ASPIREtoKnockoutPneumoniaReadmissionsDesigning&DeliveringWhole-PersonTransitionalCare

AmyE.Boutwell,MD,MPPNCHAKnockoutPneumoniaCampaign- Webinar2

April5,2018

PurposeoftheKnockoutPneumoniaReadmissionsSeries

Thisseriesistosupportyourworktoreducepneumoniareadmissions

ØWewillfocusonconnectingconceptstoaction

ØWewillfocusonhigh-leveragestrategies toreducereadmissions

ØWewillfocusonimplementation coaching

Thebestuseofyourtimeistousethistimetoactivelyadvanceyourpneumoniareadmissionwork

ØComewithquestions,challenges,cases,data,ideasforimprovement

ØInviteyourcross-continuumpartnerstoattend

ØEmailuswithquestionsorissuestodiscussonthenextwebinar

ASPIREtoReduceReadmissions

basetemplates.com

https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html

ASPIREFramework

“Design”

“Deliver”

Reduce Pneumonia

Readmissions

Design

Deliver

ü .

ü .

KnockoutPneumoniaReadmissionsSeries

Webinar ASPIREtoKnockoutPneumoniaReadmissions Resources

March1 Knowyourdata,understandrootcauses • ASPIREGuide,Section1• ASPIRETools1and2

April5 Alignwithrelatedeffortsandresources,identifygaps • ASPIREGuide,Section2• ASPIRETools3,4

May3 Designaportfolioofstrategiesandoperationaldashboard • ASPIREGuide,Section3• ASPIRETools5,6,7

June7 Activelycollaborateacrossthecontinuum • ASPIREGuide,Section4,5• ASPIRETools9,11,12

August2 Delivereffectivepost-dischargetransitionalcare • ASPIREGuide,Section6• ASPIRETool13

September6 Self-assessmentandpreparationforin-personsession • Self-assessmenttool• Supportrequestform

October16 KnockoutPneumoniaReadmissionsin-personsession • 30dayactionplan• 90dayactionplan

November1 KnockoutPneumoniaReadmissions:SuccessStoriesPart1 • Wewelcomevolunteers

December6 KnockoutPneumoniaReadmissions:SuccessStoriesPart2 • Wewelcomevolunteers

ObjectivesforthisSession

• Knowwhattransitionalcarepractices,processes,tools,servicesalreadyexistinyourhospital

• Knowwhattransitionalcareservicesandsupportsareinplaceinthepost-acuteandambulatorysettings

• Know whatservicesandsupportsareavailableinthecommunity,includingbehavioralhealth,social,andsupportiveservices

Reflectiononyourpastmonthofreadmissionwork

Whatdidyoulearninthepastmonthaboutyourpneumoniareadmissionpatterns?

• What is your hospital’s PNA readmission rate? • How many PNA discharges do you have per day? • How many PNA patients are d/c to home per day? To SNF? • What is your PNA d/c to SNF readmission rate? • What % of your PNA readmissions return < 7 days of discharge?

Whatdidyoulearninthepastmonthaboutwhy yourpneumoniapatientsreturntothehospital?

https://www.youtube.com/watch?v=5uS6hBh1Qtg

WhatdidMrs.MacDonaldneed?

• Reminder• Clarification• Repetition• Support• Confidence• Point of Contact• Home Visit

Isthiswhatyouareprovidingtoyourpatients?

Whatdidyoulearninthepastmonthaboutwhy yourpneumoniapatientsreturntothehospital?

Segmentyourpneumoniapopulation,byrootcause:RootCause Response

Endoflifetrajectory Familymeeting,GoalsofcareReferraltohospice

Recurrentaspiration GoalsofcareEDcareplanAlternatives(admittoSNF)

Abx-Assoc.Diarrhea Anticipatorypathway(whattodoif..)Treatandreturn(SNF,homecare)Alternatives(admittoSNF)

HighINR2/2abx Titration,closefollowupdurationoftherapy

Forgot,confused,worried Post-dischargecallstoclarify,reinforce“Callmefirst”instructions

Lackself-efficacy In-personnavigation,in-homefollowup

Nowthatweknowpatternsandrootcauses,whatarewegoingtodoaboutit?

Especiallyifyoudon’thaveamagicwand….

“Werunthecarecoordinatorpilot;IthinknursingisworkingwithITongettingahigh-riskflagintherecord.Idon’tknow

howthatiscoming.…”

InventoryHospital-BasedEfforts&Resources

• Readmissionreductionactivitieshaveproliferatedovertime

• Someeffortsmayhavedevelopedinisolationfromoneanother– Notallwouldnecessarilyincludepneumoniaintheirtargetpopulation

• Resourcesorassetsmayexistthatcouldbeleveraged– Readmissionflags,highriskflagsinEMR(dotheyincludePNA?)– Post-dischargefollowupcalls(dotheyincludePNA?)– Centralizedappointmentscheduling(dotheyincludePNA?)– Pharmacistsorpharmacytechnicians(reviewforPNApatients?)– ACO,bundledpaymentteams(dotheytargetPNA?)

HospitalInventoryTool

Usethistoolto:

•Identifyreadmissionreductioneffortsacrossdepartments

•Identifywhethereffortsarecoordinated

•Identifywhetherthereisduplication

•Identifygaps– inadministrativesupport

•Identifygaps– inclinicianengagement

•Getspecific– whichpatientgroups(dx,services,program)getwhat?canweaddantorallPNApatientstothatservice?

“Youdon’tunderstand,therearejustnoresourcesinthecommunity”

InventoryCommunityEfforts&Resources

• Post-acuteandcommunityprovidersmayofferservicesandsupportshospitalstaffareunawareof

– PMCHpost-dischargecalls,transitionalcaremanagement– Front-loadedhomevisits– SNFtohometransitionalcarephonecalls,arrangingappointments,inhomeservices

• Healthplansmayofferhighriskpatientscaremanagement– NJWellcare:“advocacyteam”– SCallMCOs:transitionalcareteamstodopre-dischargeinpersonvisit

• Resourcesorassetsmayexistthatcouldbeleveraged– Communitybasedcaremanagement– Behavioralhealthclinicswithpeers,advocates,groups,transportation– Volunteer,faith-based,elderserviceandsocialserviceagencies

CommunityInventoryTool

Use this tool to identify:

• Peersupports?

• Navigators?

• Medical-legaladvocates?

• Seniorservices?

• Faithbasedorcommunityvolunteers?

• Formalpartnerships?

• Informalarrangements?

• Optimizingavailableresources?

• Islinkageaseasyasitneedstobe?

• Gapsinservicesandsupports?

MedicaidManagedCareOrganizations(MCOs)

MCOscanassistwith:– IdentifyPCP– HomeNursing– Medicationadherence– Dischargeplanningfromalllevelsofcare– DiseaseManagement– ComplexCaseManagement– Coordinationofservices

• Examples:– Transitionalcarestaff– Complexcaremanagers– Behavioralhealthcaremanagers– Mobilizeresourcestomeetbasichealth-relatedneeds

AdultDayHealthCare

• AdultDayServicesprovidesanorganizedprograminacommunitygroupsettingtopromotesocial,physicalandemotionalwellbeing.Theseprogramsofferavarietyofactivitiesdesignedtomeettheneedsandinterestsofeacholderadultwhoreceivescare.

• InterdisciplinaryTeamconsistingofa:CenterDirector,RegisteredNurse,LicensedSocialWorker,Dietician,CNA,GNA,CMA,andTherapeuticRecreationalDirector.

• Services:IndividualizedCarePlans,DailyNurseAssessments,PT,OT,medicationadministration,woundcare.

• Ifyouhavequestionsaboutadultdayservicescontact:ThelocalDepartmentofSocialServicesTheAreaAgencyonAging

https://www.ncdhhs.gov/assistance/adult-services/adult-day-services

BonSecoursBaltimoreHealthSystem

InternalInventory• PeerrecoverycoachesintheED• OutcomesManagement• SocialWork• BehavioralHealthProgram• Clinicsprovidepost-discharge

followup<7-10daysforanyone• IT:ACOpatientsflagged• IT:UseCRISPfornotifications

What’sneedednext:• Carecoordinationmodelforhighriskpatients• Createcareplansforhighutilizers• Integratemedicalandbehavioralhealthcareclinicalinformation• Continuetoinnovatetomeetneedofpatients

CommunityInventory• HealthEnterpriseZone• TheCoordinatingCenter• HomelessOutreachProgram• TransitionalHousingProviders• HomeHealthAgencies• SkilledNursingFacilities• BaltimoreAreaAgencyonAging• CollaborationwUMMidtown

Source:presentationtoHSCRCCareCoordinationworkgroup,Dec2014

ReflectonFindingstoDate

• Whichinternalhospital-basedprocessesorresourcescouldbemobilizedtobetterserveourpneumoniapatients(pallcare,pharmacist,SW,ToC)?

• Whatprocessesorservicesexistwithpostacutepartners,andaretheybeingappliedtoourpneumoniapatients(warmhandoffs,circleback,virtualco-management,SNFMD/PAs,EDtreatandreturnpathways)?

• Whatservicesexistinambulatorycareandaretheybeingdeliveredtoourpneumoniapatients(realtimenotificationofPCP,timelypostdischargecontact,transitionalcaremanagement,PCMHcaremanagement)?

• Whatservicesexistinthecommunitythatcanbetteraddressourpneumoniapatients’needsforsupportiveservices,check-ins,contact,reassurance?

Recommendations

1. Develop arunninglistoftherootcausesofPNAreadmissions

2. Developaworkinglistofstrategiestoaddressthoserootcauses

3. Knowifyouhavehospital-basedservicesthatcanaddressthoserootcauses

4. AskyourSNFs,HomeHealth,andPCPpracticesiftheyhaveenhancedsupportsandservices– knowwhattheydo,forwhom,andwhetherthisappliestopneumoniapatientsaswell

5. Learnmoreaboutthecommunityservicesandsupportsthatexistthatcouldbemobilizedforyourpneumoniapatients

Thankyouforyourcommitmenttoreducingreadmissions

AmyE.Boutwell,MD,MPPPresident,CollaborativeHealthcareStrategiesAdvisor,NCHAPneumoniaKnockoutCampaignAmy@CollaborativeHealthcareStrategies.com

617-710-5785

ContactUs

KarenSouthard,RN,MHAVicePresident,QualityandClinicalPerformance

ksouthard@ncha.org

TrishVandersea,MPAProgramDirector

tvandersea@ncha.org