HealthEast Care Naviga0on Strategy February 17, 2011
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1 HealthEast Care Naviga0on Strategy February 17, 2011 Rahul Koranne, MD, MBA, FACP
2 Series Objec+ves At the conclusion of this learning activity, participants will be able to: 1. Identify key changes and strategies that were used to reduce avoidable readmissions. 2. Describe how the program was developed and tools the team used. 3. Discuss the outcomes of the program. 4. Discuss how these best practices may be applied in their own organization.
3 Rahul Koranne, MD (speaker); Kathy Cummings and Joann Foreman (facilitators) have no relevant financial relationships to disclose and do not intend to discuss off-label or investigational uses of commercial products or devices.
4 HealthPartners Institute for Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. HealthPartners Institute for Medical Education designates this educational activity for a maximum of 11.0 AMA PRA Category 1 Credit (s), and 13.2 contact hours by MN Board of Nursing criteria. Physicians should only claim credit commensurate with the extent of their participation in the activity.
5 Introduc0on to our Presenter Rahul Koranne, MD, MBA, FACP Medical Director: Bethesda Hospital, Home Care Physician Lead for the Care Naviga+on Strategy Ac+ve on MDH/DHS commieees around MN Reform work
6 HealthEast Care System St. Paul, Minnesota Woodwinds St. Joseph s St. John s Bethesda HealthEast Care System 4 Hospitals 12 Primary Care Clinics More than 35 specialty services Home Care & Hospice Medical Transportation Some Statistics Licensed Beds 925 Employees 7300 Volunteers 1200 Credentialed Physicians 1400
7 HEALTH CARE NEWS National Committee for Quality Assurance (NCQA) 2011 Draft ACO Criteria Care Coordination & Transitions (CT) - The organization can facilitate timely information exchange between primary care, specialty care and hospitals for care coordination and transitions. (CT 1) Care Management (CM) The organization collects & integrates data from various sources, including, but not limited to electronic sources for clinical & administrative purposes. (CM1)
8 HEALTH CARE NEWS Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) Survey Q19 During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? Q20 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
9 HEALTH CARE NEWS The Pa0ent Protec0on & Affordable Care Act (PPACA) Statute will Penalize Hospitals & Integrated Delivery Systems with Higher than Expected Readmission Rates Focus initially on: Heart Failure Acute Myocardial Infarction Pneumonia Followed by focusing on: Chronic Obstructive Lung Disease Coronary Bypass Grafting Percutaneous Coronary Interventions Vascular Procedures Clinical outcomes in FFY 2012 will dictate the penalties leveraged in FFY This means that patients discharged as soon as October 1, 2011, will have an influence on future reimbursement.
10 HEALTH CARE NEWS Medicare Accountable Care Organizations Shared Savings Program New Section 1899 of Title XVIII Preliminary Questions & Answers CMS/Office of Legislation Question: What are the types of requirements that such an organization will have to meet to participate? Answer: The statute specifies the following: Have defined processes to promote evidenced-based medicine, report the necessary data to evaluate quality and cost measures Coordinate care
11 HealthEast Acute Hospitals IP Margin & Charges - by Age % of Margin % of Charges 60% 50% 50% 46% 40% 32% 30% 20% 23% 19% 23% 10% 4% 3% 0% Age Group
12 NRC PICKER Dimensions of Patient-Centered Care
13 Complex Patient Encounter Flow 6 5 Acuity Level Jan Mar May July Sep Dec InPt Visits Outpt Visits Cardiac Rehab Office Visits Home
14 The Continuum of Care Acuity/Cost Acute Care Transition Coach TCU/SNF Institutional Rehab Care Self Specialty Clinics Primary Clinics Home Care Community Health Worker & Parish Nursing Clinics Community-Based Care Health Alert Self Based upon SG2 2010
15 Patient Centered patient/family partnership Effective - impact clinical quality measures. Safe - close care gaps, reduce complications HealthEast Care Navigation Vision Promise: Care for patients within an integrated and patient centered model of care that leverages all components of the HealthEast Care System delivering a coordinated and positive care experience. GUIDING PRINCIPLES PATIENT CENTERED Timely - prevent care delays Equitable culturally responsive Efficient best use of resources across continuum Help me through my care experience. Help me to manage across episodes. Connect me to the right resources. Coordinate my whole experience with HealthEast. Communicate with me in ways I understand. Excellent Patient Experience Financial Alignment Quality Outcomes Effective Specialty Programs Right Care Right Time Right Place Care Model HISTORY Episodic Care Provision Program-Driven Solutions Financial Silos Episodic Care Longitudinal Care Relationship Steering Team 5/29/08
16
17 HealthEast Care Naviga0on Driver Diagram Primary Drivers Patient Information Sharing Secondary Drivers Connecting the EMR Midas Enterprise Care Management Tools for hand-off, communication, Referrals, protocols Goal Model for Improved: Health outcome Care experience Cost per capita Transition Management Patient/Family Centered Flow, throughput Evidence based care Navigator / coach roles Medication reconciliation Follow up care Advance Directives Culturally responsive systems & staff Language services Education Screening & risk assessment Financial Alignment Partnerships Contracts System leverage Across silos
18 HE Transition Coach Four Pillars Medication Management Personal Health Record Follow-up with PCP Education regarding Red Flags Prescriptive Interventions Hospital meeting Post-Discharge Home Visit Post-Discharge 3 phone calls Diagnoses: CHF, CAD, Arrhythmia, PVD, COPD, CVA, Diabetes, Hip Fracture & Joint Replacement
19 Chronic Care Model Community Resources & Policies Health System Health Care Organization Self- Management Support Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes
20 Transi0on Coach Pilot Program History Sept 2007 Dec 2007 June 2008 Feb 2009 March 2009 Implemented pilot program on one floor at St. John s Hospital. Patients from Roselawn & Maplewood Clinics Expanded to All floors at St. John s Hospital. Expanded to All HE Clinics Added second Transition Coach to serve St. Joseph s Hospital Expanded age criteria to 50+ Added 3rd Transition Coach to serve St. Joseph s Hospital And Woodwinds Hospital
21 Three Dimensions of Value Population Health Experience of Care Per Capita Cost Triple Aim
22 Transition Coach Results January - November persons enrolled Quality 32% Medication Discrepancy Addressed Percent of patients that found program to be helpful/very helpful with Managing Medications 85% Better understanding on when to call PCP 83% Better prepared to work with PCP 77% Follow-up appointments 69% Patient using the PHR 71% Patient Satisfaction Cost 12 % readmission rate 30 days post discharge (for any level of intervention) Compared to national average 20-25% Data system conversion in December of 2009
23 Transi0on Coach Model Choosing the Details Staff: HealthEast model is RN based Home Visit is key Scope of program Training The Staff TCU; SNF; Healthcare Direc+ve; Hospice How many +mes to enroll someone before they are considered un- coachable? Transi+on Coach mindset (cer+fica+on from U of Colorado) Hospital staff and Primary Care staff educa+on Adapt tools to meet your needs Communica+on system and forms Introduc+on leeer Personal Health Records Data Collec+on systems
24 Welcome LeSer Jane Kemper, R.N. St. Joseph s Hospital Woodwinds Hospital Julie Leahy, R.N. St. Joseph s Hospital Ruth Ratajczak, R.N. St. John s Hospital Woodwinds Hospital
25 Demonstra0ng Value Integrate your documenta0on systems to your accoun0ng and quality systems from day 1 Establish a credible baseline Measure value to hospital Readmission rate (30 day all cause) ED return (7 day all cause) LOS upon readmission (by diagnosis) Pa+ent Sa+sfac+on: Hospital and Program Medica+on Discrepancy Referral to Care and services Post Discharge Home Care, Hospice, Outpa+ent services Reduce Total Cost of Care Partnerships with Payers
26 Lessons Learned Collect and Monitor your data Number screen vs. enrolled; reasons for disenrollment; program comple+on +melines; average case load; audit the coaching etc. Create a credible baseline Watch environmental trends Reimbursement Changes in local market Changes in quality indicators NQF Measuring & Repor+ng Care Coordina+on Paradigm shi^/adap0ve change Hospital centric to full con+nuum Communica0on is key Stakeholders including physician groups, staff etc. Pa+ent stories across con+nuum as wins
27 The Continuum of Care Acuity/Cost Acute Care Transition Coach TCU/SNF Institutional Rehab Care Self Specialty Clinics Primary Clinics Home Care Community Health Worker & Parish Nursing Clinics Community-Based Care Health Alert Self Based upon SG2 2010
28 Acute Care Navigation Work Hospital floor Transition Coach Specialty Navigator D/C PCP Navigator Specialty Navigator PCP Navigator Inpatient Care Managers (redesign of roles) D/C plans care progression flag others Teaming with Physicians Key Connections Home Care Palliative Care Transitional Care
29 Post Acute Care Long Term Acute Care Hospital Most complex and Cri+cal pa+ents High quality in a lower cost structure Home Care High pa+ent sa+sfac+on in a lower cost structure Reduce readmissions and ED visits Other Community based services Partnerships with TCU SNFs Community Health Workers, Parish nurses etc.
30 Awards & Recognition 1st three level II certified transition coaches in nation - September 2007 Front page article in St. Paul Pioneer Press newspaper - October 2008 Poster Session Minnesota Alliance for Patient Safety Conference - November 2008 Presentation at ICSI (Institute for Clinical Systems Improvement) seminar - November 2008 Poster Session National IHI conference - December 2008 AHA (American Hospital Association) acknowledgement as Innovative Care Model - Mar 2009 Presentation at IHI (Institute for Healthcare Improvement) seminar - May 2009 Results of Care Navigation showcased by SG2 in their completed study The Business of Managing the Perpetual Patient - July 2009 Nation Association of Agencies on Aging Innovation & Achievement Award - July 2009 HealthPartners Innovation of the year Award November 2009 Article in MN Physician Magazine MHA Innovation of the Year Award May 2010 Presentation at Microsoft HealthCare Users Exchange September 2010 Presentation at Minnesota Alliance for Patient Safety September 2010 Showcased as best practice in AHA Trend Watch publication November 2010 Presentation of 2 Workshops at Annual IHI meeting December 2010
31 Managing the Middle Game
32 Ques0ons
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