A TIME OF CHANGE STEERING THE FUTURE OF CARE COORDINATION CARE COORDINATION THE NATIONAL QUALITY AGENDA SIX PRIORITIES OF THE NATIONAL QUALITY AGENDA

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1 A TIME OF CHANGE STEERING THE FUTURE OF CARE COORDINATION THE NATIONAL QUALITY AGENDA SIX PRIORITIES OF THE NATIONAL QUALITY AGENDA 1. Safer Care 2. Patient Engagement 3. Effective Prevention and Treatment 4. Best Practices in Healthy Living New Delivery Models CARE COORDINATION Integrating Communicating Organizing Synchronizing ASSOCIATED WITH CARE COORDINATION Patient and Family Satisfaction Overuse, Underuse Length of Hospital stay Hospital Readmission Medical Errors, Medication Errors Duplication or Gaps in Services 1

2 Almost 1/5 of hospitalized patients are readmitted within 30 days PREVENTING HOSPITAL READMISSIONS: A $25 BILLION OPPORTUNITY Opportunity Solutions Rate is going down but still almost 18% About 75% of readmissions considered preventable Source: Office of Information Products and Data Analytics, CMS, 2013 National Priorities Partnership, 2010 My Story All these people All these tests HOW DO WE CAPTURE Did they get my tests? Why doesn t this person know much about me? I was supposed to get home care today, are they coming soon? 2

3 WHY? overall U.S. quality score down. care pull the AND YET, WE SPEND A LOT OF TIME DOING IT Staff Nurse Practice Time The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, 7.2% 17.2% 35.3% 19.3% 20.6% Document Patient Care Assess/VS Care Coord Med Admin Commonwealth Fund, 2014 Hendrich, et al, 2008 Patients and Families spend even more time What is this thing called care coordination?? Source: Lind 2012 in Antonelli & Rogers, 2013 CARE COORDINATION 2006 CARE COORDINATION 2010 Measurement Domains: - Healthcare Home - Proactive Plan of Care and follow-up - Communication - Information Systems - Transitions or hand-offs National Quality Forum Framework for Defining and Measuring Care Coordination, 2006 McDonald et al, 2010 AHRQ Care Coordination Measurement Atlas 3

4 CARE COORDINATION 2014 CAPTURING CARE COORDINATION Patient needs and preferences Communication and information sharing Organization of patient care activities Appropriateness Integrated plan of care National Quality Forum, 2014 Timing deliberate synchronization Outcomes Explicit continuum perspective YOU ARE COORDINATING CARE WHEN YOU: with patients, families and other team members about the plan of care and keeping it on track. Get the needed people involved at the right time and right place to that appropriate services are provided. Work with patients and families to identify their goals and preferences and them in the plan of care. that the needed services have been identified, arranged, and are delivered when needed. YOU ALSO ARE COORDINATING CARE Organize services to make them more manageable Arrange for care following hospitalization CARE COORDINATION What can we do?? Second nature Intuitive Done without thinking INVISIBLE 4

5 1. RECOGNIZE IT When I do this I am coordinating care CARE COORDINATION FOR PATIENTS Care Coordination is: Getting the right care at the right time Having my providers talk with each other Not having to worry if something I need will be done Knowing everyone is on the same page 2. BE AWARE OF THE EVIDENCE What do we know about Care Coordination? Care Coordination TRANSITIONAL CARE Best known and studied care coordination process Most hospitals and systems using a combination of models Most common driver: Reduction of hospital readmissions Case Management Transitional Care Search for less expensive models, substitution of diverse providers, role of HIT 5

6 EVIDENCE-BASED TRANSITIONAL CARE MODELS Boost Better outcomes for Older adults Project Red Re-engineered discharge Care Transitions Model Coach Evidence-based Models SW Bridge Model INTERACT Interventions to reduce acute care transfers Transitional Care Model HIGH VALUE TRANSITIONAL CARE INTERVENTIONS One primary care coordinator In-hospital assessment Development of a transitional plan of care with active engagement of patient, family, hc team Home visits usually for 2-3 months with monitoring, self-care education early identification of changes in status, risk Telephone support and counseling Attendance at post-hospital primary care visits Naylor et al, 2011 IN PRIMARY CARE The Affordable Care Act has introduced numerous Initiatives focused on building care coordination in primary care. EVIDENCE IN PRIMARY CARE Most studies look at interventions for populations with chronic illness Medicare Coordinated Care Demonstration HIGH VALUE COMMUNITY- BASED CARE COORDINATION INSIDER-EXPERT Common to successful programs 6

7 CONSISTENT ELEMENTS Communication Consistent Relationship Medication Education Self-management Education Telephone support STILL AHEAD Dealing with Variability in: Who receives care coordination Who delivers the care coordination interventions How the care coordination intervention is delivered (Dose, consistency, duration) When care coordination starts, ends What outcomes are measured, when COMPLEX PROCESSES Teamwork System Thinking Evidence-based practice 3. MEASURE IT If you were asked to propose a comprehensive assessment tool for care coordination I WOULD ASK: STATE OF CARE COORDINATION MEASURES Few measures overall; few new measures being submitted for review Very few in the areas of patient engagement, synchronization, outcomes Most are provider and condition specific and limited in their continuum perspective 7

8 EXAMPLES OF ENDORSED MEASURES FOR CARE COORDINATION Patients with transient ischemic event ER visit who had a follow up office visit Reconciled medication list received by discharged patient Transition record with specified elements received by discharged patients PRIORITIES IN CARE COORDINATION MEASURES Joint Creation of Person Centered Plan of Care Comprehensive Assessment Function, social needs, behavioral health needs Use of Health Neighborhood To execute Plan of Quality of Services Timeliness, reliability of services, accessibility Achievement of Outcomes Experience Care team s experience of care coordination Goal Setting Synchronization Progress toward goals Shared decision making Bi-directional communication Health outcomes, functional status Shared Accountability Efficiency Plan documents care team Avoid redundant assessments 4. ADVOCATE FOR MEANINGFUL POLICY POLICY AGENDA FOR NURSE CARE COORDINATION Payment for qualified health professionals Funding for measure development and testing Funding to test and expand high value practice models Workforce development Standardization of competencies for accreditation and maintenance of certification Meaningful Use and HIT American Nurses Association & American Academy of Nursing May 2015 POLICY PRIORITIES Expand payment for consistency across all qualified health professionals delivering high value care coordination activities including bachelor s prepared nurses Accelerate the design, endorsement and use of rigorously tested care coordination measures including those central to the domains of nurse care coordination. 8

9 IT SHOULD HAPPEN: In every setting Across all settings SELECTED REFERENCES Agency for Healthcare Research and Quality (AHRQ). (2014) Care coordination measures atlas update. Rockville, MD: Agency for Healthcare Research and Quality. Brown, R.S, Peikes, D., Peterson, G., & Razafindrakoto, C.M. (2012). Six features of Medicare Coordinated Care Demonstration Programs that cut hospital admissions of high risk patients. Health Affairs, 31(6), Haas, S. A,, Swan, B.A., & Haynes, T.S.(Eds). (2014). Care coordination and transition management core curriculum. Pitman, NJ: American Academy of Ambulatory Care Nursing. Lamb, G. (Ed). (2013). Care coordination: the game changer. Silver Spring, MD: American Nurses Association. SELECTED REFERENCES CONT. Naylor, M.D., Bowles, K.H., McCauley, K.M., Maccoy, M.C., Maislin, G., Pauley, M.V. & Krakauer, R. (2013). High value transitional care: translation of research into practice. Journal of Evaluation in Clinical Practice, 19, , Ouslander, J. G., Lamb, G., Tappen, R., Herndon, L., Diaz, S., Roos, B., Grabowski, D. C., & Bonner, A. (2011). Interventions to reduce acute care transfers from nursing homes. Journal of the American Geriatrics Society, 59, Peikes, D., Chen, A., Schore, J., & Brown, R. (2009). Effects of care coordination on hospitalization, quality of care, and health expenditures among Medicare beneficiaries. JAMA, 301(6), Thorpe, KE & Ogden, L.L. (2010). The foundation that health reform lays for improved payment, care coordination, and prevention. Health Affairs, 29(6), Thank you!!! 9