nd b usine ss e ntitie s to a dva nc e he a lth a nd e c o no mic o ppo rtunity fo r a ll Virg inia ns.

VHHA 2015-2020 I MPROVE ME NT PRI ORI T I E S 1. Ho spita l re a dmissio ns 1a . Hospital- wide … (ne w foc us on high utilize r s) 1b . Po st-a c ute tra nsfe rs 1c . T o ta l hip/ T o ta l kne e Re pla c e me nt 30-da y re a dmissio ns 2. Clo stridium diffic ile – He althc are -ac q uire d I nfe c tio ns 3. Pa tie nt E xpe rie nc e – HCAHPS 4. Se rio us Sa fe ty E ve nts

State wide L e ar ning & Ac tion • Sta te wide c o lla b o ra tive June 2016 to No ve mb e r 2018 • oc us o n PAC, HU, T HR/ T K R in pa ra lle l F • E ng a g e with pa rtne rs in PAC • E ng a g e with VHQC fo r c r oss- c ontinuum wo rk • E ng a g e with AAAs fo r c ommunity base d c a re / CT I • Pro vide , use , inte rpre t data fro m VHHA & VHQC

Planne d Ac tivitie s for L e ar ning & Ac tion June 16 th* Hig h L e ve ra g e Stra te g ie s Aug ust 17 th* Da ta / Me a sure me nt Se pte mb e r 8 th* Re duc ing PAC Re a dmissio ns Oc to b e r 20 th* I mpro ving Ca re fo r Hig h Utilize rs No ve mb e r 15 th I n-Pe rso n L e a rning E ve nt 9-3:30 15 th De c e mbe r Ar tic ulating Your Str ate gy Ja nua ry 25 th “De e p Dive ” se rie s b e g ins NE W *All we b inars will b e o ffe re d at 10am

ART I CUL AT I NG YOUR ST RAT E GY Amy Boutwell, MD, MPP Collaborative Healthcare Strategies Pre side nt a my@ c o lla b o ra tive he a lthc a re stra te g ie s.c o m (617) 710-5785

AGE NDA • Why wo rk to a rtic ula te yo ur re a dmissio n re duc tio n stra te g y? • E xa mple fro m Ca rilio n Clinic • E xa mple fro m Rive rside He a lth Syste m • Spe c ific a c tio n ste ps

WHY ART I CUL AT E YOUR RE ADMI SSI ON RE DUCT I ON ST RAT E GY?

• Analyze Your Data A • Sur ve y Your Cur r e nt Re admission Re duc tion E ffor ts Analysis S Re duc e • Plan a Multi- fac e te d, Data- Infor me d Por tfolio of Str ate gie s P Re admissions • Imple me nt Whole - Pe r son T r ansitional Car e for All I Ac tion • Re ac h Out and Collabor ate with Cr oss- Continuum Pr ovide r s R • E nhanc e Se r vic e s for High- Risk Patie nts E Bo utwe ll e t a l. Ava ila b le a t: http:/ / www.a hrq .g o v/ pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / inde x.html

1. Data Analysis 2. Readmission Review 3. Hospital Inventory 4. Community Inventory 5. Portfolio Design 6. Operational Dashboard The guide comes with 13 7. Portfolio Presentation customizable tools to be used 8. Conditions of Participation Handout in hospital teams’ day-to-day operations. 9. Whole-Person Transitional Care Planning 10. Discharge Process Checklist 11. Community Resource Guide 12. Cross Continuum Collaboration 13. ED Care Plan Examples Bo utwe ll e t a l. Ava ila b le a t: http:/ / www.a hrq .g o v/ pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / inde x.html

ART I CUL AT E YOUR ST RAT E GY • Conduct a hospital and community-based inventory of readmission reduction related efforts and resources • Analyze what resources and efforts are in place to articulate your hospital’s current readmission reduction driver diagram • Use the inventory and driver diagram to consider whether there are gaps to fill or opportunities to improve implementation of existing efforts

HOSPITAL INVENTORY TOOL Use this to o l to : • I de ntify re a dmissio n re duc tio n e ffo rts a c ro ss de pa rtme nts • I de ntify whe the r e ffo rts a re c o o rdina te d • I de ntify whe the r the re is duplic a tio n • I de ntify g a ps – in a dministra tive suppo rt • I de ntify g a ps – in c linic ia n e ng a g e me nt • Ge t spe c ific – wha t spe c ific a lly is tha t te a m do ing ? Who le a ds tha t e ffo rt? , e tc . http:/ / www.a hrq .g o v/ site s/ de fa ult/ file s/ wysiwyg / pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / me dre a d-to o ls.pdf

COMMUNITY INVENTORY TOOL I de ntify pro vide rs/ a g e nc ie s a lso wo rking to re duc e re a dmissio ns: • Pa tie nt-Ce nte re d Me dic a l Ho me s • Po st-a c ute c a re pro vide rs • Pe e r suppo rts, Na vig a to rs • Me dic a l-le g a l a dvo c a te s • Be ha vio ra l he a lth pro vide rs • Me dic a id MCO c a re ma na g e rs Co nside r: • Are we o ptimizing a va ila b le re so urc e s? • I s linka g e a s e a sy a s it ne e ds to b e ? http:/ / www.a hrq .g o v/ site s/ de fa ult/ file s/ wysiwyg / pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / me dre a d-to o ls.pdf

MANAGED CARE ORGANIZATIONS MCOs c a n a ssist with: • I de ntify PCP • Ho me Nursing • Me dic a tio n a dhe re nc e • Disc ha rg e pla nning fro m a ll le ve ls o f c a re • Dise a se Ma na g e me nt T o pic fo r F e b rua ry 2017 we b ina r • Co mple x Ca se Ma na g e me nt • Co o rdina tio n o f se rvic e s • E xa mple s: • T ra nsitio na l c a re sta ff • Co mple x c a re ma na g e rs • Be ha vio ra l he a lth c a re ma na g e rs • Mo b ilize re so urc e s to me e t b a sic he a lth-re la te d ne e ds

OTHER “ACCOUNTABLE” PROVIDERS IN VA Model 3 Bundled Payment Participants Advanced Home Care Gainesville, VA Advanced Home Care Wise, VA American Homecare Richmond, VA Avante At Harrisonburg Harrisonburg, VA Avante At Lynchburg Lynchburg, VA Avante At Roanoke Roanoke, VA Avante At Waynesboro Waynesboro, VA Cedar Lawn Investments, LLC Abingdon, VA Chatham Health And Rehabilitation Center, LLC Chatham, VA Chesterfield Healthcare Group, Inc. Chester, VA Danville Healthcare Group, Inc. Danville, VA Hampton Healthcare Group, LLC Virginia Beach, VA Healthsouth Rehabilitation Hospital Of Northern Virginia, LLC Aldie, VA Leewood Investments & Associates, LLC Annandale, VA Liberty Ridge Healthcare Group, LLC Lynchburg, VA Nova Healthcare Group, LLC Weber City, VA Stafford Healthcare Group, Inc. Fredericksburg, VA Stanardsville Healthcare, LLC Stanardsville, VA So urc e : CMMI we b site

ANAL YZE YOUR F I NDI NGS  Are a ll re a dmissio n re duc tio n re la te d a c tivitie s c a pture d?  Will this stra te g y a ddre ss the ro o t c a use s o f re a dmissio ns fo r yo ur ta rg e t po pula tio n?  Wha t ta rg e t po pula tio ns ha ve no t b e e n prio ritize d? Why?  Wha t stra te g ie s ha ve no t b e e n prio ritize d? Why?  Are the fo llo wing da ta -info rme d o r hig h-le ve ra g e e le me nts inc lude d? I f no t, why no t?  Me dic a id a dults  Be ha vio ra l he a lth  So c ia l suppo rt ne e ds  Hig h utilize rs  Hig h risk dia g no se s b a se d o n yo ur da ta (se psis, re na l fa ilure , sic kle c e ll, e tc )  Disc ha rg e s to po st-a c ute c a re se tting s  Co lla b o ra tio ns with: MCOs, BH pro vide rs, c linic s, so c ia l se rvic e s, ho using se rvic e s  Do e s this stra te g y a lig n with va lue b a se d / a lte rna tive pa yme nts a nd o the r inc e ntive s?  Me dic a re re a dmissio n pe na ltie s? Me dic a re va lue -b a se d purc ha sing (to ta l c o st)? Bundle s?  Bo a rd-le ve l g o a ls re la ting to q ua lity, pa tie nt e xpe rie nc e , dispa ritie s, o r ste wa rdship?

DRAF T YOUR DRI VE R DI AGRAM

CARI L I ON CL I NI C Jo hn Sc humac he r, Pro c e ss I mpro ve me nt Co nsultant Paul O’ Quinn, Dire c to r Pro c e ss I mpro ve me nt

Carilion Clinic Hip & Knee Readmission Strategy Map Paul O’Quinn, Process Improvement Director John Schumacher, Process Improvement Consultant December 15, 2016 Creation Date: 2016-12-01 18:15, Revision Date: 2016-12-07 1138

(Single-Page View of Map) Sample Strategy Map to Demonstrate Readmission Application