Filling the Gaps and Patching the Cracks – Connected Filling the Gaps and Patching the Cracks Connected Care for Home Health Care Agencies Barbara Katz, RN, MSN President, BK Healthcare Consulting, LLC www.bkhealthconsulting.com
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 bkhealthconsulting.com 2
The Problem of Health Care Fragmentation 2,573 hospitals will face readmission penalties this year. Is yours one of them? Advisory.com, 2018 ….health care in America sometimes hurts even as it helps. Appointments can be difficult to get. Clinics and emergency rooms are often According to NEJM Catalyst’s overcrowded. Doctors’ latest Insight Council survey , recommendations can be organizations labeling health professional burnout a moderate or confusing and difficult to serious problem remains substantial follow. And when the bills at 83%. arrive, the costs can be NEJM Catalyst (2017) unexpected and devastating. Commonwealth Fund, 2018 bkhealthconsulting.com 3
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 bkhealthconsulting.com 4
The Roots and Fruits of Health Care Fragmentation Connecting Care for Patients , JB Bartlett, 2018 bkhealthconsulting.com 5
Connected Care A systems approach to connecting the dots of care to achieve the quadruple aim Care Communication Collaboration Care Transitions Teamwork Coordination Patient Centeredness bkhealthconsulting.com
Patient Centeredness - What Patients Want Personalized communication, in person and Social Media digital support/ Retail health Convenient Compassion and information access to care at emotional a reasonable support cost Patient Requirements Health Care professional coordination teamwork Apps and Telemedicine wearables Preferences honored, decisions shared Connecting Care for Patients FIGURE 7-1 What Patients Want — Some Key Themes from the Literature
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 bkhealthconsulting.com 8
The Building Blocks of Connected Care Structure • Patient centered culture • Integrated organizational Metrics structure • Readmission rates • Engaged and able clinicians • HH Compare scores • Lean work processes • Adverse events • Optimized technology • HHCAHPS results • Employee satisfaction/retention • Cost per episode bkhealthconsulting.com 9
Is Connected Care Worth It? What it Takes : Time + Effort + Focus + Resources + Brainpower + Innovation Potential Benefits • Drives value based payment success • Eliminates quality problem root causes • Engage and retains employees • Lowers costs of care • Improves the patient experience bkhealthconsulting.com 10
The Senior Management Role Shared goals Clinical Data and culture analysis change Senior Management Resources Process and tools improvement Teamwork support structures Connecting Care for Patients , JB Bartlett, 2018 bkhealthconsulting.com 11
The Middle Manager Role • Process engineer Change Manager • Performance manager • Translator • Clinical coach • Tightrope walker • Problem solver • Therapist • Business manager • Facilitator • Innovator Firefighter 12 bkhealthconsulting.com
The Clinician Role Patient Care Case Management • Assessment • Care planning • Direct care tasks • Care coordination • Patient teaching • Transition management • Emotional support • Interdisciplinary teamwork • Patient coaching • Use technology to • Caregiver help support care bkhealthconsulting.com 13
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 bkhealthconsulting.com 14
Case Study Analysis 1. Carefully listen to the story. Connected Care Strategies Unfilled gaps and cracks Connected Care Strategies Applied Unfilled Gaps and Cracks Applied 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 of your insights. bkhealthconsulting.com 15
Collaboration • The right partners engaged • Common goals accepted • Trust and respect practiced • Shared language used • Collaborative decisions made • Critical issues identified • Effective action taken bkhealthconsulting.com 16
Teamwork Shared Goals and Leadership Thoughtful decision Defined Effective making roles actions Respect for Conflict individuals and Group identity Mutual support resolution disciplines BK Health Care Consulting
Collaboration/Teamwork Structures INSIDE • Interdisciplinary conferencing OUTSIDE • High risk patient “huddles” • Discharge conferences at SNFs • Complex case conferences • Liaison visits to hospitals, SNFs, ALFs • Team meetings for idea sharing • Improvement collaboratives • Shared scheduling • High risk patient conferences • Case sharing • Cross organizational improvement • Process Improvement teams teams • Health neighborhoods BK Health Care Consulting
October, Teamwork is a 2018, topic of Linked-In interest to Post health professionals bkhealthconsulting.com 19
Communication - Key Principles Drive out fear The next step is the customer Remember the ripple effect Close the loop BK Health Care Consulting
Communication Essentials Who needs to know? What is the goal of the communication? Who is accountable? Right audience What information is Right needed? What is the receiver’s Feedback message understanding and reaction? Communication Goals Achieved What method will work best? When is the information Right Right (Written, electronic, in-person, timing method needed? visual, video) bkhealthconsulting.com 21
Care Transitions - Fractured or Flowing? Connecting Care for Patients , JB Bartlett, 2018 bkhealthconsulting.com 22
Care Transitions Best Practices Clear accountability across handoffs Formal process Patient personal Send and verify Plan for for each key pt info received medical follow medical records transition at next step. up Effective Care Transitions Communication with the Compete all patient and follow up tasks family Family caregiver Knowledge of red involved and flags Complete informed medication reconciliation Connecting Care for Patients , JB Bartlett, 2018 bkhealthconsulting.com 23
Care Coordination in Home Health Care BK Health Care Consulting
Frontline Connected Care Tools Sampler Interpersonal Written/electronic Team tools Coordinating tools and Communication Communication techniques Active listening Emails, texts, phone calls Visible measurement Liaison visits Scripting Templates and forms Interdisciplinary Case management plans conferencing SBAR reporting Shared electronic medical High risk patient huddles Joint care plans records Motivational “Cheat sheets” for Complex case conferences Calendars, tracking databases interviewing (MI) patients/staff or spreadsheets Use HHCAHPS Patient portals Shared schedules Procedures language in teaching Flowcharts BK Health Care Consulting
Connecting Care for Patients , JB Bartlett, 2018 bkhealthconsulting.com 26
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 bkhealthconsulting.com 27
Closing High Risk Gaps and Cracks • Social determinants of health • Health disparities • Mental health • Family caregivers • Frailty and dementia • End of life bkhealthconsulting.com 28
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 BK Health Care Consulting
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 bkhealthconsulting.com 30
How Is Your Organization Doing? What Things Could You Do to Better Connect the Dots of Care? Connecting Care for Patients , JB Bartlett, 2018 bkhealthconsulting.com 31
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