Coordination of Care Initiative Cuyuna/Riverwood Community - - PowerPoint PPT Presentation

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Coordination of Care Initiative Cuyuna/Riverwood Community - - PowerPoint PPT Presentation

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Coordination of Care Initiative Cuyuna/Riverwood Community Community Meeting March 28, 2019 Download meeting agenda and slide handout: Agenda Presentation 2 Welcome & Introductions 3 Meeting Agenda and Objectives

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Coordination of Care Initiative Cuyuna/Riverwood Community

Community Meeting March 28, 2019

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Download meeting agenda and slide handout:

  • Agenda
  • Presentation
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Welcome & Introductions

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Meeting Agenda and Objectives

  • Discuss care coordination efforts across Minnesota

and share community scorecard report

  • Learn how the East Metro CoC community Mental

Health workgroup created a comprehensive three- episode behavioral health video training series for care providers and family caregivers

  • Participate in discussion on how the videos and

training can be used across health care settings

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Coordination of Care Initiative Update

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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

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Coordination of Care Communities

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Success Stories Webinar Series

Successful Strategies for Sustained Community Improvement Tuesday, January 22, 2019, 12–1:00pm – More At Your Service: Benefits of Home Health Agencies Working with their QIN Tuesday, February 26, 2019, 12–1:00pm – More Using Data to Drive Community Quality Improvement Efforts Tuesday, March 26, 2018, 12–1:00pm – More Home-based Innovative Strategies to Prevent Readmissions Tuesday, April 23, 2019, 12–1:00pm – More Changing the Culture: Improving Recognition and Management of Sepsis Thursday, May 30, 2019, 12–1:00pm – Register Achieving Community Goals by Partnering with Aging and Disability Resource Centers Tuesday, June 25, 2019, 12–1:00pm – Register

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.

Download the webinar series flier.

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Other Upcoming Event

LSQIN Webinar - Trauma and Its Impact on Behavioral Health Concerns in Primary Care - Thursday, April 11, 2019, 12 – 1:00 p.m. – Register

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Featured Tool - Mora Community

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Home Health Gap Collaborative Tools

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Community Scorecard

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The Community

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Admissions (community)

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Admissions (comparative)

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Admissions (vs. goal)

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Number of Fewer Admissions Needed to Meet Goal

  • This community had 786 admissions in the most

recent 12 months (Q4 2017 – Q3 2018).

  • Needed to be at 873 admissions for final

measurement (Q4 2017 – Q3 2018), which was surpassed by 87 admissions!

  • Congratulations! This community has achieved

the CMS goal!

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Readmissions (community)

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Readmissions (comparative)

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Readmissions (vs. goal)

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Number of Readmissions Needed to Meet Goal

  • This community had 112 readmissions in the most

recent 12 months (Q4 2017 – Q3 2018).

  • Needed to be at 125 readmissions for final

measurement (Q4 2017 – Q3 2018), which was surpassed by 87 readmissions!

  • Congratulations! This community has achieved

the CMS goal!

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Next Community Meeting

Date and time of the next community meeting is to be

  • determined. Stay tuned for an announcement from

Stratis Health.

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Featured Presentation —

Mental Health Video Training Series and Tools

Dean Neumann, APR Community Relations Director HealthEast Care System

  • St. Joseph’s Hospital Mental Health and Substance Use Services
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Post-Acute Care Mental Health Training Series

Stratis Health / Cuyuna-Riverwood Coordination of Care Quarterly Meeting March 28, 2019

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Presenter and Objectives

Dean Neumann, Community Relations Director

  • St. Joseph’s Hospital Mental Health and Substance

Use Services Objectives:

  • Understand why the series was developed
  • Understand how best to use the videos and written

teaching aids

  • Understand the timing and sequence of the

information

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Background

September 2017

  • Providers voice concern about caring

for persons with intense mental illness symptoms Workgroup Formed

  • Identify training needs,

experts, content and format Video Series

  • Stratis Health

Grant

Lake Superior East Metro Coordination of Care Committee presentation

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Target Audiences

For care providers and caregivers – especially those without formal clinical training programs

  • Assisted living direct care staff
  • Family caregivers
  • Home care nursing staff
  • Home care chore staff
  • Nursing facility nursing assistants
  • Residential care staff
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Training Goals

3/25/2019 CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

  • Boost understanding of older adult

mental health

  • Equip providers and caregivers with

techniques to prevent and de-escalate behavioral crises that may lead to unnecessary hospitalization

  • Improve behavioral / mental health
  • utcomes for older adults
  • Encourage more education and training
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Advisory Group

3/25/2019 CARE PROVIDERS OF MINNESOTA | Leading Members to Excellence | #CPMEducates

  • Michelle Wincell O’Leary – Touchstone Mental Health
  • Patti Cullen – Care Providers of Minnesota
  • Peter Thelen – Andrew Residence
  • Dean Neumann – St. Joseph’s Hospital
  • Kay King – NAMI Minnesota
  • Aira Wandamacher – CareChoice Cooperative
  • Janelle Shearer – Stratis Health
  • Nancy Miller – Stratis Health
  • Jane Gendron – Stratis Health
  • Teresa Lewis – MN DHS
  • Julie Apold – Leading Age Minnesota
  • Barb Jeroski - HealthStar Home Health
  • Leslie Brown – Tealwood Senior Living
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Older Adult Mental Health Basics

Video #1 in a series

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Prevention & De-escalation

Video #2 in a series

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Person-centered care and collaboration

Video #3 in a series

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Facilitator Guide

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Two Methods

  • Fill-in during viewing –

“open book test”

  • Provide quiz after

viewing Answer Checking

  • Self-score after taking

the quiz

  • Facilitator scores

Time codes listed in answer sheet for each quiz question

Video Quiz

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Fact Sheet

  • Hand out separately
  • r
  • Post on bulletin

boards / provider common areas

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Action Checklist

  • Pocket-size reminder card
  • Carry and apply during daily work
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Sample Plans and Templates

  • Geriatric Depression

Screening Tool

  • Sample Crisis

Prevention Plan

  • Person-centered Care

Plan Template

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Overview of Three Videos

Older Adult Mental Health Basics Explain common mental illness disorder categories – share the compelling statistics - address the fear and inadequacy many providers and caregivers feel – confront stigma and derogatory labels – express hope and treatment can be effective – convey how you as a care provider or family caregiver - can support – provide resources for more help. Crisis Prevention & De-escalation Describe common behaviors and triggers likely to cause behavioral events – Suggest prevention tips to reduce behaviors - Demonstrate “right way / wrong way” de- escalation scenarios - how to apply new learning after an event – offer additional resources. Person-centered care & collaboration Importance of individual behavioral care plan - creative solutions to diminish / redirect behaviors - when to consult with outside professionals for behavioral assessments / evaluations – offer additional resources

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Video Training Series Locations

https://www.lsqin.org/initiatives/ behavioralhealth/ http://www.stratishealth.org

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Video Highlights

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What Worked?

  • Sponsoring organization
  • Phenomenal workgroup
  • Longer planning period yielded better

content

  • Excellent video production company
  • On-camera talent and location shooting
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Unforeseen Challenges

  • Longer planning period than anticipated
  • Search for funding
  • Prioritizing topics, content and experts
  • Balancing clinical focus with audience health

literacy

  • Cost constraints
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Advice For Similar Projects

  • Find a good project manager
  • Timeline takes longer when you’re doing something new
  • Be “over-inclusive” to insure key stakeholder buy-in
  • Volunteers have limited time – trade-off between time and budget
  • Everyone brings strengths to the table
  • Some will be disappointed
  • Be willing to be a long-term champion
  • Some may do more work than others
  • Don’t’ get paralyzed - Just “Do It”
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Contact

Dean Neumann – St. Joseph’s Hospital Director of Community Relations Email: deneumann@healtheast.org Phone: 651-232-3921

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Community Discussion

How can the videos and training be used in various health care settings?

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Contact Information

Nancy R. Miller, Stratis Health nmiller@stratishealth.org 952-853-8528 or 877-787-2847

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This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C3-19-32 032519