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 # 6 De e p Dive Se rie s: E D-b a se d Stra te g ie s Ja nua ry 25, 2017

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 . Ho spita l-wide 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

HOME I S T HE HUB: 2016 Ac tivitie s E ve nts • Ma y VHHA Bo a rd Pre se nta tio n • I de ntify “Hig h-L e ve ra g e Stra te g ie s” • June “Hig h L e ve ra g e Stra te g ie s” • Pre se nta tio n to VHHA Bo a rd • Aug ust Da ta / Me a sure me nt • Pa rtne rship with Virg inia QI O • Se pte mb e r Po st-Ac ute Ca re • We b ina r Se rie s: “Hig h L e ve ra g e Stra te g ie s” • Oc to b e r Multi-Visit Pa tie nts (hig h utilize rs) • I n-Pe rso n L e a rning E ve nt • No ve mb e r I n-pe rso n L e a rning E ve nt • Me e ting with SNF Asso c ia tio n le a de rhsip • De c e mb e r Artic ula te yo ur Stra te g y

HOME I S T HE HUB: 2017 Ac tivitie s Pla nne d E ve nts  Ja nua ry 25 De e p Dive : E D-b a se d Stra te g ie s • De e p Dive we b ina rs • F e b rua ry 22 Spe c ia l T o pic : Pa ye r-Ba se d E ffo rts • Spe c ia l T o pic we b ina rs • Ma rc h 15 Offic e Ho urs with Dr. Bo utwe ll • Offic e Ho urs fo r individua l c o a c hing • April 19 Spe c ia l T o pic : CHWs • Sta te -wide ”Sprint” • Ma y 17 Offic e Ho urs with Dr. Bo utwe ll • Ho me is the Hub “Pla yb o o k” • June 14 De e p Dive : Po st-Ac ute Ca re • I n-Pe rso n Me e ting : Suc c e sse s • July 12 Ho me is the Hub Pla yb o o k • Aug ust 16 Offic e Ho urs with Dr. Bo utwe ll • Oc to b e r 18 I n-Pe rso n Me e ting *All we b inars will b e o ffe re d at 10am

DE E P DI VE : E D-BASE D ST RAT E GI E S 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 • Co nc e pt: T he E D is a n impo rta nt se tting fo r re a dmissio n re duc tio n e ffo rts • E xa mple : Oppo rtunitie s to tre a t-a nd-re turn to skille d nursing fa c ilitie s • E xa mple : Ca re te a ms tha t “re a c h in” to E D to sa fe ly a vo id re a dmissio n • E xa mple : Using E D Ca re Pla ns to b ring b e tte r info rma tio n to the po int o f c a re • Re c o mme nda tio ns: T a king a c tio n

OBJE CT I VE S 1. De sc rib e why the E me rg e nc y De pa rtme nt is a n impo rta nt se tting in whic h to de plo y re a dmissio n re duc tio n e ffo rts 2. De sc rib e ho w to ide ntify the “drive r o f utiliza tio n” 3. De sc rib e “E D Ca re Ale rts” a nd ho w te a ms a re using the m to re duc e re a dmissio ns a nd impro ve c a re

T HE E D I S AN I MPORT ANT SE T T I NG F OR RE ADMI SSI ON RE DUCT I ON

ST ART RE ADMI SSI ON RE DUCT I ON I N T HE E D • We ha ve b e e n ta ug ht tha t the b e st wa y to re duc e re a dmissio ns wa s to impro ve the tr ansitio n o ut o f the ho spita l • So me inno va tive te a ms ha ve ide ntifie d o ppo rtunitie s to re duc e re a dmissio ns whe n a pa tie nt pre se nts to the E D, pr e )admit : io r to the de c isio n to (r • Ma ssa c huse tts Ge ne ra l Ho spita l Hig h Co st Be ne fic ia ry De mo nstra tio n • CMS Pio ne e r ACO Pro g ra m (3-da y wa ive r) • CMS MSSP ACO Pro g ra m • CMS Bundle d Ca re Pro g ra m • Ma ryla nd ”CMS wa ive r” • I NT E RACT (I nte rve ntio ns to Re duc e Ac ute Ca re T ra nsfe rs)

I NCRE ASE OPPORT UNI T I E S T O T RE AT AND RE T URN

I NCRE ASE T RE AT AND RE T URN • Ask: do a hig h pe rc e nt o f pa tie nts se nt to yo ur E D fro m SNF g e t a dmitte d? • Ask: I s the re a hig h re a dmissio n ra te a mo ng yo ur pa tie nts disc ha rg e d to SNF ? • Ask yo ur E D sta ff “Why? ” • Ask “why” 5 time s – e lic it the a ssumptio ns, no rms, pa tte rns • Co nside r – is (re )a dmitting the pa tie nt the fa ste r, e a sie r, “sa fe r” thing to do ? • Co nside r – ho w c a n sa fe ly re turning the pa tie nt to SNF b e ”e a sie r? ”

• Why the pa tie nt wa s se nt in • Na me , numb e r o f a pe rso n to c a ll a t the SNF • Wha t the SNF c a n do https:/ / inte ra c t2.ne t/ to o ls_v4.html

“RE ACH I N – T RANSI T I ON OUT ” Re a l-time no tific a tio n o f c o mmunity b a se d c a re te a ms

”E D CARE AL E RT S” A ne w to o l to b ring b e tte r info rma tio n to the po int o f c a re

T YPE S OF CARE PL ANS • L ongitudinal Car e Plan • A c o mpre he nsive pla n to a c hie ve he a lth-pro mo ting g o a ls a nd o b je c tive s. Spe c ific g o a ls re g a rding c linic a l, b e ha vio ra l, a nd/ o r func tio na l sta tus a re o fte n inc lude d, a nd a re me a sure d via se ria l a sse ssme nts o ve r time . L o ng e r te rm; c a re ma na g e me nt o ve r time . • T r ansitional Car e Plan • I de ntifie s po st-ho spita l ne e ds, pa tie nt prio ritie s, a nd re a dmissio n risks a nd the pla n to a ddre ss tho se ne e ds, prio ritie s a nd mitig a te risks in the 30 da ys po st disc ha rg e . F o c us o n e nsure linka g e to pro vide rs a nd se rvic e s within the 30 da y tra nsitio na l pe rio d. • E D Car e Plan • Summa ry info rma tio n fo r the E D pro vide r to info rm sa fe , e ffe c tive , a nd c o nsiste nt c a re in the E D a nd fa c ilita te disc ha rg e with te a m-b a se d fo llo w up, a s a ppro pria te .

E D CARE PL AN: E ME RGI NG T OOL I N T HE F I E L D • Purpo se : I mpro ve the ma na g e me nt o f the hig h-risk pa tie nt - the ne xt time the y c o me to the E D • Audie nc e : E D c linic a l sta ff • Co nte nt: • E xe c utive summa ry o f pr utilizatio n a nd te sting ; io r • I de ntific a tio n o f the dr o f ho spital utilizatio n ; ive r • Re c o mme ndatio ns fo r c o nside ra tio n • I de ntific a tio n o f a c a re ma na g e r/ pro vide r c o ntac t

E D CARE PL ANS: L E SSONS F ROM T HE F I E L D • Br e vity: No mo re tha n 1 pa g e ; the e sse ntia l summa ry info rma tio n in a wa y tha t sa ve s time a nd pro mo te s q ua lity, info rme d de c isio n ma king . • Audie nc e : Who is yo ur inte nde d a udie nc e ? E D do c ? De ve lo p the “c linic a l sna psho t” a nd re c o mme nde d inte rve ntio ns with the e nd-use r in mind. • Summar : ” T his summa ry is no t just a c linic a l ize the “utilization” par t of “high utilize r summa ry, b ut a utiliza tio n pro file . Qua ntify prio r visits, a dmissio ns, te sts, c o nsults to c o nve y wha t ha s b e e n do ne in the pa st. • De le gate the synthe sis, c ollabor ate on the plan: De le g a te the dra fting o f the c a re pla n summa ry to a me mb e r o f the hig h-risk c a re te a m. Me e t a s a te a m to de ve lo p re c o mme nda tio ns a nd ne xt ste ps.

E D CARE PL AN E XAMPL E • Summa rize utiliza tio n • I de ntify “why” - the drive r o f utiliza tio n • Re c o mme nda tio ns fo r E D to c o nside r • Who to c a ll re : de c isio n to a dmit • Da te c re a te d/ c a re pla n te a m sig no ff Bo utwe ll e t a l: De sig ning a nd De live ring Who le -Pe rso n T ra nsitio na l Ca re , 2016. Se e Cha pte r 6 a nd T o o l 13: https:/ / www.a hrq .g o v/ pro fe ssio na ls/ syste ms/ ho spita l/ me d ic a id re a d mitg uid e / ind e x.html