Filling the Gaps and Patching the Cracks Connected Care for Home - - PowerPoint PPT Presentation

Barbara Katz, RN, MSN

President, BK Healthcare Consulting, LLC www.bkhealthconsulting.com

Filling the Gaps and Patching the Cracks – Connected

Filling the Gaps and Patching the Cracks

Connected Care for Home Health Care Agencies

Learning Outcomes

• Explain the issue of care fragmentation
• Describe connected care
• List connected care implementation

steps

• Apply connected care to a case study
• Identify obstacles to connected care

and ways to overcome them

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The Problem of Health Care Fragmentation

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2,573 hospitals will face readmission penalties this

• year. Is yours one of them?

Advisory.com, 2018

According to NEJM Catalyst’s latest Insight Council survey,

• rganizations labeling health

professional burnout a moderate or serious problem remains substantial at 83%. NEJM Catalyst (2017)

….health care in America sometimes hurts even as it

• helps. Appointments can be

difficult to get. Clinics and emergency rooms are often

• vercrowded. Doctors’

recommendations can be confusing and difficult to

• follow. And when the bills

arrive, the costs can be unexpected and devastating. Commonwealth Fund, 2018

• Mrs. Harriman’s Patient Journey
• 16 health care organizations
• 55 in-person interactions
• 14 medications
• 5 medical records
• 3 major care transitions
• 2 hours of daily medical tasks
• Countless phone calls and emails
• Hundreds of EOBs and bills
• Overwhelmed patient and caregiver

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The Roots and Fruits of Health Care Fragmentation

Connecting Care for Patients, JB Bartlett, 2018

Connected Care

A systems approach to connecting the dots of care to achieve the quadruple aim

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Communication Collaboration Teamwork Care Transitions Care Coordination

Patient Centeredness

Patient Centeredness - What Patients Want

Patient Requirements

Personalized communication, in person and digital Convenient access to care at a reasonable cost Care coordination Preferences honored, decisions shared Health professional teamwork Compassion and emotional support

Connecting Care for Patients FIGURE 7-1 What Patients Want—Some Key Themes from the Literature

Social Media support/ information Telemedicine Retail health Apps and wearables

The Patient Centered Organization

• Patient goals drive care
• Patient focus drives decisions
• Metrics matter
• Language counts
• Patients have a voice
• Processes are patient friendly
• Staff are supported in caring

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The Building Blocks of Connected Care

Structure

• Patient centered culture
• Integrated organizational

structure

• Engaged and able clinicians
• Lean work processes
• Optimized technology

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Metrics

• Readmission rates
• HH Compare scores
• Adverse events
• HHCAHPS results
• Employee satisfaction/retention
• Cost per episode

Is Connected Care Worth It?

Potential Benefits

• Drives value based payment success
• Eliminates quality problem root causes
• Engage and retains employees
• Lowers costs of care
• Improves the patient experience

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What it Takes: Time + Effort + Focus + Resources + Brainpower + Innovation

The Senior Management Role

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Senior Management

Shared goals Clinical culture change Process improvement Teamwork support structures Resources and tools Data and analysis

Connecting Care for Patients, JB Bartlett, 2018

The Middle Manager Role

• Process engineer
• Performance manager
• Clinical coach
• Problem solver
• Business manager
• Facilitator
• Innovator

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Change Manager

• Translator
• Tightrope walker
• Therapist

Firefighter

The Clinician Role

• Assessment
• Direct care tasks
• Patient teaching
• Emotional support
• Patient coaching
• Caregiver help

Case Management

• Care planning
• Care coordination
• Transition management
• Interdisciplinary

teamwork

• Use technology to

support care

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Patient Care

Applying Connected Care

The Heart Failure Readmission Project

• Major medical center in an urban area
• HF readmission reduction goal
• Task force led by MD Quality Director
• One home health agency
• Three hospital units
• Three preferred provider SNFs
• A HF disease management clinic
• Potential shared savings

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Case Study Analysis

• 1. Carefully listen to the story.
• 2. Write down examples of

how connected care was applied.

• 3. Write down examples of

unfilled gaps and cracks in the project.

• 4. Be prepared to share some
• f your insights.

Connected Care Strategies Applied Unfilled Gaps and Cracks

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Connected Care Strategies Applied Unfilled gaps and cracks

Collaboration

• The right partners engaged
• Common goals accepted
• Trust and respect practiced
• Shared language used
• Collaborative decisions made
• Critical issues identified
• Effective action taken

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Teamwork Shared Goals and Leadership

Thoughtful decision making

Respect for individuals and disciplines Conflict resolution

Defined roles

Group identity

Effective actions

Mutual support

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Collaboration/Teamwork Structures

INSIDE

• Interdisciplinary conferencing
• High risk patient “huddles”
• Complex case conferences
• Team meetings for idea sharing
• Shared scheduling
• Case sharing
• Process Improvement teams

OUTSIDE

• Discharge conferences at SNFs
• Liaison visits to hospitals, SNFs, ALFs
• Improvement collaboratives
• High risk patient conferences
• Cross organizational improvement

teams

• Health neighborhoods

BK Health Care Consulting

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October, 2018, Linked-In Post

Teamwork is a topic of interest to health professionals

Communication - Key Principles

Drive out fear The next step is the customer Close the loop Remember the ripple effect

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Communication Essentials

Communication Goals Achieved Right audience Right message Right method Right timing Feedback

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Who needs to know? What information is needed? What is the goal of the communication? Who is accountable? What method will work best? (Written, electronic, in-person, visual, video) When is the information needed? What is the receiver’s understanding and reaction?

Care Transitions - Fractured or Flowing?

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Connecting Care for Patients, JB Bartlett, 2018

Care Transitions Best Practices

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Effective Care Transitions Clear accountability across handoffs Plan for medical follow up Communication with the patient and family Complete medication reconciliation Compete all follow up tasks Send and verify pt info received at next step.

Patient personal medical records Knowledge of red flags Family caregiver involved and informed Formal process for each key transition

Connecting Care for Patients, JB Bartlett, 2018

Care Coordination in Home Health Care

BK Health Care Consulting

Frontline Connected Care Tools Sampler

Interpersonal Communication Written/electronic Communication Team tools Coordinating tools and techniques Active listening Emails, texts, phone calls Visible measurement Liaison visits Scripting Templates and forms Interdisciplinary conferencing Case management plans SBAR reporting Shared electronic medical records High risk patient huddles Joint care plans Motivational interviewing (MI) “Cheat sheets” for patients/staff Complex case conferences Calendars, tracking databases

• r spreadsheets

Use HHCAHPS language in teaching Patient portals Shared schedules Procedures Flowcharts

BK Health Care Consulting

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Connecting Care for Patients, JB Bartlett, 2018

Optimizing Technology – Best Practices

• Integrate platforms and data
• Electronic communication standards
• Train for optimal technology use
• Involve staff in design and modifications
• Share clinician “tips and tricks”
• Robust help desk and knowledge base
• Technology improvement part of QAPI

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Closing High Risk Gaps and Cracks

• Social determinants of health
• Health disparities
• Mental health
• Family caregivers
• Frailty and dementia
• End of life

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What Makes This So Hard?

• The Overwhelm (local markets, regulations, profitability, staffing)
• Mindset
• Single patient/clinician vs. population focus
• It’s all about us
• Focus on my department/profession
• Tradition
• Skill/resource gaps
• Too many people “coordinating care”
• Payment barriers

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Connected Care Step by Step

• Apply techniques to strategic

projects

• Identify and patch gaps with QAPI
• Build management and staff skills
• Constantly collaborate
• Become a learning organization
• Expect and encourage innovation

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How Is Your Organization Doing?

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What Things Could You Do to Better Connect the Dots of Care?

Connecting Care for Patients, JB Bartlett, 2018

Thank You Now, let’s get started on filling the gaps and patching the cracks for patients!

Barbara Katz, President, BK Health Care Consulting, LLC (203-464-5310), Barbara@bkhealthconsulting.com

BK Health Care Consulting