Welcome & Introductions 2 1 6/20/2019 Meeting Agenda and - PDF document

6/20/2019 Coordination of Care Initiative East Metro Community Quarterly Meeting June 24, 2019 Regions Hospital Welcome & Introductions 2 1

6/20/2019 Meeting Agenda and Objectives • Discuss coordination of care efforts across Minnesota and review East Metro community data. • Understand key concepts related to health equity and how one organization is approaching the elimination of health care disparities. • Describe how the Anxiety Shared Pathway can be used throughout the continuum to provide caregivers with integrative therapy techniques to help residents/clients mitigate anxiety. • Recognize participation in the Coordination of Care initiative and celebrate community accomplishments to improve care transitions. 3 Coordination of Care Initiative Update 4 2

6/20/2019 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 5 Coordination of Care Communities 6 3

6/20/2019 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 – More 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 7 Community Scorecard 8 4

6/20/2019 The Community 9 Admissions (community) 10 5

6/20/2019 Readmissions (community) 11 Medicare QIN-QIO Program 2019-2024 CMS priorities • Improving behavioral health outcomes, focusing on decreased opioid misuse • Increasing patient safety • Increasing chronic disease self-management • Increasing quality of care transitions • Improving long-term care quality 12 12 6

6/20/2019 Superior Health Quality Alliance New partnership • Lake Superior QIN o MetaStar (WI), MPRO (MI) and Stratis Health (MN) • Joined by: o Illinois Health and Hospital Association o Michigan Health & Hospital Association o Midwest Kidney Network o Minnesota Hospital Association o Wisconsin Hospital Association 13 13 Best Practice Presentation Sidney Van Dyke 14 7

6/20/2019 Health Equity East Metro Coordination of Care Meeting June 24, 2019 Sidney Van Dyke, Director Health Equity and Language Access, Regions Hospital Patient story Connecting the Broken Threads of the Hmong Paj Ntaub by Seexeng Lee 8

6/20/2019 Simultaneous interpreting Simultaneous Interpreting Average Length of Stay by Language Regions Hospital Mental Health Health equity Health equity means that everyone has a fair and just opportunity to be as healthy as possible. Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017. 9

6/20/2019 Business Case on Many Levels Return on investment to society Better care/outcomes lead to lower cost of care Improving overall quality results Attracting patients in changing demographic Minnesota Trends Communities of color in MN will grow faster than 8% White white population American between 1995 and 51% Indian 2025 Asian or Pacific 104% Islander African 113% American 248% Hispanic origin Source: State Demographic Center at Minnesota Planning Percentage of people of color in MN: 19% (2015)  25% (2035) 10

6/20/2019 Health equity Health equity means that everyone has a fair and just opportunity to be as healthy as possible. Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017. 11

6/20/2019 Disparities Health disparity Health care disparity Differences in health that Differences in health are closely linked with insurance coverage, social, economic, and/or access to and use of care, environmental and quality of care disadvantage. delivered. Differences that cannot be explained by variations in health needs, patient preferences, or treatment recommendations. Our Approach to Health Equity Collect data Race/ Language and eliminate Ethnicity gaps in care Sexual Income orientation Support Health Partner with language Equity communities access Gender Age Build understanding of Physical Religion equity, diversity, ability inclusion & bias 12

6/20/2019 Breast Cancer Screening by Race Interventions Gap is 7.4% Gap is 12.9% 100% points points 80% Same day access 60% HEDIS 2018 National 90 th Customized messages Percentile = 82.2% 83.1% 40% based on consumer 75.7% 78.9% 69.3% insights data 20% 481 Community 0% outreach 1st Qtr 2006 4th Qtr 2018 Patients who are white Patients of color Our Data Journey 2019 will begin Collection of REaL data collecting SDoH data Reports by request Stand alone equity dashboard Equity incorporated into existing dashboards 13

6/20/2019 Health equity in all we do Health Stewardship Experience People Measurably improve Demonstrate Ensure everyone Increase diversity health equity by community benefit feels welcome, across all roles and addressing disparities included, valued strengthen culture of inclusion Operationalized at the system and local levels Conversations about Race & Racism 2,000+ leaders engaged and charged to facilitate conversations with teams 14

6/20/2019 Equitable Care Champions • Grassroots program of champions to support education, awareness at local level • Over 170 Champions across the organization since 2003, expansion in 2016 Regions Hospital 2019 Equity Priorities FOCUS AREA WHY TACTICS • Find new ways to hear from patients of color, Disparity in survey particularly American-born African Americans Experience • response rates Engage African American trusted partners • Develop skills/knowledge in Experience Council • Build data infrastructure to identify disparities Hospital’s most racially • Design new systems/building for equity Birth Center • diverse population Strengthen community partnerships focused on equity • Focus on food insecurity screening and referral Address community need Community • Use data to identify new areas of opportunity while recognizing • Health Needs Increase community partnerships for disproportionate impact sustainable impact • Focus on decreasing avoidable readmissions for Disparity in preventable African American dual-eligible patients Readmissions • all-cause readmissions Improve access, systems, and community partnerships • Integrate Psychiatry, Foot and Ankle and Graduate Medical Participation in national Internal Medicine residents into Regions’ Education equity collaborative strategy to eliminate health care disparities 15

6/20/2019 Discussion questions 1 What questions do you have? How are your organizations addressing 2 health and health care disparities ? What commitment can you make 3 today to advance health equity? Best Practice Presentation Kendra Willey 32 16

6/20/2019 Anxiety Shared Pathway Toolkit Shared Pathway Workgroup A workgroup was formed out of the Coordination of Care Initiative to develop a Shared Pathway that would help reduce hospital readmissions. 34 17

6/20/2019 Shared Pathway Workgroup • The workgroup consisted of a variety of participants throughout the care continuum, from hospital and transitional care settings to home care and hospice, Stratis Health, and even a DME company. • Integrative therapy experts were added to the group who were able to provide valuable input around various modalities and treatment options. 35 Anxiety Shared Pathway The work group determined that they would develop a pathway focused on reducing anxiety. • Anxiety is one of the leading causes of hospital readmissions and crosses many diagnoses • Mitigation of anxiety symptoms can be achieved in variety of care settings • Good Samaritan Society-Specialty Care Center had a framework that included assessment tools, modalities and protocols 36 18

6/20/2019 Anxiety Shared Pathway • The intent is for the pathway to be used throughout the continuum to provide caregivers with integrative therapy techniques to offer their residents/clients to mitigate anxiety • This will ultimately lead to better outcomes, increased feelings of satisfaction and well-being 37 Anxiety in Post-Acute Clients • Anxiety symptoms can affect many individuals in post-acute settings • Common diagnoses with anxiety components include CHF and COPD • Many health other health conditions can stir symptoms of anxiety 38 19