Montgomery County Round Table & Luncheon “Partnering for Action in 2016” March 29, 2016 A Special Round Table Event with All Montgomery County Hospitals and Post Acute Care Providers Brooke Grove Retirement Village
Today’s Objectives 1. Discuss existing and future collaborative efforts in Montgomery County between hospitals and post-acute partners 2. Identify successful strategies for improved transitions and reduced admissions 3. Participate in smaller round table discussions to plan collaborative activities 4. Commit to action with community partners to improve care transitions across the county 2
History • Round table sessions • Life Span & MHA sessions/education • Hospital meetings • 911 facilities • Preferred providers • Hospital workgroup / VHQC • HEALTH Partners Coalition • VHQC Care Transitions Project • Collaborative funding proposals for improved care coordination • Nexus Montgomery 3
Perspective – What do we know? a. Approx. 125,000 Medicare beneficiaries a. 13, 30-day readmissions each day b. 76 admissions each day c. 78 ED visits each day d. 15 observation stays each day b. 18% HHA, 20% SNF, 15% Home, 2% Hospice c. >10% - Readmissions occur on Day 1 d. Sepsis Source: Medicare Part A & B Claims Data through Qtr. 2, 2015
Readmissions by Discharge Destination Discharged to: In Montgomery Co. In Maryland Home 15.7% 17.5% with/HH 17.2% 19.9% SNF 17.0% 19.5% Hospice 2.2% 1.9% 5
Top 10 Principal Diagnoses Leading to a 30-Day Readmission 6
HEALTH Partners Days Until Readmission HEALTH Partners Days until Readmission Frequency Breakdown (Q4-2014 to Q3-2015) 11.5% within 1 day of discharge! 300 25% of readmissions occur within 4-5 days of discharge 250 50% of readmissions occur within 11 days of discharge 200 150 100 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 7
How are you improving transitions? a. Readmissions a. Penalties are a reality! What you do now matters. b. Quality Outcomes a. Used to make decisions about care. c. Improvement Activities a. Adopting proven interventions b. Measuring impact d. Collaboration a. Working alone doesn’t work. 8
Pre-Round Table Survey http://www.interact2.net 9
Results • Not all answered…. • 7/27 are using INTERACT – most are SNFs • 1-3 tools (2), 4-8 tools (3), Just starting (1) • <6 Mths. (2), 6-12 Mths. (1), >12 Mths. (3) • Tools Used the Most: 1. SBAR: 5 2. STOP & WATCH: 4 3. Transfer Form: 4 4. Transfer Checklist: 4 5. Capabilities Checklist: 3 6. QI Tool: 2 7. Hospital Tracking Tool: 2 10
Goal a. Identify opportunities for providers to embrace similar interventions to impact care transitions on a larger scale. b. Measure effectiveness of interventions/improvement activities. c. Spread the adoption of successful interventions across the county. d. Next level e. Recognition 11
Hospital Sharing • Suburban Hospital • Adventist Shady Grove Hospital • Washington Adventist Hospital • MedStar Montgomery Medical Center • Holy Cross Hospital 12
Partnering For Action in 2016 Montgomery County Round Table February 10, 2016 13
SNF/NH Collaboration Historical Perspective • 2005 the Nursing Home Collaborative was established by Suburban Hospital and included multiple nursing facilities. It was originally initiated out of the Medicine and Family Practice QA Committee as a way to better coordinate the care between facilities. It was a large and productive group as long as common concerns were addressed. • 2010 Healthcare focus began changing with a focus on readmissions and care coordination. The meeting was transferred to Director of Care Coordination, 2010 to develop inter-facility groups focusing on readmissions • 2011 Collaborative effort initiated with Hebrew Home from the Charles E Smith Life Community to address readmissions and build more collaborative relationships between the physicians in both entities. March 28, 2016 14
Lessons Learned • Building strong relationships is instrumental for safe, smooth transition and lowering risk for hospitalization • The foundation of the relationship needs to based on Communication, Collaboration and Continuity of Care March 28, 2016 15
Getting to “Yes” Readmissions become a Priority • Projects have been a collaboration between the two unrelated organizations, each offering different levels of care •Regular meetings were planned between the organizations, meeting sites were alternated •Organizations brought their own perspectives and priorities to the table •Reduction of Readmissions was identified as a priority •Critical stakeholders were identified and an effective choice was made with respect to staff from each organization to focus on Readmissions work. • Both leadership and clinical staff were included March 28, 2016 16
Why Use INTERACT ? • INTERACT’s Goal to improve care and reduce the frequency of potentially avoidable transfers to acute hospital aligns perfectly with initiatives currently in place in the acute care hospital settings. March 28, 2016 17
SBAR Tool: A Great Example on How to Enhance Communication Situation •Concise statement of the problem •What is happening now? Background •Brief and pertinent information related to the situation •What had happened? Assessment •Analysis and consideration of options •What do you see or think is going on? Recommendation •Suggest/recommend action •What do you want to happen? March 28, 2016 18
Suburban’s Bundle of Strategies to Prevent Readmissions • Early Risk Screening • Identify patients early in admission • Interdisciplinary Care Planning • Representative from SNF invited to attend ID rounds • Patient and Family Education • Effort to coordinate educational materials between facilities March 28, 2016 19
Suburban’s Bundle of Strategies to Prevent Readmissions (continued) • Medication Management • Participated in Cardinal Grant • Primary Provider Handoff • Sent Hospitalists on site visit to SNF • ED Workgroup • ED physicians available for consult by phone March 28, 2016 20
Suburban’s Bundle of Strategies to Prevent Readmissions (continued) • Transitions of Care •Case reviews •Collaboration on pathways •Transition Guide RNs care planning w/complex patients •Paper prescriptions for C2 -C5 medications •Warm handoff RN to RN March 28, 2016 21
Case Management
Wish List • Real time notification of every re-admitted patient • Root Cause Analysis of readmission by nursing facility • Monthly meetings to discuss readmissions – Palliative care consults • Data from Nursing facilities on readmission rates • Closing the loop – Outcomes of patients – Referrals to Home Health – Notification about potential readmissions after dc
Wish List • Joint plans of care for frequently readmitted patients • INTERACT Tools: – Capabilities Checklist – Transfer form Bright colored paper – SBAR Direct phone numbers for provider to provider report
For More Information Jo Cimino, MSN, RN, ACM Director of Case Management Phone: 240-826-6532 or 301-891-5326 Fax: 240-826-5264 or 301-891-6275
SNF PARTNERSHIPS Cur urrent rent partner tnersh ship ip with h St. . Thom omas s Moore ore Readmission reduction of 5% since beginning of partnership Infectious Disease MD makes weekly visits to St. Thomas Moore to evaluate patients that have been discharged from WAH Facilitation of viewing EMR’s from both entities to increase communication. All ED MD’s and Pop Health staff have access to EMR INTERACT Capabilities list Implementation of SBAR communication tool MD to MD RN to RN
SNF PARTNERSHIPS EMR Access to two ManorCare facilities to launch mid-February MD to MD calls RN to RN calls Dedicated call line at both the facility and at WAH ED SBAR communication INTERACT Capabilities list Physicians at ManorCare facilities all credentialed at WAH Beginning Bi-Weekly Readmission Reviews first week of February
TRANSFUSION PROGRAM Developed for SNF’s that do not transfuse patients at their facilities Full Time RN M/W/F Non-emergent transport Able to take vent and dialysis patients
CONTACT INFO Zachary y Goodli ling ng Manager, Population Health Washington Adventist Hospital 301-891-6395 zgoodlin@a n@adv dventi entist sthe healthca thcare. re.co com Katherin erine Barmer er Director of Population Health Management Adventist Healthcare kbarme mer@a r@adv dvent ntisthea thealthca thcare re.c .com om
March 29, 2016 Improving Population Health through Community Partnerships Diana Saladini Director, Outpatient Services & Population Health Dsaladin@medstarmontgomery.org 31
Focus on The Triple Aim • Framework developed by the Institute for Healthcare Improvement (IHI) to optimize health system performance – Improving the patient experience of care (including quality and satisfaction) – Improving the health of populations – Reducing the per capita cost of health care. Source: Institute for Healthcare Improvement, http://www.ihi.org/Engage/Initiatives/TripleAim 32 March 29, 2016
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