IHI Virtual Expedition Improving Transitions to Post Acute Care - PDF document

8/18/2017 April 27, 2017 These presenters have nothing to disclose IHI Virtual Expedition Improving Transitions to Post Acute Care Settings, Including Home Session 1: Building the Will, Ideas and Execution for Successful Transitions Peg Bradke, RN, MA Sue Leavitt Gullo, RN, BSN, MS Today’s Host 2 Vibha Honasoge, Project Assistant Co-Op, Institute for Healthcare Improvement (IHI), supports multiple projects on the Expedition, Passport, and Leadership Alliance teams. Currently, Vibha’s primary responsibility is enrolling members in Passport, an IHI program that allows facilities to pay a yearly rate for unlimited access to Expeditions and LQIs, as well as discounts to several other IHI programs. Vibha is a sophomore at Northeastern University in Boston, MA, pursuing a Bachelor’s degree in Philosophy, Political Science, and Economics. 1

8/18/2017 Audio Broadcast 3 You will see a box in the top left hand corner labeled “ Audio broadcast .” If you are able to listen to the program using the speakers on your computer , you have connected to the audio broadcast. Phone Connection (Preferred) 4 To join by phone : 1) Click on the “Participants” and “Chat” icon in the top, right hand side of your screen to open the necessary panels 2) Click the button on the right hand side of the screen. 3) You can select to call in to the session, or to be called. If you choose to call in yourself, please dial the phone number , the event number and your attendee ID to connect correctly. 2

8/18/2017 WebEx Quick Reference 5 • Please use chat to “ All Participants ” for questions Raise your hand • For technology issues only, please chat to “ Host ” Select Chat recipient Enter Text Chat – who is in the room with you? 6 Names and the Organization you represent Example: Sam Jones, Midwest Health Please send your message to All Participants 6 3

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8/18/2017 9 IHI Open School In the Field On Campus Professionals, GME Faculty, and Students and Professors Residents Free access to catalog of online courses 35+ CEUs for nurses, pharmacists, and Earn IHI Open School Basic Certificate in physicians Quality & Safety MOC Part 2 Activity points for select Join growing Chapter Network – over 775 medical specialty boards have started around the world Tracking tool to monitor staff progress Cost-effective annual subscriptions for groups ($28-$72 per person) and individuals ($300). For more info, visit IHI.org/OpenSchool or contact openschool@ihi.org. What is an Expedition? 10 ex • pe • di • tion (noun) 1. an excursion, journey, or voyage made for some specific purpose 2. the group of persons engaged in such an activity 3. promptness or speed in accomplishing something 5

8/18/2017 Expedition Director 11 Sue Leavitt Gullo, RN, BSN, MS, Director, Institute for Healthcare Improvement, brings 35 years of health care experience to IHI, focusing for the past 10 years on leading and directing organizations across multiple improvement work streams. Her areas of expertise include maternal and child health, patient safety, and leadership. Working at the country level with senior leaders in nongovernmental organizations and hospital systems, Ms. Gullo has been the Senior Director in the field to execute projects, provide translational leadership, and coach and support frontline teams and consumers of health care. She has led the IHI Perinatal Community since its inception in 2004 and is co-lead for IHI's maternal and infant health priority area. Ms. Gullo was elected to the Association of Women’s Health, Obstetrical, and Neonatal Nursing Board of Directors in 2014 and is also a member of other national maternal- child health advisory committees. Previously, she was Director of Women’s Services at Elliot Hospital in Manchester, New Hampshire, and she spent 25 years at the front line of health care delivery as an oncology and medical-surgical nurse. Chat 12 What is your goal for participating in this Expedition? Please send your message to All Participants 12 6

8/18/2017 Today’s Agenda 13  Ground Rules & Introductions  Pre-Survey Debrief  Building the Will, Ideas and Execution for Successful Transitions IHI’s Model for Improvement  Action Period Assignment Ground Rules 14  We learn from one another – “All teach, all learn”  Why reinvent the wheel? – Steal shamelessly  This is a transparent learning environment  All ideas/feedback are welcome and encouraged! 7

8/18/2017 Expedition Objectives 15 Identify reliable and effective models of care transitions from a hospital admission to post-acute care. Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during transitions. Build an effective improvement team including patients and families as well as acute, post-acute and community care partners Identify successful approaches in identifying clinical-community linkages to make an ideal individualized person centered transition of care plan. Identify key issues and strategies related to readmissions for racial and ethnically diverse patients Engage participants in sharing strategies and innovative thinking to explore real life issues related to transitions. Discuss disruptive innovations and models that support patients to provide effective self-care at home. Schedule of Calls 16 Session 1: Building the Will, Ideas and Execution for Successful Transitions April 27, 2017, 1:00 PM – 2:30 PM Eastern Time Session 2: Leveraging the Expertise of Direct-Care Staff to Reduce Hospital Readmissions: Project RED, Re-Engineered Discharge May 11, 2017, 1:00 PM – 2:00 PM Eastern Time Session 3: Achieving Equity: Readmissions and Real World Lessons May 25, 2017, 1:00 PM – 2:00 PM Eastern Time Session 4: Building Partnerships to Establish a Post-Acute Preferred Provider Network June 8, 2017, 1:00 PM – 2:00 PM Eastern Time Session 5: Disruptive Innovations in Self Care and Health Equity June 22, 2017, 1:00 PM – 2:30 PM Eastern Time 8

8/18/2017 Pre-Survey Results 17 • Thanks to those who took the survey! Faculty 18 Peg M. Bradke, RN, MA, Vice President of Post-Acute Care at UnityPoint-Cedar Rapids, Iowa, St. Luke's, oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. She serves as the executive sponsor for the Population Health and Care Coordination work in her region. In her 25-year career in heart care services, Ms. Bradke has held state administrative positions. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step- down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also served as faculty for the Institute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (State Action on Avoidable Rehospitalizations) initiative. She is Senior Leader for the Practice Change Leaders Program. 9

8/18/2017 19 Rebecca’s Story – IHI National Forum 2002 Rebecca Bryson lives in Whatcom County, WA and suffers from diabetes, cardiomyopathy, congestive heart failure, and a number of other significant complications. During the worst of her health crises, she saw 14 doctors and took 42 medications. In addition to the challenges of understanding her conditions and the treatments they required, she was burdened by the job of coordinating communication among all her providers, passing information to each one after every admission, appointment, and medication change. http://www.ihi.org/offerings/Initiatives/STAAR/Pages/Materials.aspx#videos 20 Rebecca’s Story Rebecca said if she were to dream up a tool that would be truly helpful, it would be something that would help her keep her care team all on the same page. Bryson described 3 Challenges that stem from Health Care being location and process centered not Patient Centered:  Medical Records  Navigating a large health care system with Gatekeepers Failing to address the Patient’s “Medical Persona”  Rebecca summarizes her experience in this way – “ Patients are in the worst kind of maze, one filled with hazards, barriers, and burdens .” http://www.ihi.org/offerings/Initiatives/STAAR/Pages/Materials.aspx#videos 10

8/18/2017 21 What can Rebecca teach us? We need to connect the care and we should be responsible and not place the burden on the patient. 22 Achieving Desired Results “Results” 11

8/18/2017 23 The Major Challenges Avoidable Hospitalization are prevalent, costly, and burdensome for patients/families and providers No one provider or patient can “just work harder” to address the idea smooth transition Our delivery system is highly fragmented - providers often act in isolation and patients are usually responsible for their own care coordination Misaligned Incentives 24 Payment Reform Value-Based Payment models/Bundles for Acute Episodes of care/Medicare Advantage/ Risk Contracts/Readmission Penalties – Costs are vital to control – Can make the difference whether a Health Care System can be profitable – Costs can be controlled without adversely affecting quality – Data is convincing in this regard – Part of the Triple Aim – Quality – Cost – Patient Experience 12