Collaborations. from the Field
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1 Care Transitions Community Wide Collaborations Best Practices and Experiences Best Practices and Experiences from the Field
2 CCTP Monthly Webinar: July 2012 This webinar focused on the topic of engaging SNFs, home health organizations, and other LTC providers. We heard dfrom two CCTP faculty members, Jennifer Pruitt and Vickie Worden and Cyndi Burke from the Atlanta Regional Commission about how SNFs in their communities collaborated with hospitals and other community partners on improving care transitions.
3 Jennifer Pruitt, MSOTR, NHA Burcham Hills Retirement Community Lansing, MI
4 Jennifer Pruitt, MSOTR, NHA Burcham Hills Retirement Community In 2006 the cost to Medicare for all SNF related readmissions was $4.34 billion and 78% or $3.39 is estimated to be potentially avoidable. When you take into account that the cost to Medicare for all unplanned readmissions is $17.4 billion, The SNF contribution of $3.39B is 20%
5 Jennifer Pruitt, MSOTR, NHA Burcham Hills Retirement Community Administration proposal: Beginning in 2015, individual skilled nursing facilities with aboveaverage re hospitalization rates would have their reimbursement rates cut by up to 3%. The Administration proposal is very similar in approach to the hospital readmission reduction program in the Affordable Care Act.
6 Jennifer Pruitt, MSOTR, NHA Burcham Hills Retirement Community Successful Communities in the 9 th Statement of Work (SOW) partnered with post acute providers. Reduction of Readmissions became a communitywide effort. All down stream providers have a role in readmission and improvement at every transition is critical.
7 Jennifer Pruitt, MSOTR, NHA Burcham Hills Retirement Community Create a strategy to organize the SNF community Organize a community wide summit Recruit workgroup members Identify and discuss care transitions challenges between hospital to SNF and SNF to Home or Home CareTransitions Identify common root causes Identify action items for improvement
8 Jennifer Pruitt, MSOTR, NHA Jennifer Pruitt, MSOTR, NHA Burcham Hills Retirement Community
9 Vickie Worden, RN CCTP Faculty & Hillcrest Health and Rehab
10 Vickie Worden, RN CCTP Faculty & Hillcrest Health and Rehab Where we were: Silos of healthcare Competitive Afraid to share our secrets
11 Vickie Worden, RN CCTP Faculty & Hillcrest Health and Rehab How we came together: Started meeting once a month Brainstormed what an ideal transition would look like Developed tracking tools that monitored reason for transfer, medical instability, efforts to handle the situation at the SNF and time and dt date.
12 Vickie Worden, RN CCTP Faculty & Hillcrest Health and Rehab Where we went: Did site visits Not just a tour, but actually worked with each other for ½ a day Developed a template for nurse to nurse calls Looked at transfer sheets What information did we need? Trained our staff in the nurse to nurse call, disease specific education, interact tools
13 Vickie Worden, RN CCTP Faculty & Hillcrest Health and Rehab Where we are today: Much improved communication between the hospital and the SNF Developed relationships that are purposeful Able to work together without fear of not getting referrals or retaliation Improved patient outcomes
14 Cyndi Burke Atlanta t Regional lcommission i
15 Cyndi Burke Atlanta Regional Commission 20 25% of all hospital readmissions are from patients in rehabilitation or admitted to SNFs. If we are not intervening with these patients, we are missing i a large percentage of the readmitted d hospital population.
16 Cyndi Burke Atlanta Regional Commission Need to partner with SNFs, HH and rehab facilities to help them understand the role of CCTP and to better reach this population. CROSS SETTING MEETINGS Hospitals, nursing homes, patient advocacy organizations and other stakeholders in communities committed to improving quality and lowering readmission rates realizing that if all community service providers are not connecting, readmissions will continue to be a problem in our community
17 Cyndi Burke Atlanta Regional Commission Next steps: Move forward in developing more formal partnerships with SNFs Did not want to make next move arbitrarily without ih understanding di community roles Because of this foundation work better poised to make the next move.
18 Next Steps
19 1. Build and sustain a community coalition with a focus on improving i transitions ii of care for Medicare beneficiaries.
20 2. To be a vehicle for the patient and family voice.
21 3. To encourage person centered and person directed d models dl of care.
22 4. To collaborate and encourage efforts of organizations i with ihshared visions. ii
23 5. To advance public policies that further the vision. ii
24 Desired Partners & Providers Skilled Nursing Facilities Home Health lhagencies Hospice Organizations Palliative i Care Organizations i Dialysis Facilities Other Oh downstream providers
25 To participate in the Southern Ohio CCTP please register before you leave today!
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