MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION - PowerPoint PPT Presentation

MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE Presented by: Linda Efferen, MD, MBA Medical Director Suffolk Care Collaborative 19

THE MAX SERIES SUPPORTS AN INTERDISCIPLINARY CARE TEAM AT A SPECIFIC LOCATION TO IMPROVE PATIENT CARE The MAX Series Program focuses on local process improvement for a specific patient population to H impact overall DSRIP measures and improve patient health. The DSRIP program focuses on statewide system reform to improve population health. DSRIP GOAL Reduce avoidable hospital admissions and ED use by 25% over the next 5 years Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

Composition of the MAX Action Team The MAX Series Program impacts change at the local hospital/provider level. The Action Team is an interdisciplinary front-line team comprised of 8 – 10 individuals that are directly involved in meeting the target population’s diverse medical, behavioral and social needs. Sample List of Action Team Members Urgent Care / ED Clinics • Patient or Family Member* Mental • ED Physician Other Care Health • Primary Care Physician Coordination Centers • Nurses Programs • Care Managers H • Social Worker Primary Care Community Clinics • Behavioral Health Counsellor / Psychiatry Paramedics Liaison • Manager Community Homeless • Other representatives that can be key to Health Shelters providing care for this patient population *Required Source : Emergency Department Super Utilizer Programs, Rural Health Value Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

MAX Series Program Topics Topic 1 Topic 2 Topic 3 Super Utilizers: Super Utilizers: Integrating Behavioral Meeting Complex Meeting Complex Health And Primary Patient Needs Patient Needs Care Services Reduce avoidable hospital use by 25% over 5 years (better care, better health, lower costs) Ensure care Care system redesign coordination to Care system redesign to better meet improve outcomes for to better meet complex and high-cost patients with complex and high-cost patient needs Behavioral Health patient needs diagnoses October 2015 February 2016 March 2016 (pilot – limited availability!) Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

FOR EACH TOPIC, THE MAX SERIES PROGRAM IS DELIVERED IN THREE PHASES Phase 2: Clinics and Phase 1: Assessment and Phase 3: Improvement Cycles Preparation Reporting Assessment Call with PPS: Discuss questions about the program and confirm interest in topics Enrollment Call with PPS: MAX Team calls with Executive Sponsor, PPS MAX MAX MAX Leads and Champions to Workshop 1 Workshop 2 Workshop 3 confirm enrollment Action Period support: PPS Baseline Assessment  Weekly 30 min telephone status update (between Process (including: surveys, Coach and Team Lead) site visit, etc.)  On-site visit mid-PDSA cycle (during 1 st or 2 nd PDSA cycle) MAX Series  Emergency/Troubleshooting on-site visit by Coach (based on PPS need)  Teleconference attendance during presentation of Medicaid Accelerated eXchange Designed by KPMG for the NYS Department of Health Delivery System results after each PDSA cycle Reform Incentive Payment (DSRIP) Program 2015.

A JOURNEY TO REDUCE PREVENTABLE COPD ED VISITS Presented by: Julie Vinod, DNP, MS, ANP-C, RN Assistant Director of Nursing Operations Brookhaven Memorial Hospital Medical Center 24

A Journey to Reduce Preventable COPD ED visits Presented by: Julie Vinod DNP, MS, ANP-C,RN Date: June 17, 2016

MAX Series Team Sponsors: Keisha Wisdom, V.P.CNO and Dr. Zeyneloglu, CQMO Administrative Lead: Karen Shaughness, LCSW Dr. Julie Vinod DNP, MS, ANP – C, RN Asst. Director of Nursing ( Team Lead) Stanley John MHA, BS, RT, RRT-NPS Director Respiratory Care & Support Services Tameka Squire BSN Clinical Instructor Samuel Beckles RN Nurse Manager, COPD Unit Elfriede Weiss-Paquette LCSW Coordinator Collaborative Care, PCMH Dr. S. DeAngelis Medical Director of ED Brianne Rizzo Director, Care Management Monica Schlie Social Worker in the ED Jessica Philius Care Manager, COPD Unit Bernadette Peters Care Manager POE RN Jody Felice, RN Home Care Nurse Steven Sanderson Decision Support Analyst

Problem Statement: Does the implementation of COPD bundle reduce the ED visits by 10% among patients with primary and secondary diagnosis of COPD for a period of one year?

Objective To reduce the number of COPD Super Utilizer ED visits by 10% in one year

Sample Individuals with primary and secondary diagnosis of COPD who had ≥ 3 ED visits and/or >1 readmissions from Jan 2015 to Sept 2015

Sample Size Total number of COPD ED visits/patients from Jan 2015 to Sept 2015 432 COPD ED visits (62 patients) 71 COPD readmissions( 27 patients)

Our Accomplished Action Plans  Created COPD Super Utilizer List  Created a Flagging System  Created 62 patient profiles  Opened a COPD Unit  Created a secured shared drive to document and communicate within the action team

Our Accomplished Action Plans  Educated the frontline staff  Created a multidisciplinary COPD Plan of Care  Created a workflow for COPD patients  Created a care coordinated note template

Our Accomplished Action Plans  Created a Home Assessment tool  Created a Graduation Protocol  Created Health Home enrollment spread sheet  Established a Brookhaven Better Breathers Club

Flagging System Body Copy here:

Patient Profile

Stake Holders  Executive Team/Leadership Team  Nursing  Physician  Primary Care Provider  Respiratory

Stake Holders  Care Management  Education Department  IT  Pharmacy  Coordinator Collaborative Care  Home Care and Health Homes

Team Strategy Body Copy here Brookhaven Team Team Lead Meeting Meeting Every Every Friday from 10am Wednesday from to 1030 am 230pm to 4pm Contact via email as Contact with Expert on needed MIX IT website (Max Series Group)

COPD Journey… Priority Reasons for ED utilization  Medications  Pain  Comfort/ Security  Substance Abuse/ Mental Illness  Social Needs

Common Attributes  Majority lived alone  Over 80% have concurrent Behavioral Health diagnosis  All met criteria for Health Home  Some for Home Care

Improved Process  Changed the ED and Inpatient Unit culture of treating super utilizers via education of staff, EMR flagging of cohorts; sharing of patient success stories with staff  Created in depth Assessment process in ED and referral to HH and PCP immediately  Utilized motivational interviewing techniques

Improved Process  Began true Care coordination with external agencies, such as OP providers, Health Homes, Home Care, residential providers, Inpatient and ED staff  Conducted Case Conferences on patient to change their pattern of behavior Care, residential providers, Inpatient and ED staff

Key Elements of Success  Diverse and Integrated Team who commits several hours a week to project  Strong administrative support and Team lead  Desire to embrace change  Accurate Data  Timely Communication  Collaboration with community agencies

Our Dashboard Base Target Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Metrics line 1. Percentage of Super Utilizer Cohort 100% 0% 0% 22% 69% 85% 85% 85% 85% with a completed patient profile 2. TBD: Patient Engagement (e.g. 100% n/a 0% 16% 40% 54% 70% 75% 83% Correct Responses to Ask-Teach Moments) 3. Percentage of Super Utilizer Cohort n/a n/a n/a n/a n/a 21% 70% 70% 73% enrolled in Health Home 4. Number of admissions among Super 0 12 7 8 14 12 10 8 10 Utilizer Cohort per month 5. Number of ED Visits by defined 0 46 35 29 35 29 24 20 26 Super Utilizer Cohort per month

Our Dashboard 100 80 60 Baseline 40 Nov 20 0 Dec Jan Feb March April May

Our Impact Total Cohort Before After Result (%) (61patients) ED VISITS 65.1/month 36.3/month -44% ED IP 15.5/month 8.5/month -45% ADMISSIONS ED 5.3/month 3.75/month -29% READMISSIONS

Our Impact 80 60 40 20 0 Before After

Health Home Data 75% of patients are enrolled in a Health Home Engaged Health Home to educate care managers of their benefit and application process

Case Study DD is a 57 year old female with multiple chronic conditions, including depression. She has,  14 hospital visits in a 6 month period including,  5 admissions and 3 readmissions. As the first patient of the program, DD received a needs assessment which uncovered a need for frequent education and support for follow-up appointments.

Case Study contd.  She is now receiving care coordination services, which have helped connect her to primary care, Medicaid transportation, and alternatives to the ED  Ms. DD has been engaged to a Adult Day Care center  DD has not returned to the ED since  DD graduated in MAY