Welcome & Introductions 2 1 6/20/2019 Meeting Agenda and - - PDF document

6/20/2019 1

Coordination of Care Initiative East Metro Community

Quarterly Meeting June 24, 2019 Regions Hospital

2

Welcome & Introductions

6/20/2019 2

3

Meeting Agenda and Objectives

• Discuss coordination of care efforts across Minnesota and

review East Metro community data.

• Understand key concepts related to health equity and how one
• rganization is approaching the elimination of health care

disparities.

• Describe how the Anxiety Shared Pathway can be used

throughout the continuum to provide caregivers with integrative therapy techniques to help residents/clients mitigate anxiety.

• Recognize participation in the Coordination of Care initiative and

celebrate community accomplishments to improve care transitions.

4

Coordination of Care Initiative Update

6/20/2019 3

5

Coordination of Care Initiative Goals

• Improve quality of care for Medicare beneficiaries

who transition among care settings

• Reduce 30-day hospital readmission rates and

admission by 20% by 2019

• Increase the number of days at home
• Establish sustainable, transferrable transition

practices across the spectrum of care

6

Coordination of Care Communities

6/20/2019 4

7

Success Stories Webinar Series

Successful Strategies for Sustained Community Improvement Tuesday, January 22, 2019, 12–1:00pm – More At Your Service: Benefits of Home Health Agencies Working with their QIN Tuesday, February 26, 2019, 12–1:00pm – More Using Data to Drive Community Quality Improvement Efforts Tuesday, March 26, 2018, 12–1:00pm – More Home-based Innovative Strategies to Prevent Readmissions Tuesday, April 23, 2019, 12–1:00pm – More Changing the Culture: Improving Recognition and Management of Sepsis Thursday, May 30, 2019, 12–1:00pm – More Achieving Community Goals by Partnering with Aging and Disability Resource Centers Tuesday, June 25, 2019, 12–1:00pm – Register

This six-webinar series highlights the innovative work the Lake Superior QIN COC partners have done across care settings and in the community to improve transitions of care and reduce readmissions.

Download the webinar series flier

8

Community Scorecard

6/20/2019 5

9

The Community

10

Admissions (community)

6/20/2019 6

11

Readmissions (community)

12

Medicare QIN-QIO Program 2019-2024

12

CMS priorities

• Improving behavioral health outcomes,

focusing on decreased opioid misuse

• Increasing patient safety
• Increasing chronic disease self-management
• Increasing quality of care transitions
• Improving long-term care quality

6/20/2019 7

13

Superior Health Quality Alliance

13

New partnership

• Lake Superior QIN
• MetaStar (WI), MPRO (MI) and Stratis Health (MN)
• Joined by:
• Illinois Health and Hospital Association
• Michigan Health & Hospital Association
• Midwest Kidney Network
• Minnesota Hospital Association
• Wisconsin Hospital Association

14

Best Practice Presentation

Sidney Van Dyke

6/20/2019 8

Health Equity

East Metro Coordination of Care Meeting June 24, 2019

Sidney Van Dyke, Director Health Equity and Language Access, Regions Hospital

Patient story

Connecting the Broken Threads of the Hmong Paj Ntaub by Seexeng Lee

6/20/2019 9

Simultaneous interpreting

Average Length of Stay by Language Regions Hospital Mental Health

Simultaneous Interpreting

Health equity

Health equity

means that everyone has a fair and just

• pportunity to be as

healthy as possible.

Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.

6/20/2019 10

Return on investment to society Better care/outcomes lead to lower cost of care Improving overall quality results Attracting patients in changing demographic

Business Case on Many Levels Minnesota Trends

248% 113% 104% 51% 8%

Hispanic origin African American Asian or Pacific Islander American Indian White

Source: State Demographic Center at Minnesota Planning

Communities of color in MN will grow faster than white population between 1995 and 2025

Percentage of people of color in MN:

19% (2015)  25% (2035)

6/20/2019 11

Health equity

Health equity

means that everyone has a fair and just

• pportunity to be as

healthy as possible.

Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.

6/20/2019 12

Disparities

Health disparity

Differences in health that are closely linked with social, economic, and/or environmental disadvantage.

Health care disparity

Differences in health insurance coverage, access to and use of care, and quality of care delivered.

Differences that cannot be explained by variations in health needs, patient preferences, or treatment recommendations.

Our Approach to Health Equity

Health Equity Collect data and eliminate gaps in care Partner with communities Build understanding of equity, diversity, inclusion & bias Support language access

Race/ Ethnicity Language Income Sexual

• rientation

Gender Age Physical ability Religion

6/20/2019 13

Breast Cancer Screening by Race

82.2% 83.1% 69.3% 75.7% 0% 20% 40% 60% 80% 100% 1st Qtr 2006 4th Qtr 2018

Patients who are white Patients of color HEDIS 2018 National 90th Percentile = 78.9%

Gap is 12.9% points Gap is 7.4% points

Interventions

Same day access Community

• utreach

Customized messages based on consumer insights data

481

Our Data Journey

Equity incorporated into existing dashboards Stand alone equity dashboard Reports by request Collection of REaL data 2019 will begin collecting SDoH data

6/20/2019 14

Health equity in all we do

Health

Measurably improve health equity by addressing disparities

People

Increase diversity across all roles and strengthen culture of inclusion

Stewardship

Demonstrate community benefit

Experience

Ensure everyone feels welcome, included, valued

Operationalized at the system and local levels

Conversations about Race & Racism

2,000+ leaders engaged and charged to facilitate conversations with teams

6/20/2019 15

• Grassroots program of

champions to support education, awareness at local level

• Over 170 Champions

across the organization since 2003, expansion in 2016

Equitable Care Champions

Regions Hospital 2019 Equity Priorities

WHY FOCUS AREA TACTICS

Disparity in preventable all-cause readmissions Experience Disparity in survey response rates Birth Center Hospital’s most racially diverse population Community Health Needs Address community need while recognizing disproportionate impact

• Focus on food insecurity screening and referral
• Use data to identify new areas of opportunity
• Increase community partnerships for

sustainable impact

Readmissions

• Focus on decreasing avoidable readmissions for

African American dual-eligible patients

• Improve access, systems, and community

partnerships

Graduate Medical Education Participation in national equity collaborative

• Find new ways to hear from patients of color,

particularly American-born African Americans

• Engage African American trusted partners
• Develop skills/knowledge in Experience Council
• Build data infrastructure to identify disparities
• Design new systems/building for equity
• Strengthen community partnerships focused
• n equity
• Integrate Psychiatry, Foot and Ankle and

Internal Medicine residents into Regions’ strategy to eliminate health care disparities

6/20/2019 16

Discussion questions

1 2 3

What questions do you have? How are your organizations addressing health and health care disparities? What commitment can you make today to advance health equity?

32

Best Practice Presentation

Kendra Willey

6/20/2019 17

Anxiety Shared Pathway Toolkit

34

Shared Pathway Workgroup

A workgroup was formed out of the Coordination of Care Initiative to develop a Shared Pathway that would help reduce hospital readmissions.

6/20/2019 18

35

Shared Pathway Workgroup

• The workgroup consisted of a variety of participants

throughout the care continuum, from hospital and transitional care settings to home care and hospice, Stratis Health, and even a DME company.

• Integrative therapy experts were added to the group

who were able to provide valuable input around various modalities and treatment options.

36

The work group determined that they would develop a pathway focused on reducing anxiety.

• Anxiety is one of the leading causes of hospital

readmissions and crosses many diagnoses

• Mitigation of anxiety symptoms can be achieved in

variety of care settings

• Good Samaritan Society-Specialty Care Center had

a framework that included assessment tools, modalities and protocols

Anxiety Shared Pathway

6/20/2019 19

37

Anxiety Shared Pathway

• The intent is for the pathway to be used throughout

the continuum to provide caregivers with integrative therapy techniques to offer their residents/clients to mitigate anxiety

• This will ultimately lead to better outcomes,

increased feelings of satisfaction and well-being

38

Anxiety in Post-Acute Clients

• Anxiety symptoms can affect many individuals

in post-acute settings

• Common diagnoses with anxiety components

include CHF and COPD

• Many health other health conditions can stir

symptoms of anxiety

6/20/2019 20

39

Anxiety in Post-Acute Clients

Other factors which contribute to anxiety symptoms

• Underlying depression
• Underlying/untreated generalized anxiety
• Health anxiety
• Situational anxiety*

* transition, loss of abilities, financial, housing, other social determinants of health, etc.

40

Barriers with Anxiety

Anxiety can negatively affect outcomes in post-acute clientele

• Increase rehospitalization rates
• Ability to participate in therapies (PT/OT/SLP)
• Lack of engagement in personal health
• Conversely, hyper-vigilance in personal health care

which can then create barriers to safe progression and transition

6/20/2019 21

41

GSS Specialty Care Process

• Worked with Mental Health/psych DNP student to

address anxiety in post-acute, TCU setting

• Completed literature review regarding anxiety and

this population

• Developed a pathway to help mitigate symptoms
• f anxiety in efforts to reduce rehospitalization

42

GSS Specialty Care Process

• Used a screening tool on all TCU residents –

Short Health Anxiety Inventory (SHAI)

• Depending on score on the SHAI score,

corresponding interventions were implemented

6/20/2019 22

43

Pathway Interventions

Low-level anxiety symptoms –

• care planned for aromatherapy, deep breathing,

hand massage, acupressure

Mid-level symptoms –

• all of the above plus a visit from Wellness

Coordinator or chaplaincy as appropriate

44

Pathway Interventions

High-level symptoms –

• all of the above plus, invitation to weekly

anxiety group, referral to house psychologist

Group included: sharing, validation, art process, and cognitive behavioral therapy (CBT) components

6/20/2019 23

45

Pathway Barriers

• Residents were reluctant to come to a group

for a myriad of reasons

• SHAI tool did not seem to capture all anxiety

symptoms

• SHAI tool is 18 questions long and “wordy”
• Trialed GAD 7 and had much better results

46

Toolkit

• The workgroup determined an internet-based

toolkit would be the best approach to educate and prepare staff to implement their own integrative therapy programs

• Representatives from Stratis Health were able to
• btain permission to house the toolkit on their

website

6/20/2019 24

47

Toolkit Content

48

Toolkit Content

6/20/2019 25

49

Toolkit Content cont.

50

Toolkit Content cont.

6/20/2019 26

51

Toolkit Content cont.

52

Toolkit Content cont.

6/20/2019 27

53

Toolkit Content cont.

54

Toolkit Content cont.

6/20/2019 28

55

Toolkit Content cont.

56

Toolkit Content cont.

6/20/2019 29

57

Toolkit Content cont.

58

Toolkit Content cont.

6/20/2019 30

59

Please share this information with your colleagues. We will also be approaching a variety of agencies to help promote the toolkit.

Promotion

60

Link to Web Page:

https://www.lsqin.org/initiatives/coordination-of-care/

Direct Link to the PDF:

https://www.lsqin.org/wp-content/uploads/Anxiety- Shared-Pathway-toolkit.pdf

Toolkit Link

6/20/2019 31

61

Kendra Willey, Wellness Resource Coordinator Good Samaritan Society - Specialty Care Community kwilley@good-sam.com

__________

Nicole Mattson, Administrator Good Samaritan Society - Specialty Care Community nmattson@good-sam.com Peg Lusian, Vice President Fairview Partners plusian1@fairview.org

Questions

62

Appreciation! Recognition! Celebration!

6/20/2019 32

63

National/Regional Accomplishments

National

• 90,961 hospital readmissions avoided
• 388 communities
• 1.1 billion dollars cost avoided

Regional (Lake Superior QIN – MI, MN, WI)

• 15,500 hospital readmissions avoided
• 26 communities
• 199 million dollars cost avoided

64

East Metro Accomplishments

Participation:

• 221 individual participants
• 107 different organizations
• Assisted living facilities
• Clinics
• Community organizations
• Government groups
• Health plans
• Health systems
• Home health agencies
• Hospice programs
• Hospitals
• Nursing homes
• Pharmacy Groups
• University
• Resource suppliers
• Quality/safety
• rganizations

6/20/2019 33

65

East Metro Accomplishments

Workgroups:

• Mental Health
• Mental health training videos and support materials
• Discharge Process Out of the Hospital
• Post-Acute access to the ready-only EMR; Shared

Pathways workgroup

• Care Transitions SNF to Home
• Pilot using a pathway for follow up phone calls
• Medication Management
• Medication discrepancy tool (draft)

66

East Metro Area Accomplishments

What changes has your organization made to improve care transitions, care coordination or reduce unnecessary hospital readmissions in the past three years?

6/20/2019 34

67

Recognition

68

Celebration!

6/20/2019 35

69

Contact Info

Nancy R Miller, Stratis Health nmiller@stratishealth.org, 952-853-8528 Janelle Shearer, Stratis Health jshearer@stratishealth.org, 952-853-8553

This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C3-19-237 061919