[PPT] - HOME I S T HE HUB An I nitia tive to Ac c e le ra te Pro g PowerPoint Presentation

SLIDE 1

HOME I S T HE HUB

An I nitia tive to Ac c e le ra te Pro g re ss to Re duc e Re a dmissio ns in Virg inia We b ina r # 3 – I mpro ving Ca re fo r Hig h Utilize rs Oc to b e r 20, 2016

SLIDE 2

HOUSE K E E PI NG

Slide s we re se nt this mo rning
We b ina r is b e ing re c o rde d
Ple a se use the “te le pho ne ” o ptio n
Audio pin pro mpt
All pa rtic ipa nts a re mute d
Ra ise yo ur ha nd
Ask a q ue stio n
Wa rm up

SLIDE 3

WE L COME AND OVE RVI E W

Abraham Segres VHHA

Vic e Pre side nt, Qua lity & Pa tie nt Sa fe ty

a se g re s@ vhha .c o m (804) 965-1214

SLIDE 4

VI RGI NI A HOSPI T AL & HE AL T HCARE ASSOCI AT I ON

An a sso c ia tio n o f 30 me mb e r he a lth syste ms re pre se nting 107 c o mmunity, psyc hia tric , re ha b ilita tio n a nd spe c ia lty ho spita ls thro ug ho ut Virg inia .

Visio n

T hro ug h the po we r o f c o lla b o ra tio n, the a sso c ia tio n will b e the re c o g nize d driving fo rc e b e hind ma king Virg inia the he a lthie st sta te in the na tio n b y 2020.

Missio n

Wo rking with o ur me mb e rs a nd o the r sta ke ho lde rs, the a sso c ia tio n will tra nsfo rm Virg inia ’ s he a lth c a re syste m to a c hie ve to p-tie r pe rfo rma nc e in sa fe ty, q ua lity, va lue , se rvic e a nd po pula tio n he a lth. T he a sso c ia tio n’ s le a de rship is fo c use d o n: princ iple d, inno va tive a nd e ffe c tive a dvo c a c y; pro mo ting initia tive s tha t impro ve he a lth c a re sa fe ty, q ua lity, va lue a nd se rvic e ; a nd a lig ning fo rc e s a mo ng he a lth c a re a nd b usine ss e ntitie s to a dva nc e he a lth a nd e c o no mic o ppo rtunity fo r a ll Virg inia ns.

SLIDE 5

VHHA 2015-2020 I MPROVE ME NT PRI ORI T I E S

1. Ho spita l re a dmissio ns

1a . Hospital- wide … (ne w foc us on high utilize r

s)

1b . Po st-a c ute tra nsfe rs 1c . T

ta l hip/ T
ta l kne e Re pla c e me nt 30-da y re a dmissio ns
2. Clo stridium diffic ile – He althc are -ac q uire d I

nfe c tio ns

3. Pa tie nt E

xpe rie nc e – HCAHPS

4. Se rio us Sa fe ty E

ve nts

SLIDE 6

State wide L e ar ning & Ac tion

Sta te wide c o lla b o ra tive June 2016 to No ve mb e r 2018
F
c us o n PAC, HU, T

HR/ T K R in pa ra lle l

E

ng a g e with pa rtne rs in PAC

E

ng a g e with VHQC fo r c r

ss- c ontinuum wo rk
E

ng a g e with AAAs fo r c ommunity base d c a re / CT I

Pro vide , use , inte rpre t data fro m VHHA & VHQC

SLIDE 7

Planne d Ac tivitie s for L e ar ning & Ac tion

June 16th* Hig h L e ve ra g e Stra te g ie s Aug ust 17th* Da ta / Me a sure me nt Se pte mb e r 8th* Re duc ing PAC Re a dmissio ns Oc to b e r 20th* I mpro ving Ca re fo r Hig h Utilize rs

Nove mbe r 15th In- Pe r son L e ar ning E ve nt 9- 3:30

De c e mb e r 15th Suc c e sse s in 2016 a nd Pla ns fo r 2017

*All we b inars will b e o ffe re d at 10am

SLIDE 8

I MPROVI NG CARE F OR HI GH UT I L I ZE RS

Amy Boutwell, MD, MPP Collaborative Healthcare Strategies

Pre side nt

a my@ c o lla b o ra tive he a lthc a re stra te g ie s.c o m

(617) 710-5785

SLIDE 9

AGE NDA

Hig h Utilize rs: ke y sta tistic s
I

de ntifying ro o t c a use s: the “drive rs o f utiliza tio n”

L

e sso ns le a rne d fro m e ffo rts to impro ve c a re fo r pa tie nts with hig h utiliza tio n

Spe c ific a c tio n ste ps

SLIDE 10

OBJE CT I VE S

1. Unde rsta nd ho w to de fine a nd ide ntify “hig h utilize rs;” 2. Unde rsta nd the impo rta nc e o f ide ntifying the “drive r o f utiliza tio n;” 3. I de ntify 3 pra c tic a l ne xt ste ps yo u c a n ta ke to re duc e re a dmissio ns fo r hig h utilize rs

SLIDE 11

HI GH UT I L I ZE RS: K E Y ST AT S

SLIDE 12

DE F I NI T I ONS

I t is impo rta nt to b e spe c ific :

Hig h utilize r = ma ny a dmissio ns
Hig h c o st = to ta l c o st o f c a re
Co mple x = c o mple xity ma y o r ma y

no t b e HU o r hig h c o st

Hig h Utilize r Hig h Co st Co mple x

SLIDE 13

PROPOSE D T E RMI NOL OGY

Altho ug h “hig h utilize r” is de sc riptive sho rt-ha nd, it is so me wha t inde lic a te
Pro po se to use : “multi-visit patie nts,” o r

“MVPs”

I

t spe c ific a lly fo c use s impro ve me nt te a ms o n the c o re issue we a re fo c use d o n a ddre ssing – multiple ho spita liza tio ns, tha t ma y b e a sympto m

f unide ntifie d o r unme t ne e ds

SLIDE 14

K E Y ST AT S 4+ 7% – 25% – 60% 38%

CHIA Ho spita l-wid e All Pa ye r Re a d missio ns in Ma ssa c huse tts June 2016 AHRQ HCUP Sta tistic a l Brie f # 184 No ve mb e r 2014 AHRQ HCUP Sta tistic a l Brie f # 190 Ma y 2015

SLIDE 15

4+ ho spita liza tio ns/ ye a r
7% o f ho spita lize d pe rso ns
Use d 25% o f a ll ho spita liza tio ns
Ac c o unte d fo r ~60% o f a ll

re a dmissio ns

Re a dmissio n ra te 38% v. 8%

So urc e : Ma ssa c huse tts Ce nte r fo r He a lth Info rma tio n a nd Ana lysis http :/ / www.c hia ma ss.g o v/ a sse ts/ d o c s/ r/ pub s/ 15/ CHIA-Re a d missio ns-Re po rt-June -2015.pd f

K E Y ST AT S

SLIDE 16

T OP DI AGNOSE S

Ac ute me dic a l: se psis, UT

I , pne umo nia , c e llulitis

Chronic me dic a l: CHF

,COPD, dia b e te s, sic kle c e ll

Be ha viora l he a lth: mo o d diso rde rs, sc hizo phre nia , E

T OH

Co mb inatio n o f me dic al, b e havio ral he alth and so c ial ne e ds

SLIDE 17

4+ ho spita liza tio ns/ ye a r
~49,000 disc ha rg e s
~22,000 re a dmissio ns
~45% re a dmissio n ra te
Se psis, COPD, HF

, ARF , PNA, UT I , AMI

ME DI CARE MVPs I N VI RGI NI A

SLIDE 18

I MPROVI NG CARE F OR MUL T I

VI

SI T PAT I E NT S

Strate g ie s fro m ho spital-b ase d te ams

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I DE NT I F Y T HE “DRI VE R OF UT I L I ZAT I ON”

Ask “why”
I

de ntify the drive r(s) o f utiliza tio n

L

iste n fo r all the fa c to rs tha t le a d to a c ute c a re utiliza tio n

Asse ss fo r c linic a l – b e ha vio ra l – so c ia l ne e ds
Do n’ t o ve r-me dic a lize re c urre nt utiliza tio n

SLIDE 20

61 man with 8 hospitalizations for shor tne ss of br e ath.

“Oh ho ne y, I ’ m in he re e ve ry c o uple o f we e ks and it always take s ab o ut 5 days to tune me up”

32 man with a life time of unc ontr

lle d diabe te s.

“I ne e d ho using , no t a she lte r. I ne e d so me o ne to he lp make sure I take my me dic ine s. I n a she lte r the y do n't do that and the y kic k yo u

ut e ve ry mo rning . I

ne e d a stab le re side nc e and no o ne is ab le to he lp with that."

SLIDE 21

RE ADMI SSI ON RE VI E W T OOL

Purpose:

To understand patient perspective
To understand root causes
To understand there are multiple factors
To identify opportunities for improvement
To develop a better plan for the patient
To develop better services to offer

Recommendation:

Interview all MVPs
Best practice: review all readmissions

Ho spita l Guid e to Re d uc ing Me d ic a id Re a d missio ns

SLIDE 22

ST RAT E GI E S F OR MANAGI NG T HE CARE OF MVPs

1. Re a l-time ide ntific a tio n
2. I

de ntify the “drive rs” o f utiliza tio n

No t the c c o r prima ry dx, no t e ve n the c hro nic dz, b ut ra the r the so c ia l, b e ha vio ra l, c linic a l

fa c to rs tha t drive s re pe a te d use

Ofte n b e st ide ntifie d using a no n-c linic a l le ns
3. Addre ss the drive r(s) o f utiliza tio n
Hig h fre q ue nc y c o nta c t in the c o mmunity
Pro b le m-so lving o c c urs o ve r time until drive r is a ddre sse d
F

re q ue ntly so c ia l wo rke rs a nd na vig a to rs a re e ffe c tive

4. Use “c a re pla ns” to c o nve y utiliza tio n histo ry, drive r(s) o f utiliza tio n, se rvic e s in pla c e , a nd ke y

a dvic e to E D sta ff to g uide c a re a t ne xt pre se nta tio n

SLIDE 23

I DE NT I F Y AND E NGAGE I N RE AL

T

I ME

Pa tie nt is he re , no w
Prio ritize e ng a g e me nt
Unde rsta nd pa tie nt’ s prio ritie s, ne e ds, c o nc e rns
E

sta b lish a trusting , he lpful re la tio nship b a se d o n the pa tie nt’ s ne e ds a nd prio ritie s a nd no t le a ding with a me dic a lize d a g e nda

SLIDE 24

“DO SOME T HI NG DI F F E RE NT ”

Arra ng e fo r
Co o rdina te
F
llo w up
Na vig a te
Advo c a te
Che c k in
Re a ssure

“Ma na g e me nt sta rts with the ho spita l b a se d te a m – no t just a sse ssing a nd re fe rring , b ut initiating a nd fo r so me a mo unt o f time , pr

viding the a c tive follow

up and suppor t with the g o a l o f de finitive ly linking the pa tie nt to the se rvic e s a nd

suppo rts re q uire d to re duc e utiliza tio n.”

SLIDE 25

COL L ABORAT E

I

de ntify a nd e ng a g e pro vide rs, a g e nc ie s, pa ye rs

Co o rdina te
Co lla b o ra te
Alig n
L

e ve ra g e e a c h o the rs’ e ffo rts

Ca se c o nfe re nc e
Cre a te , use c a re pla ns

“T he multidisc iplina ry te a m is ne e de d to do this….we ne e d to re ly o n o the r e xpe rtise ”

SLIDE 26

WORK T O ACHI E VE ST ABI L I T Y

Ma na g e me nt a nd fo llo w up a re ite ra tive
Oc c ur b a c k a nd fo rth a c ro ss se tting s a nd o ve r time

“T he ultimate o utc o me o f this [c o llab o rative , c ro ss-se tting ] pro c e ss is to b ring so me o ne fro m an unstab le c yc le o f hig h utilizatio n to inc re ase d stab ility and lo we r utilizatio n”

SLIDE 27

We ha ve g o ne fro m a ho spita l tha t wa s de a ling with pa tie nts a nd c rise s in the mo me nt to o ne whe re we kno w the pa tie nt…. We a re mo re c ollabor

ative and wor k be tte r toge the r…a ll o f o ur de pa rtme nts a re c lo se r a nd this

ha s e xte nde d to the c ommunity as we ll.

“ “

SLIDE 28

E XAMPL E HOSPI T AL

BASE

D MVP PROGRAM

T

a rg e t po pula tio n: a ll a dults with 4+ ho spita liza tio ns in pa st 12 mo nths

427 pe o ple , c o lle c tive ly utilize d 2200 a dmissio ns; 38% re a dmissio n ra te
F

la g to ide ntify in re a l-time

I

T pro duc e s a da ily re po rt – g o e s to a de dic a te d HU te a m

De dic a te d te a m re spo nds in re a l-time
I

de ntify c linic a l/ b e ha vio ra l/ so c ia l issue s tha t ma y b e “driving ” utiliza tio n

Ca re te a m: 3SW, 3CHW pa tie nt-fa c ing , with MD/ RN o ve rsig ht a nd ma na g e me nt
T

ime ly fo llo w up within 2 da ys

Co nne c tio n, c o nta c t, pro b le m so lving , re so urc e mo b iliza tio n to a c hie ve “sta b ility”
E

ve r ything e ffe c tive o c c ur s o utside the time c o nstr aints o f the c linic al e nc o unte r

SLIDE 29

L E SSONS L E ARNE D

I

de ntifying MVPs in while the y a re in-ho use is e sse ntia l

E

sse ntia l to fa c ilita te suc c e ssful po st-ho spita l e ng a g e me nt

T

a ke a “c o ntinua tio n o f c a re ” a ppro a c h

Offe r to c o ntinue to c a re fo r the m po st-disc ha rg e to e nsure the ir ne e ds a re me t
Avo id o ffe rs to “e nro ll” the m in a “spe c ia l pro g ra m” – no t wo rking we ll in the fie ld
Be pro a c tive , pe rsiste nt, a nd pa tie nt
E

sta b lishing a truste d, he lpful pre se nc e is ke y; ke e p trying o ve r time

Do n’ t o ve r-me dic a lize re pe a te d ho spita l utiliza tio n
Wha t is mo st “c o mple x” a b o ut MVP a re the so c ia l a nd b e ha vio ra l he a lth ne e ds
Ra re ly is the me dic ine itse lf truly c o mple x

SLIDE 30

NE W T OOL F OR T HE JOB

T he E D c are plan

SLIDE 31

T YPE S OF CARE PL ANS

L
ngitudinal Car

e Plan

A c o mpre he nsive pla n to a c hie ve he a lth-pro mo ting g o a ls a nd o b je c tive s. Spe c ific g o a ls re g a rding

c linic a l, b e ha vio ra l, a nd/ o r func tio na l sta tus a re o fte n inc lude d, a nd a re me a sure d via se ria l a sse ssme nts o ve r time . L

ng e r te rm; c a re ma na g e me nt o ve r time .
T

r ansitional Car e Plan

I

de ntifie s po st-ho spita l ne e ds, pa tie nt prio ritie s, a nd re a dmissio n risks a nd the pla n to a ddre ss tho se ne e ds, prio ritie s a nd mitig a te risks in the 30 da ys po st disc ha rg e . F

c us o n e nsure linka g e to pro vide rs

a nd se rvic e s within the 30 da y tra nsitio na l pe rio d.

E

D Car e Plan

Summa ry info rma tio n fo r the E

D pro vide r to info rm sa fe , e ffe c tive , a nd c o nsiste nt c a re in the E D a nd fa c ilita te disc ha rg e with te a m-b a se d fo llo w up, a s a ppro pria te .

SLIDE 32

E D CARE PL AN: I MPROVI NG CARE F OR NE XT T I ME

Purpo se : I mpro ve the ma na g e me nt o f the hig h-risk pa tie nt the ne xt time the y c o me to the E D Audie nc e : E D c linic a l sta ff Co nte nt:

E

xe c utive summa ry o f prio r utiliza tio n a nd te sting ;

I

de ntific a tio n o f the drive r o f ho spita l utiliza tio n;

Re c o mme nda tio ns fo r c o nside ra tio n
I

de ntific a tio n o f a po int o f c o nta c t

SLIDE 33

SLIDE 34

E D CARE PL ANS: L E SSONS F ROM T HE F I E L D

Br

e vity: No mo re tha n 1 pa g e ; the e sse ntia l summa ry info rma tio n in a wa y tha t

sa ve s time a nd pro mo te s q ua lity, info rme d de c isio n ma king .

Audie nc e : Who is yo ur inte nde d a udie nc e ? E

D do c ? De ve lo p the “c linic a l sna psho t” a nd re c o mme nde d inte rve ntio ns with the e nd-use r in mind.

Summar

ize the “utilization” par t of “high utilize r :” T

his summa ry is no t just a c linic a l summa ry, b ut a utiliza tio n pro file . Qua ntify prio r visits, a dmissio ns, te sts, c o nsults to c o nve y wha t ha s b e e n do ne in the pa st.

SLIDE 35

RE COMME NDAT I ONS

SLIDE 36

RE COMME NDAT I ONS

1. K no w yo ur da ta : ho w ma ny disc ha rg e s a nd re a dmissio ns a mo ng MVPs? 2. Re vie w 5 re a dmissio ns o f MVPs 3. I de ntify 3-4 pa rtne rs who sha re the c a re o f MVPs 4. I de ntify a nd e ng a g e MVP during ho spita liza tio n 5. F

llo w up with fre q ue nt, fle xib le c o nta c t inte nde d to b e he lpful, suppo rtive

SLIDE 37

QUE ST I ONS?

SLIDE 38

T HANK YOU F OR YOUR COMMI T ME NT T O RE DUCI NG RE ADMI SSI ONS

Amy E . Bo utwe ll, MD, MPP Adviso r, VHHA Ce nte r fo r He althc are E xc e lle nc e E xpe rt Adviso r, NYS DSRI P MAX Pro g ra m I mpro ving Ca re fo r Supe r Utilize rs Pre side nt, Co llab o rative He althc are Strate g ie s amy@ c o llab o rative he althc are strate g ie s.c o m