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© 2015 Sutter Health
Positioning Home Healthcare as a Valued Partner in
Care Transitions
Paula Suter, BSN, MASutter Center for Integrated Care
Sutter Care at Home
© 2015 Sutter Health
Learning Objectives
1
2
3
2
1. Make the case for person-centered transitions.
2. Provide a brief overview of Integrated Care Management (ICM).
3. Define ICM Transitions of Care key best practices.
4. Review outcomes realized by providers.
5. Review method to describe value to stakeholder partners
© 2015 Sutter Health
Sutter Center for Integrated Care (CIC):Facts About Who We Serve
28 Locations• 11 Home Health• 7 Hospices• 2 Infusion• 2 HME• 1 Private Duty & Geriatric Care
Management1,800 Employees (1,300)770 Volunteers20,000 Average Daily Census
Sutter Health: Transitions of Care, Complex Case Management, Advanced Illness Management, PCMH, Health Literate Organization
Outside SCAH/SH:6,800+ Providers 48 States 3 Countries: US, Canada & Singapore
© 2015 Sutter Health
Evolving “World” of Payment Reform: Impact on “Transitions of Care”
FFS World
•Decrease acute care length of stay
Penalties
World
•Decrease acute care length of stay
•Avoid readmissions e.g.: HF, MI, COPD, pneumonia which focus transitions interventions on patients with specific dx
Value
Based
World
•Focus on ALL transitions across providers, settings and time, starting with high risk patients
•Better health, better care, lower cost for optimum population management across continuum of wellness to advanced illness
© 2015 Sutter Health
Living in Two Worlds at the Same Time is Challenging
Are there foundational care delivery practices and competencies across providers?
Fee for Service
Value Based Population Reimbursement
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The Right Thing to Do:IOM Quality Chasm Report
ALL health care providers should pursue six major aims:
1) Safe2) Effective3) Patient Centered4) Timely5) Efficient6) Equitable
“ A New Health System for the 21st Century” (IOM, 2001)
“Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring patient values guide all clinical decisions.”
© 2015 Sutter Health
Focus on the Patient Experience
“Differentiation and healthcare transformation require a focus on proactively improving the human experience and creating new standards of clinical care, not simply creating customer service or service recovery programs.”
Craig Albanese, VP, Stanford Children’s Health
© 2015 Sutter Health
Integrated Care Management (ICM):Foundation for Care Transitions
Person-Centered
- Care with dignity and respect
- Values, needs and preferences drive care
- Patient as partner
Evidence-Based
- Clinical best practices
- Patient Engagement:
Self-management support
Health literate care
Coordinated Care
- Seamless transitions across providers, settings and time
- Meaningful and timely information exchange
Improved outcomes leading to better health, better care and lower cost
© 2015 Sutter Health
Patient Engagement Requires Provider “Behavior Change”
Health Literate Care
• Use of plain language without jargon
• Presents clinical evidence that is clear
• Uses patient activated learning methods
• Uses teach-back process to validate learning
Self-Management Support
• Uses motivational interviewing to identify values, needs & preferences
• Assesses patient skill & confidence
• Provides actionable options, elicits questions
• Identifies/ reduces barriers
• Structures goal setting to improve confidence
Improved outcomes
Evidence
TalkChoices
© 2015 Sutter Health
Best evidence to date: meta-analysis conducted by Leppin, et al. evaluated 42 randomized trials related to care transitions
Most effective interventions:
• Augmentation of patient self-care - 1.3 times more effective than all other interventions
• Programs/ protocols with at least 5 unique components delivered by 2 or more people
Source: Leppin, A, et al., Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA, May 12, 2014
Why the Emphasis on Person-Centered Care and Self-Management Support?
© 2015 Sutter Health
ICM - TOC Objectives
• Provide transition of care support services in the hospital and home settings.
• Restructure in-home care processes to optimally support transitioning patients.
• Provide a systematic approach for the care of patients discharged from the hospital who are at high risk for re-hospitalization.
© 2015 Sutter HealthPower Point Template 3
12
TJC Foundation ICM Practice/ Tool/competency
Patient/ family action/ engagement
Universal precautions approach to HL, identification of patient goals and preferences through open-ended questions and reflective listening, teach back
Early identification for “at risk” patients
Look for common barriers: low self rating of health, depression, low literacy, cognitive deficits, lack of social support, etc
Transitions planning Protocols to guide care delivery, ie - phone vs face to face visits dependant on risk level
Medication management Thorough medication reconciliation, medication risk assessment, assistance with medication adherence
Multidisciplinary collaboration and transfer of information
Broad use of SBAR in provider and patient communication, team review of high risk patients
Leadership support Creating a learning environment and reviewing readmissions for improving practice
ICM –TOC Alignment with TJC Foundations for Safe Transitions
© 2015 Sutter Health
Our Over Arching Transitions Philosophy
Do for …Do with …
Cheer on
© 2015 Sutter Health
Patient Engagement “Touch-Points” Within 2 Weeks of Hospital Discharge
Pre-discharge
• Home Care Coordinator in-hospital patient visit
• Patient assessments: Risk for readmission
• Patient concerns & stoplight teaching
Home visits
• 1st visit w/in 24 hrs of dc
• 2nd visit w/in 72 hrs by same clinician
• 3rd visit same week
• Focus on med rec, signs & symptoms, MD f/u, personal health record3 home visits/
virtual visits
• Focus on patient engagement, medication management, barriers/ confidence-building
Remote monitoring
• Remote monitoring with focus on health coaching
Week 1
Week 2
Homevisits continuebasedon need
© 2015 Sutter Health
Critical Questions for Care Coordinators
Who are my riskiest patients? •Which patients over utilize care?•Which patients are not managing their health/ condition well?
What is placing them at risk? •Who are my engage-able patients? •What are their individual risk factors/ barriers?
What Interventions will have the greatest impact?
•Which interventions are most efficacious?•What wrap around services can augment care delivery?
© 2015 Sutter Health
ICM TOC : Practices within the Hospital
• Hospital Case Coordinators screen all patients & identify “high risk”
• All high risk patients visited by “health coach” while hospitalized
• “Health coach” • Identifies patient’s concerns• Begins barriers assessment (low
literacy, med management risk, depression, etc)
• Instructs patient on S & S of exacerbation
• Initiates meaningful data exchange
© 2015 Sutter Health
Identifying The High Risk Patient
• Top 5%-10% of health care spending • Poorly controlled chronic condition with multiple co-morbid
conditions• May also have basic needs unmet/ significant barriers
© 2015 Sutter Health
Drilling DownRisk Factors, Not Disease States are Critical
Start with clinical/ claims data
Comprehensive assessments/ drill down to capture additional critical data
Specific interventions based on identified barriers
Who are my high risk patients?
PersonalAssessment of Health/IHI Tool
High risk / rising risk
© 2015 Sutter Health
Risk for Re-admission:IHI Two Question Rubric
High Risk
Criteria A
•2 or more hospitalizations in past year
Criteria B
•Low confidence, poor rating of health, or fails teach-back
Source: http://www.ihi.org/engage/Initiatives/completed/STAAR/Pages/default.aspx
© 2015 Sutter Health
Single Item Health Self-Rating and One Year Event Rates
Source: DeSalvo, et.al., Health Services Research, August 2005
“In general would you say your health is…poor (1) fair (2) good (3) very good (4) excellent (5) ?”
© 2015 Sutter Health
Evaluating Risk - Case Examples
• Mt. Sinai Medical Center- EMR used to identify high risk patients for re-admission– Provider goes to bedside to administer 60 minute
psycho-social assessment (source: The Advisory Board Playbook for PH)
• Sutter Care at Home- uses IHI tool and personal assessment of health to identify high risk patients for re-admission– In-hospital liaison drills down further at bedside -
PHQ2, Single item HL screener, med management risk, lack of social support
– Information placed in agency EMR
© 2015 Sutter Health
Person-Centered Care “Always Event”:Starting in Hospital
“I have four areas we need to focus on to help prepare you and your family for discharge, but before we start on my list can you tell me what you are the most concerned or worried about when you leave here and go home?”
Then transitions of care focus areas ….
1. Medication Management Post-Discharge
2. Early Follow-up
3. Symptom Management
4. Personal Health record
© 2015 Sutter Health
Health Coach in the Hospital 1. Records this on PHR2. Places in EMR3. Asks patient to bring it
home
What concerns do you have about going home?
An “Always Event”Feeling lonely as I live alone.
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Empowering Patients with Health Literate ToolsListen to the Voice of the Patient & Family
http://bcove.me/ckmub1o1
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Interventions in the HomeFirst Visit w/i 24 hrs is an “Initiation Visit”
1) Personal concerns reviewed & revised
2) Self-management with 4 focuses:
1) Medication management
2) Knowledge of signs and symptoms
3) PCP/ specialty care follow up
4) Home safety
© 2015 Sutter Health
Continuation of discussion:
“I see that you are concerned about feeling lonely.
Can you tell me more about that? What is most important to you at this time?”
“Always Event”: What Matters Most
Feeling lonely as I live alone.
Have enough energy to visit my best friend who is in a nursing home.
Patient E
ngagement
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Continues with Assessment of Barriers
A Focus on Major/ Common and Most Potent Barriers
• Depression• Medication Management Issues• Cognitive Impairment• Low Self Confidence• Lack of Knowledge and skill
© 2015 Sutter Health
Preparing for Population Health ManagementThe Concept of the Rising Risk Patient
• Patients with 2 or more chronic conditions, or a chronic condition and psycho-social issues, e.g., patient with COPD and depression
• Goals: enhanced primary care (PCMH) with team approach and tightly managed transitions
An estimated 20% of these patients will escalate and become high risk in a year
© 2015 Sutter Health
A Potent and Prevalent Barrier: Depression
Depression identified in
fewer than 50% of cardiac and
diabetes patients
Many receiving tx are not on right dose
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Non-Adherence and Depression
• Depression - 75% greater odds of being non-adherent with medications
• There is a 65% increase in health care costs for patients with diabetes and co-morbid depression versus for those with diabetes without depression (Health Care Advisory Board, 2015)
• Implication - hardwire depression/ anxiety screening into workflow and results into PHR (PHQ-4)
© 2015 Sutter Health
Depression/ Anxiety Comorbidity...Compounded Effects
• This comorbidity occurs at rates that exceed other common medical illnesses
• Substantially increases medical utilization• Has greater chronicity• Slower recovery and greater impairment• Increased rates of recurrence• Higher suicide attempt rates than with depression alone • Negatively impacted quality of life
© 2015 Sutter Health
Typical Failures Related to Medications During Care Transitions
1. An incomplete medication reconciliation process
2. Failing to assess patient comprehension and ability related to the medication management process
3. Failing to identify and include the individual that assists with or oversees medication taking during instruction
© 2015 Sutter Health
Finding the Medication Management High Risk Patient
Full Assessment
> 65 and mult conditions/
polypharmacy
Personal Assessment of Health is Fair or
PoorPhq-2 is positive
© 2015 Sutter Health
Full Assessment Medication Risk - 3 Domains
Suter and Suter: Wanted--Measurement in Home Health Needed: Focus on Medication Risk. Home Health Care Management Practice, Sept 2014
Patient Behaviors
Regimen Complexity
Cognitive/ Physical Barriers
Example: low vision
Example: hoards d/cd medications
Example: alternating dose
© 2015 Sutter Health
High Alert Medication Stoplight Tools
A recent study found that four agents were responsible for 2/3 of all drug related hospitalizations:
1. Plavix2. Coumadin3. Insulin4. Oral Hypoglycemics
Source: Budnitz, et al. NEJM, Nov 24, 2011.
© 2015 Sutter Health
Improving Skill and ConfidenceSBAR for Patients in PHR
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Back of Stoplight Tools are Skills Patients Need for Self Management
Does your patient know how to…• Test their blood sugar?• Treat high and low blood
sugar?• Read food labels?• Care for their feet?• Safely exercise?
© 2015 Sutter Health
Identification of what matters most –
patient’s personal goal or desired
outcome.
Set short term work (SMART goal) to
move patient toward their desired outcome.
Tie to clinical goals.
Desired outcome is achieved or condition
changes and new desired outcome is
established.
Goal Setting Strategy: Connecting Clinical Goals to What Matters Most
I want to be able to enjoy
my grandchildren’s visits
I will take my morphine when I am at a
pain level of 5 every dayfor the next 3 days
I will usepurse-lip breathing
wheneverI am short of breath
every day for the next week
© 2015 Sutter Health
Moving the Patient from Active SMS to Supportive SMS
Active SMS
Establish graduation goalsProvide skill-based education
Support and reinforce new skillsBuild confidence
Graduate
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Start Small but Bold Goals:
Suggested Process Goals:1. Patient concerns documented at
time of transition - 90%
2. High-risk patients receive a visit/ encounter within 24hr of hospital discharge - 90%
3. High-risk patients placed on remote monitoring/ phone follow-up program - 90%
4. SBAR communication during case conference - 90%
Suggested Outcome Goals:1. Decrease 30 day readmission rates for
high risk patients by x%
2. Improve experience of care measures by x%
© 2015 Sutter Health
ICM Transitions of Care: Results from Providers
-100%
-80%
-60%
-40%
-20%
0%
20%
40%
-40%-47%
-38%
Decrease in 30-Day Readmission RatesAfter Implementing ICM Transitions Of Care
Series1
Our care transitions partnership with Sutter Santa Rosa resulted in a 40% decrease in 30-day rehospitalization rates from Q2-2012 to Q3-
2013.
© 2015 Sutter Health
Prepare for Future Opportunities - Managing Populations & Individual Patients
•Use of protocols to improve collaboration•Waivers for homebound status and hospital steering
ACO Level
•Service coordination•Enhanced home services
Primary Care Level
•Individual risk identification/ interventions•Patient activation with effective SMS
Patient Level
© 2015 Sutter Health
Choosing Home Health Care After Hospitalization
• In a study by Baier, et al., hospital case managers were unaware of public reports about home health quality
• Hospital case managers believed that there was little difference in agency quality
• Authors recommend using public reports to help patients differentiate among providers, while supporting patient autonomy.
Source: Choosing Home Health Care After Hospitalization 2015 Jan 9. [Epub ahead of print]Jr of Gen Internal Medicine. A Qualitative Study of Choosing Home Health Care After Hospitalization: The Unintended
Consequences of 'Patient Choice' Requirements.Baier RR1, Wysocki A, Gravenstein S, Cooper E, Mor V, Clark M.
© 2015 Sutter Health
Implications
• Have an elevator speech ready
• Know your statistics
• Become familiar with the strategic objectives of new payment models and which your partners are considering
• Embed information about how your
agency will help them meet those objectives in your elevator speech
