Montgomery County Round Table & Luncheon Partnering for Action - - PowerPoint PPT Presentation

Montgomery County Round Table & Luncheon “Partnering for Action in 2016”

March 29, 2016

A Special Round Table Event with All Montgomery County Hospitals and Post Acute Care Providers

Brooke Grove Retirement Village

• 1. Discuss existing and future collaborative efforts

in Montgomery County between hospitals and post-acute partners

• 2. Identify successful strategies for improved

transitions and reduced admissions

• 3. Participate in smaller round table discussions to

plan collaborative activities

• 4. Commit to action with community partners to

improve care transitions across the county

Today’s Objectives

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• Round table sessions
• Life Span & MHA sessions/education
• Hospital meetings
• 911 facilities
• Preferred providers
• Hospital workgroup / VHQC
• HEALTH Partners Coalition
• VHQC Care Transitions Project
• Collaborative funding proposals for improved

care coordination

• Nexus Montgomery

History

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• a. Approx. 125,000 Medicare beneficiaries
• a. 13, 30-day readmissions each day
• b. 76 admissions each day
• c. 78 ED visits each day
• d. 15 observation stays each day
• b. 18% HHA, 20% SNF, 15% Home, 2%

Hospice

• c. >10% - Readmissions occur on Day 1
• d. Sepsis

Perspective – What do we know?

Source: Medicare Part A & B Claims Data through Qtr. 2, 2015

Readmissions by Discharge Destination

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Discharged to: In Montgomery Co. In Maryland Home 15.7% 17.5% with/HH 17.2% 19.9% SNF 17.0% 19.5% Hospice 2.2% 1.9%

Top 10 Principal Diagnoses Leading to a 30-Day Readmission

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HEALTH Partners Days Until Readmission

7 50 100 150 200 250 300 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

HEALTH Partners Days until Readmission Frequency Breakdown (Q4-2014 to Q3-2015)

25% of readmissions occur within 4-5 days of discharge 50% of readmissions occur within 11 days of discharge 11.5% within 1 day of discharge!

• a. Readmissions
• a. Penalties are a reality! What you do now matters.
• b. Quality Outcomes
• a. Used to make decisions about care.
• c. Improvement Activities
• a. Adopting proven interventions
• b. Measuring impact
• d. Collaboration
• a. Working alone doesn’t work.

How are you improving transitions?

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Pre-Round Table Survey

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http://www.interact2.net

• Not all answered…. 
• 7/27 are using INTERACT – most are SNFs
• 1-3 tools (2), 4-8 tools (3), Just starting (1)
• <6 Mths. (2), 6-12 Mths. (1), >12 Mths. (3)
• Tools Used the Most:

1. SBAR: 5 2. STOP & WATCH: 4 3. Transfer Form: 4 4. Transfer Checklist: 4 5. Capabilities Checklist: 3 6. QI Tool: 2 7. Hospital Tracking Tool: 2

Results

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• a. Identify opportunities for providers to

embrace similar interventions to impact care transitions on a larger scale.

• b. Measure effectiveness of

interventions/improvement activities.

• c. Spread the adoption of successful

interventions across the county.

• d. Next level
• e. Recognition

Goal

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• Suburban Hospital
• Adventist Shady Grove Hospital
• Washington Adventist Hospital
• MedStar Montgomery Medical Center
• Holy Cross Hospital

Hospital Sharing

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Partnering For Action in 2016

Montgomery County Round Table

February 10, 2016

SNF/NH Collaboration Historical Perspective

• 2005 the Nursing Home Collaborative was established by Suburban

Hospital and included multiple nursing facilities. It was originally initiated out of the Medicine and Family Practice QA Committee as a way to better coordinate the care between facilities. It was a large and productive group as long as common concerns were addressed.

• 2010 Healthcare focus began changing with a focus on readmissions

and care coordination. The meeting was transferred to Director of Care Coordination, 2010 to develop inter-facility groups focusing on readmissions

• 2011 Collaborative effort initiated with Hebrew Home from the

Charles E Smith Life Community to address readmissions and build more collaborative relationships between the physicians in both entities.

March 28, 2016 14

Lessons Learned

• Building strong relationships is

instrumental for safe, smooth transition and lowering risk for hospitalization

• The foundation of the relationship needs to

based on Communication, Collaboration and Continuity of Care

March 28, 2016 15

Getting to “Yes” Readmissions become a Priority

• Projects have been a collaboration between the two unrelated
• rganizations, each offering different levels of care
• Regular meetings were planned between the organizations,

meeting sites were alternated

• Organizations brought their own perspectives and priorities to the

table

• Reduction of Readmissions was identified as a priority
• Critical stakeholders were identified and an effective choice was

made with respect to staff from each organization to focus on Readmissions work.

• Both leadership and clinical staff were included

March 28, 2016 16

Why Use INTERACT ?

• INTERACT’s Goal to improve care and

reduce the frequency of potentially avoidable transfers to acute hospital aligns perfectly with initiatives currently in place in the acute care hospital settings.

March 28, 2016 17

SBAR Tool: A Great Example on How to Enhance Communication

Situation

• Concise statement of the problem
• What is happening now?

Background

• Brief and pertinent information related to the situation
• What had happened?

Assessment

• Analysis and consideration of options
• What do you see or think is going on?

Recommendation

• Suggest/recommend action
• What do you want to happen?

March 28, 2016 18

Suburban’s Bundle of Strategies to Prevent Readmissions

• Early Risk Screening
• Identify patients early in admission
• Interdisciplinary Care Planning
• Representative from SNF invited to attend ID

rounds

• Patient and Family Education
• Effort to coordinate educational materials between

facilities

March 28, 2016 19

Suburban’s Bundle of Strategies to Prevent Readmissions (continued)

• Medication Management
• Participated in Cardinal Grant
• Primary Provider Handoff
• Sent Hospitalists on site visit to SNF
• ED Workgroup
• ED physicians available for consult by phone

March 28, 2016 20

Suburban’s Bundle of Strategies to Prevent Readmissions (continued)

• Transitions of Care
• Case reviews
• Collaboration on pathways
• Transition Guide RNs care planning w/complex

patients

• Paper prescriptions for C2-C5 medications
• Warm handoff RN to RN

March 28, 2016 21

Case Management

• Real time notification of every re-admitted patient
• Root Cause Analysis of readmission by nursing

facility

• Monthly meetings to discuss readmissions

– Palliative care consults

• Data from Nursing facilities on readmission rates
• Closing the loop – Outcomes of patients

– Referrals to Home Health – Notification about potential readmissions after dc

Wish List

• Joint plans of care for frequently readmitted patients
• INTERACT Tools:

– Capabilities Checklist – Transfer form  Bright colored paper – SBAR  Direct phone numbers for provider to provider report

Wish List

For More Information

Jo Cimino, MSN, RN, ACM Director of Case Management Phone: 240-826-6532 or 301-891-5326 Fax: 240-826-5264 or 301-891-6275

SNF PARTNERSHIPS

Cur urrent rent partner tnersh ship ip with h St. . Thom

• mas

s Moore

• re
• Readmission reduction of 5% since beginning of partnership
• Infectious Disease MD makes weekly visits to St. Thomas Moore to

evaluate patients that have been discharged from WAH

• Facilitation of viewing EMR’s from both entities to increase
• communication. All ED MD’s and Pop Health staff have access to

EMR

• INTERACT Capabilities list
• Implementation of SBAR communication tool
• MD to MD
• RN to RN

SNF PARTNERSHIPS

EMR Access to two ManorCare facilities to launch mid-February MD to MD calls RN to RN calls Dedicated call line at both the facility and at WAH ED SBAR communication INTERACT Capabilities list Physicians at ManorCare facilities all credentialed at WAH Beginning Bi-Weekly Readmission Reviews first week of February

TRANSFUSION PROGRAM

Developed for SNF’s that do not transfuse patients at their facilities Full Time RN M/W/F Non-emergent transport Able to take vent and dialysis patients

CONTACT INFO

Zachary y Goodli ling ng Manager, Population Health Washington Adventist Hospital 301-891-6395 zgoodlin@a n@adv dventi entist sthe healthca thcare. re.co com Katherin erine Barmer er Director of Population Health Management Adventist Healthcare kbarme mer@a r@adv dvent ntisthea thealthca thcare re.c .com

• m

Improving Population Health through Community Partnerships

Diana Saladini Director, Outpatient Services & Population Health Dsaladin@medstarmontgomery.org

March 29, 2016

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Focus on The Triple Aim

• Framework developed by the Institute for

Healthcare Improvement (IHI) to optimize health system performance

– Improving the patient experience of care (including quality and satisfaction) – Improving the health of populations – Reducing the per capita cost of health care.

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Source: Institute for Healthcare Improvement, http://www.ihi.org/Engage/Initiatives/TripleAim

March 29, 2016

Develop a Population Health Strategy

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Source: Playbook for Population Health, Advisory Board, 2013

March 29, 2016

Understand our Population: Identify High Utilizers

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Source: HSCRC Inpatient and Outpatient Case Mix Data with CRISP

• EID. Data from calendar years 2012-2015

Montgomery County High Utilizers: 3 or More Admissions

March 29, 2016

Partner Alignment

35 March 29, 2016

Partner Alignment

Open Flow of Communication to:

• Develop/Improve Processes

– Improve Care Transitions

• Warm Handover Process
• Reduce Avoidable Utilization

– Readmissions

• Multi-Disciplinary Case Review of Readmitted Patients

– Emergency Room Visits

• Improve Patient Experience & Outcomes

36 March 29, 2016

Criteria for Community Partners

• Preferred Provider Measures of Performance

– Readmission Rate – Clinical Service Offerings – Staffing Ratios – Cost of Services – Length of Stay – Federal Quality Measures – INTERACT

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QUESTIONS?

38 March 29, 2016

Montgomery County Round Table

Cathy Livingston, LCSW-C Director, Documentation Quality & Care Transitions livinc@holycrosshealth.org March 29, 2016

Agenda

• Holy Cross Health
• Readmission Prevention Activities

– O/E is better than expected for both hospitals

• Opportunities

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Holy Cross Health

• Holy Cross Hospital, Silver Spring, MD

– 435 bed acute inpatient facility

• Holy Cross Germantown Hospital, Germantown, MD

– 93 bed acute inpatient facility

• Holy Cross Health Network

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Holy Cross Health Network

• 4 outpatient health centers

– Silver Spring Aspen Hill – Gaithersburg Germantown

• 2 primary care practices
• Community health programs

– Chronic disease self-management classes – Faith Community Nurses – Community health workers – Wellness and prevention classes

• Medical adult day care

– Licensed for 35 participants – Caregiver support groups

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Readmission Prevention – Discharge Home

• Follow up phone calls: 3 calls in 30 days

– PCP appt., prescriptions filled, discharge instructions, signs & symptoms

• Skilled home care
• Transitional Care Program
• Care Link Program: mental health & substance abuse
• PCP or Health Center follow up appointments
• Payer – complex case management programs
• Pilot – home pharmacy program

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Readmission Prevention - SNF

• SNF partnerships
• Relationships with 911 area SNFs
• Post-Acute Care Nurse Liaison

– Daily contact with SNFs day after transfer

• Daily review of all readmissions
• IPC (hospitalist practice) in SNFs
• Palliative Care & Hospice

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Current SNF Communication

• SNF on-site liaisons
• Care Finder Pro
• Paper documents at transfer (from both SNF & hosp)
• CRISP
• Direct Email
• Post-Acute Care Nurse phone calls
• We can do better!

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Opportunities: SNF to hospital

• SNF to Hospital

– Sepsis is the leading reason for readmission for HCH

• Prevention, early detection & intervention
• Interact Stop & Watch tool

– Proactive Palliative Care consults prior to the need for transfer – Collaborate with hospitals for outpatient services rather than inpatient admission. Ex: transfusions, outpatient procedures – SNF to ED telephone communication – ED “Treat and Release” – Appropriate use of Observation Status rather than inpatient admission – SNF use of Interact Transfer Form & Capabilities checklist – ED wants Code status, medications, reason for transfer

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Opportunities: Hospital to SNF

• Hospital to SNF

– Better understanding of SNF capabilities – earlier transfers – Improved Transfer Summaries – RN to RN handoff – MD to MD handoff – Pre-transfer Medications

• Pre-medicate for pain, anxiety, routine meds due within 2 hours

– Ensure Class II prescriptions accompany the patient – Ensure MOLST for both ambulance crew & SNF – Improved hand off communication about end of life decisions made in the hospital

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Collaboratives

– MHA – Transitions of Care – Montgomery County Hospitals & VHQC – H.E.A.L.T.H. Partners – Payers – complex case management – Specific hospital/SNF meetings – Lifespan meetings

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Potentially Avoidable Utilization

• Prevention Quality Indicators: diagnoses that should

be successfully managed in the outpatient setting. Ex: diabetes, hypertension, asthma, COPD, Heart Failure, dehydration, UTIs, bacterial pneumonia

• Readmissions
• Potentially Preventable Complications

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Care Transitions

• We need to share best practices and learn from each
• ther.
• With the new waiver – either we all succeed or we all

fail – collaborative relationships are essential.

• Forums such as these are very helpful – thank you for

inviting us to participate.

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…identify one or two items that many could embrace throughout the county?

• High impact for issues that have wide-spread
• pportunity

…measure our collective efforts?

• To show the impact of efforts across the

spectrum of care - processes

Wouldn’t it be nice if we could…

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Spread out!

• Do not sit with others from your organization
• Interact with people from different
• rganizations

Share

• Use the guided questions to talk about
• pportunities

Participate

• Volunteer to take notes, share and report
• ut to the larger group

Mini-Round Table Discussions

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At tables

• 1. Find question sheet in packet
• 2. Identify note taker at each table
• 3. Discuss each question – the more sharing

the better

• 4. Report-out
• 5. Collect notes from each table
• 6. Identify themes
• 7. Next steps

Round Table Sharing

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Volunteers from mini-table conversations

• a. Ideas shared that sparked more interest?
• b. Successful interventions shared?
• c. INTERACT Tools conversation, ideas?
• d. What opportunities were identified?
• e. Needs/expectations related to partners?
• f. Data collection insights?

Report Out

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• Next Steps
• 1. Learn about HEALTH Partners
• 2. Learn about the Nursing Home

Improvement Network

• Commitment to Action Form
• Online Community
• Future County Meetings
• Round Table
• Conference Calls, etc.

Committing to ACTION

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H.E.A.L.T.H. Partners

Montgomery County Post-Acute Care Providers Roundtable With Local Hospitals

Presented by: Mary Joseph RN, BC, CPHQ Primary Care Coalition MaryJane_Joseph@PrimaryCareCoalition.org 301-628-3458 February 9,2016

About the Primary Care Coalition (PCC)

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Vision: A community in which all residents have the

• pportunity to live healthy lives

Montgomery County: A model for providing access to high quality, efficient care for all Mission: Develop and coordinate a community-based health care system that strives for universal access and equity for low-income, uninsured, and ethnically diverse community members.

H.E.A.L.T.H. Partners

2011

• Partnered with DHHS Aging and Disabilities; Holy Cross Hospital;

Housing Opportunities Commission; PCC to improve care transitions for dual eligible patients in Montgomery County

2013

• Coalition formed with Delmarva
• 16 organizations and residents of Holly Hall
• Access to hospital Medicare admission and readmission data
• Small tests of change

2014

• Over 20 organizations represented
• Change from Delmarva to VHQC
• Spread other senior housing units

2015

• Continued monthly meetings and small tests of change
• Pharmacy MTM outcome study

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H.E.A.L.T.H. Partners

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Purpose:

• Build and sustain a community coalition with a focus on improving

transitions of care

• Encourage person-centered and person-directed models of care by

providing a platform for the patient and family voice

• Collaborate and encourage efforts of organizations with shared

visions

• Advance public policies that furthers the vision
• Share Best Practices in caring for community residents

Mission:

To improve the transition of care from hospital to community for residents of the region, thereby reducing preventable readmissions to acute care hospitals.

First Site-Holly Hall

96 units/112 Residents On site resident counselor

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Race

• African American 49%
• Asia 18%
• White 32%
• Middle Eastern 1%

Age

• < 60 years 17%
• > 60 years 83%

Ethnicity

• Hispanic 22%
• Non-Hispanic 78%

Disabilities:

• Medically Frail 42%
• Physical Disability 29%
• Psychological/Neurological 16%
• Cognitive 10%

Interventions/Tests of Change

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Data

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• The H.E.A.L.T.H partners community (Montgomery

County) has approximately 127,434 Medicare beneficiaries.

• VHQC provides part A & B claims data and ongoing

analysis for communities to assist with the identification of improvement opportunities.

• Readmissions
• Admissions
• ED visits
• # of days from discharge to readmission
• Top Diagnoses
• Specific Focus Areas

Resident Engagement

• Resident Meeting
• Resident Brochure
• Resident Interviews

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Medication Therapy Management

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• Pharmacist services provided by ALFA Specialty

Pharmacy

EMS Interventions

Daily notification

65 New Hampshire Ave Incident Shift Date 808/09/2014 Incident Date Time Call Type Unit Apartment Location 14-0090550 08/09/2014 19:02:58 26-A-11 A716 310 10120 New Hampshire Ave. 2014 EMS Visits Holly Hall 2012-2013 Average = 4 per Month Building 1/14 2/14 3/14 4/14 5/14 6/14 7/14 8/14 9/14 10/14 11/14 12/14 Total 10100 3 2 4 2 3 3 5 2 1 1 2 4 32 10110 2 2 1 1 1 2 1 3 13 10210 4 1 1 2 2 2 12 Total 3 4 6 2 7 5 7 4 2 5 5 7 57 EMS Visits by Building (2012-2014) Building Apartments EMS 2012/100 Apartments EMS 2012/100 Apartments EMS 2012/100 Apartments Arcola Towers 141 28 23 48 Elizabeth House 160 23 25 38 Forest Oaks 175 32 33 75 Waverly House 158 46 34 46 Holly Hall 96 55 45 63 Bauer Park 142 13 17 Town Center 112 13 20

Monthly Stats

Technology

• Care2Care
• Provides a patient-centered record including

– Essential care elements – Barriers to care and self-management goals

• Facilitates optimal outcomes as the patient moves through

the continuum of care

• Community Health Gateway
• Web and call center solution
• Easy to understand discharge instructions & medication

information

• Help in navigating healthcare and community services
• Increased community collaboration

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Successes

• Community Engagement
• Over 60% of residents have signed release of

information

• Hospital transitional care teams working

together

• EMS notification and follow-up
• MTM with positive outcomes on 20 residents in

several housing sites

• Introduction of technology to assist in personal

health management

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Maryland - Virginia Nursing Home Improvement Network

• 1. Decrease the use of unnecessary

antipsychotic medication

• 2. Prevent and reduce healthcare associated

infections

• 3. Increase mobility of long-stay residents
• 4. Improve quality measures
• 5. Decrease potentially avoidable

hospitalizations

Nursing Home Improvement Network Goals

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• 1. Learning from both colleagues and experts
• 2. National Nursing Home Quality Care

Collaborative

• 3. Change package tools and resources
• 4. Consultation with VHQC quality consultants
• 5. Plan-Do-Study-Act (PDSA) cycles to test

improvement strategies and tactics

A Collaborative Approach

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• 1. Flexible, no-cost structure for improvement
• 2. Quality Assurance Performance Improvement

(QAPI) tools and resources

• 3. Latest strategies and techniques from

successful colleagues and QI experts

• 4. Intervention development ideas and assistance
• 5. Support for participation in other QI initiatives

Benefits of Participation

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Organizational quality goals Quality Assurance and Performance Improvement (QAPI) The Partnership to Improve Dementia Care Advancing Excellence CMS Nursing Home Action Plan MD All Payer Model Maryland-Virginia Nursing Home Improvement Network

Aligning QI Efforts

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• 1. Form an interdisciplinary QI team
• 2. Complete the QAPI self-assessment
• 3. Utilize a data-driven and proactive

approach to quality improvement

• 4. Develop and apply strategies for

implementing QAPI and overall quality

• 5. Participate in network activities
• 6. Actively share best practices with other

facilities

Your Commitment

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• 1. Prepare data reports and facilitate analysis

to support overall quality improvement

• 2. Provide consultation by qualified staff and

faculty with expertise in quality improvement

• 3. Share best practices and evidence-based

tools and resources to support overall quality improvement

• 4. Develop and facilitate collaboration using

workshops and peer mentoring

VHQC Commitment

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Contact VHQC

Sheila McLean, Program Director smclean@vhqc.org 804.289.5345 Linda Harris, Improvement Consultant lharris@vhqc.org 804.289.5340 Theresa Mandela, Improvement Consultant tmandela@vhqc.org 804.289.5352

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This material was prepared by VHQC, the Medicare Quality Innovation Network Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/C.2.HAC/2/5/2016/2378

• a. H.E.A.L.T.H. Partners
• b. Nursing Home Improvement Network
• c. Commitments for Action
• a. Submit green sheet
• b. Join NHIN
• c. Join HEALTH Partners (yellow charter)
• d. Join VHQC’s Online Community (flyer)
• d. Participate in next sessions, calls and

activities…stay tuned!

Next Steps

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Save the Date

Toolkit 2016: Build on you Emergency Preparedness Program Monday, June 6th 8:00-4:30 Holy Cross Hospital Auditoriums Region V Emergency Response Hospital-SNF Workshop

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This material was prepared by VHQC, the Medicare Quality Innovation Network Quality Improvement Organization for Maryland Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. VHQC/C.3.CT/2/8/2016/2379

Questions?

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• Please complete your session evaluation
• Submit action forms at registration.
• Thank you, Brook Grove, for hosting & lunch!
• Enjoy networking throughout lunchtime.