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

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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 impact overall DSRIP measures and improve patient health. The DSRIP program focuses on statewide system reform to improve population health.

H

DSRIP GOAL Reduce avoidable hospital admissions and ED use by 25%

• ver 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.

Source: Emergency Department Super Utilizer Programs, Rural Health Value

Mental Health Centers Urgent Care / ED Clinics Primary Care Clinics Other Care Coordination Programs Community Paramedics Homeless Shelters Community Health

H

• Patient or Family Member*
• ED Physician
• Primary Care Physician
• Nurses
• Care Managers
• Social Worker
• Behavioral Health Counsellor / Psychiatry

Liaison

• Manager
• Other representatives that can be key to

providing care for this patient population

*Required

Sample List of Action Team Members

Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

Topic 1 Topic 2 Topic 3 Super Utilizers: Meeting Complex Patient Needs Integrating Behavioral Health And Primary Care Services Super Utilizers: Meeting Complex Patient Needs Reduce avoidable hospital use by 25% over 5 years (better care, better health, lower costs) Care system redesign to better meet complex and high-cost patient needs Ensure care coordination to improve outcomes for patients with Behavioral Health diagnoses Care system redesign to better meet complex and high-cost patient needs

October 2015 (pilot – limited availability!) February 2016 March 2016

MAX Series Program Topics

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

Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.

MAX Series

Medicaid Accelerated eXchange

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 Leads and Champions to confirm enrollment PPS Baseline Assessment Process (including: surveys, site visit, etc.)

Phase 1: Assessment and Preparation Phase 2: Clinics and Improvement Cycles

Phase 3: Reporting

Action Period support:

• Weekly 30 min telephone status update (between

Coach and Team Lead)

• On-site visit mid-PDSA cycle (during 1st or 2nd PDSA

cycle)

• Emergency/Troubleshooting on-site visit by Coach

(based on PPS need)

• Teleconference attendance during presentation of

results after each PDSA cycle

MAX Workshop 1 MAX Workshop 2 MAX Workshop 3

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

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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

• f

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

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

Metrics

Target Base line Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

• 1. Percentage of Super Utilizer Cohort

with a completed patient profile

100% 0% 0% 22% 69% 85% 85% 85% 85%

• 2. TBD: Patient Engagement (e.g.

Correct Responses to Ask-Teach Moments)

100% n/a 0% 16% 40% 54% 70% 75% 83%

• 3. Percentage of Super Utilizer Cohort

enrolled in Health Home

n/a n/a n/a n/a n/a 21% 70% 70% 73%

• 4. Number of admissions among Super

Utilizer Cohort per month

12 7 8 14 12 10 8 10

• 5. Number of ED Visits by defined

Super Utilizer Cohort per month

46 35 29 35 29 24 20 26

Our Dashboard

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

Our Impact

Total Cohort (61patients) Before After Result (%)

ED VISITS

65.1/month 36.3/month

• 44%

ED IP ADMISSIONS

15.5/month 8.5/month

• 45%

ED READMISSIONS

5.3/month 3.75/month

• 29%

Our Impact

20 40 60 80 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

Future Steps

 Continue to identify new super utilizers  Maintain Integrated care approach to assessment and treatment  Replication of project with new cohort of patients who have AMI and CHF

THANK YOU

QUESTIONS???