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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 # 5 – Artic ula ting Yo ur Stra te g y De c e mb e r 15, 2016

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

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

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.

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

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

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 No ve mb e r 15th I n-Pe rso n L e a rning E ve nt 9-3:30

De c e mbe r 15th Ar tic ulating Your Str ate gy

Ja nua ry 25th “De e p Dive ” se rie s b e g ins

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

NE W

ART I CUL AT I NG YOUR ST RAT E GY

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

AGE NDA

• Why wo rk to a rtic ula te yo ur re a dmissio n re duc tio n stra te g y?
• E

xa mple fro m Ca rilio n Clinic

• E

xa mple fro m Rive rside He a lth Syste m

• Spe c ific a c tio n ste ps

WHY ART I CUL AT E YOUR RE ADMI SSI ON RE DUCT I ON ST RAT E GY?

Bo utwe ll e t a l. Ava ila b le a t: http:/ / www.a hrq .g o v/ pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / inde x.html

Re duc e Re admissions Ac tion Analysis

A

• Analyze Your

Data

S

• Sur

ve y Your Cur r e nt Re admission Re duc tion E ffor ts

P

• Plan a Multi- fac e te d, Data- Infor

me d Por tfolio of Str ate gie s

I

• Imple me nt Whole - Pe r

son T r ansitional Car e for All

R

• Re ac h Out and Collabor

ate with Cr

• ss- Continuum Pr
• vide r

s

E

• E

nhanc e Se r vic e s for High- Risk Patie nts

1. Data Analysis 2. Readmission Review 3. Hospital Inventory 4. Community Inventory 5. Portfolio Design 6. Operational Dashboard 7. Portfolio Presentation 8. Conditions of Participation Handout 9. Whole-Person Transitional Care Planning 10. Discharge Process Checklist 11. Community Resource Guide 12. Cross Continuum Collaboration 13. ED Care Plan Examples

The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day

• perations.

Bo utwe ll e t a l. Ava ila b le a t: http:/ / www.a hrq .g o v/ pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / inde x.html

ART I CUL AT E YOUR ST RAT E GY

• Conduct a hospital and community-based inventory of readmission reduction

related efforts and resources

• Analyze what resources and efforts are in place to articulate your hospital’s current

readmission reduction driver diagram

• Use the inventory and driver diagram to consider whether there are gaps to fill or
• pportunities to improve implementation of existing efforts

HOSPITAL INVENTORY TOOL

Use this to o l to :

• I

de ntify re a dmissio n re duc tio n e ffo rts a c ro ss de pa rtme nts

• I

de ntify whe the r e ffo rts a re c o o rdina te d

• I

de ntify whe the r the re is duplic a tio n

• I

de ntify g a ps – in a dministra tive suppo rt

• I

de ntify g a ps – in c linic ia n e ng a g e me nt

• Ge t spe c ific – wha t spe c ific a lly is tha t te a m

do ing ? Who le a ds tha t e ffo rt? , e tc .

http:/ / www.a hrq .g o v/ site s/ de fa ult/ file s/ wysiwyg / pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / me dre a d-to o ls.pdf

COMMUNITY INVENTORY TOOL

I de ntify pro vide rs/ a g e nc ie s a lso wo rking to re duc e re a dmissio ns:

• Pa tie nt-Ce nte re d Me dic a l Ho me s
• Po st-a c ute c a re pro vide rs
• Pe e r suppo rts, Na vig a to rs
• Me dic a l-le g a l a dvo c a te s
• Be ha vio ra l he a lth pro vide rs
• Me dic a id MCO c a re ma na g e rs

Co nside r:

• Are we o ptimizing a va ila b le re so urc e s?
• I

s linka g e a s e a sy a s it ne e ds to b e ?

http:/ / www.a hrq .g o v/ site s/ de fa ult/ file s/ wysiwyg / pro fe ssio na ls/ syste ms/ ho spita l/ me dic a idre a dmitg uide / me dre a d-to o ls.pdf

MANAGED CARE ORGANIZATIONS

MCOs c a n a ssist with:

• I

de ntify PCP

• Ho me Nursing
• Me dic a tio n a dhe re nc e
• Disc ha rg e pla nning fro m a ll le ve ls o f c a re
• Dise a se Ma na g e me nt
• Co mple x Ca se Ma na g e me nt
• Co o rdina tio n o f se rvic e s
• E

xa mple s:

• T

ra nsitio na l c a re sta ff

• Co mple x c a re ma na g e rs
• Be ha vio ra l he a lth c a re ma na g e rs
• Mo b ilize re so urc e s to me e t b a sic he a lth-re la te d ne e ds

T

• pic fo r F

e b rua ry 2017 we b ina r

OTHER “ACCOUNTABLE” PROVIDERS IN VA

Model 3 Bundled Payment Participants Advanced Home Care Gainesville, VA Advanced Home Care Wise, VA American Homecare Richmond, VA Avante At Harrisonburg Harrisonburg, VA Avante At Lynchburg Lynchburg, VA Avante At Roanoke Roanoke, VA Avante At Waynesboro Waynesboro, VA Cedar Lawn Investments, LLC Abingdon, VA Chatham Health And Rehabilitation Center, LLC Chatham, VA Chesterfield Healthcare Group, Inc. Chester, VA Danville Healthcare Group, Inc. Danville, VA Hampton Healthcare Group, LLC Virginia Beach, VA Healthsouth Rehabilitation Hospital Of Northern Virginia, LLC Aldie, VA Leewood Investments & Associates, LLC Annandale, VA Liberty Ridge Healthcare Group, LLC Lynchburg, VA Nova Healthcare Group, LLC Weber City, VA Stafford Healthcare Group, Inc. Fredericksburg, VA Stanardsville Healthcare, LLC Stanardsville, VA So urc e : CMMI we b site

ANAL YZE YOUR F I NDI NGS

 Are a ll re a dmissio n re duc tio n re la te d a c tivitie s c a pture d?  Will this stra te g y a ddre ss the ro o t c a use s o f re a dmissio ns fo r yo ur ta rg e t po pula tio n?  Wha t ta rg e t po pula tio ns ha ve no t b e e n prio ritize d? Why?  Wha t stra te g ie s ha ve no t b e e n prio ritize d? Why?  Are the fo llo wing da ta -info rme d o r hig h-le ve ra g e e le me nts inc lude d? I

f no t, why no t?

 Me dic a id a dults  Be ha vio ra l he a lth  So c ia l suppo rt ne e ds  Hig h utilize rs  Hig h risk dia g no se s b a se d o n yo ur da ta (se psis, re na l fa ilure , sic kle c e ll, e tc )  Disc ha rg e s to po st-a c ute c a re se tting s  Co lla b o ra tio ns with: MCOs, BH pro vide rs, c linic s, so c ia l se rvic e s, ho using se rvic e s  Do e s this stra te g y a lig n with va lue b a se d / a lte rna tive pa yme nts a nd o the r inc e ntive s?  Me dic a re re a dmissio n pe na ltie s? Me dic a re va lue -b a se d purc ha sing (to ta l c o st)? Bundle s?  Bo a rd-le ve l g o a ls re la ting to q ua lity, pa tie nt e xpe rie nc e , dispa ritie s, o r ste wa rdship?

DRAF T YOUR DRI VE R DI AGRAM

CARI L I ON CL I NI C

Jo hn Sc humac he r, Pro c e ss I mpro ve me nt Co nsultant Paul O’ Quinn, Dire c to r Pro c e ss I mpro ve me nt

Carilion Clinic Hip & Knee Readmission Strategy Map

Paul O’Quinn, Process Improvement Director John Schumacher, Process Improvement Consultant December 15, 2016

Creation Date: 2016-12-01 18:15, Revision Date: 2016-12-07 1138

Sample Strategy Map to Demonstrate Readmission Application (Single-Page View of Map)

RI VE RSI DE HE AL T H SYST E M

Ke ndra Co o pe r RN, MSN-HCQ, CPHQ Syste m Dire c to r, Quality and Outc o me s

Kendra Cooper, RN, MSN-HCQ, CPHQ System Director, Quality Outcomes 12/15/16

Driver Diagram A Framework for Readmission Improvement

S yst em Overview

Riverside Health System

3 divisions

Acute Care Services

5 acute care hospitals 754 beds 3 specialty hospitals 222 beds

Lifelong Health

10 nursing homes 943 beds 4 P ACE centers Helping 650 nursing-home eligible participants stay in their homes In-home health

• Home Health
• Home-enabling technology
• House calls

Riverside Medical Group

Medical home model

• 110 practices
• 565+ providers
• 35 specialties

45% 30% 25%

S yst em Overview

Steps in Framing our Readmission Reduction Efforts

1) Select a Driver Diagram 2) Driver Diagram Gap Analysis 3) Develop Teams based on gaps- “Driver Action Teams” 4) Design & Implement a Sustainment Checklist 5) Design & Implement a Riverside specific Readmission Playbook

Premier & Partnerships for Patients Driver Diagrams

Driver Gap Analysis

*Partial List. Owner names excluded for privacy.

Readmission Reduction Playbook and Checklist

Readmission Reduction- “PLAYBOOK” Example Report Out

Readmission Interview- Live at all acute facilities. Risk Stratification (RS)- Live at all acute facilities. Med Reconciliation- RRMC pharm tech successful. IPOC- Discuss -Anticipated D/ C date, Risk S core, Barriers, ACP. Follow Up Appointment- Facility champions at each acute location. Follow Up Phone Calls- Pilot : Centralize to Riverside Nurse program; S NF Discharge Process- Pt & family educ.; DC checklist; emphasize teach-back LLH- INTERACT tool used to review readmissions. Meeting/ exceeding benchmarks. RMG- New representatives added. Access for follow up appointments Other: Community Health Network Approach; S teering team members attend CHN Readmission meetings. Virginia Hospital & Healthcare Association Collaborative- Home is the Hub. Premier webinar series- Reducing Avoidable Admissions. Playbook – final edits and distribution. http

ttp:/ ://www.mha haonl

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ne.or

• rg/resou
• urces/mha

ha-public lications ns/readmis ission

• ns-reduc

uction-pl playbo book

IPOC-Interdisciplinary Plan of Care

RE COMME NDAT I ONS

DESIGN A DATA-INFORMED STRATEGY

1. Wha t is o ur aim? 2. Wha t do e s o ur data sho w?

3. Who sho uld we fo c us o n?

4. Wha t sho uld we do? Ma ny te a ms sta rt in the r

e ve r se o rde r!

E XAMPL E 1: BAL T I MORE HOSPI T AL

Re duc e ho spita l-wide re a dmissio ns b y 20% I nte rve ne in E D prio r to (re )a dmit

Re a l-time id e ntific a tio n E D sta ff a va ila b le to c o o rd ina te Use ind ivid ua lize d c a re pla ns

Re lia b ly de live r inpa tie nt tra nsitio n o f c a re pra c tic e s

Who le -pe rso n ne e d s a sse ssme nt E ng a g e c a re g ive r/ ”le a rne r” Custo mize d instruc tio ns & te a c h b a c k Arra ng e fo r fo llo w up & se rvic e s

Pro vide o r link to tra nsitio na l c a re se rvic e s

F

• llo w up pho ne c a lls

Be d sid e d e live ry o f me d ic a tio ns 30-d a y tra nsitio na l c a re se rvic e s L ink to c o mmunity suppo rt

De ve lo p c ro ss-se tting pa rtne rships, no rms & pro to c o ls

Mo nthly c ro ss-c o ntinuum me e ting s Cro ss-se tting re a d missio n re vie ws Wa rm ha nd o ffs, “re c e ive r” o rie nte d Sha re use o f c o mmo n to o ls, e g INT E RACT

DRAF T YOUR DRI VE R DI AGRAM

RE L I ABL Y I MPL E ME NT YOUR ST RAT E GY, USI NG DAT A T O DRI VE I MPROVE ME NT

QUE ST I ONS?

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

HAPPY HOL IDAYS, AND SE E YOU IN T HE NE W YE AR!

Amy E . Bo utwe ll, MD, MPP Adviso r, VHHA Ce nte r fo r He althc are E xc e lle nc e 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