Andrea LeBlanc, COO Brenda Czad, Directr f Hme Care Rbert Pahlavan, HeathWyse CEO M.O.D.E.L. Care Mtivatin M.O.D.E.L. Care Fundatin M.O.D.E.L. Care Imprtance and Cllabratin with ur EMR Vendr What is M.O.D.E.L. Care? M.O.D.E.L. Care Implementatin and HealthWyse Supprt 1
Describe M.O.D.E.L. Care and its patient care impact. Explain hw M.O.D.E.L. Care ensures best practices and delivers the highest quality f care. Demnstrate hw technlgy and specifically a strng partnership with yur EMR vendr can enable M.O.D.E.L. Care and deliver better patient care. Getting t M.O.D.E.L. Care 2
Meaningful Organized Develped Effective/Efficient Lasting Quality Meaningful Organized Develped Effective/Efficient Lasting Quality 3
Rb Pahlavan, CEO f HealthWyse Innvatin in care supprted by technlgy: Cnsistent lgistics Shared infrmatin (medical/psych-scial/etc.) Facilitated practive apprach t caregiving Partnership between vendr and prvider: Special technlgy supprts Fully-integrated system t supprt infrmatin exchange Allws fr data-fcused prcess imprvement & discvery 4
M.O.D.E.L. Care Will Create: A cnsistent high standard f quality care Outstanding patient satisfactin Outstanding referral cnfidence in predictable high quality and highly efficient care AND.. If the emplyee perfrms well, the patient receives ptimal care and therefre the agency perfrms well! They ll: Knw what t expect when hme care/hspice is cming t the dr Experience cnsistency n matter which staff member is serving them Trust yu Feel and be well cared fr by every staff member Receive the highest f quality care The care fcus will be n THEIR challenges and NOT the emplyees The care will be abut the patients gals and nt the clinicians needs fr the day. 5
Emplyees: Care abut patients (and it needs t be all abut the patient) Care abut and take pride in their perfrmance which affects the patient Understand they prvide gd care t patients but believe everyne has rm fr imprvement Want t be a team player and care abut their place f wrk and clleagues They understand that what they d MATTERS! High internal and natinal patient care satisfactin and utcme results will psitin agencies t be the: PROVIDER OF CHOICE Wrking with an intuitive EMR and building strng partnerships with the EMR vendr is critical t btaining and assessing meaningful data. This becmes yur deplyment strategy as yu ll see when we talk abut implementing M.O.D.E.L. Care. 6
Brenda Czad, AHCH Directr f Hme Care M.O.D.E.L. Care Is: A template that will be used t educate and guide best practice Intended t mdify behavirs related t standardized best practice expectatins A sustainable practice change 7
Be intentinal abut making care meaningful Present yurself prfessinally when yu arrive fr a visit Wear neat, clean clthing (agencies: cnsider unifrms) Have I.D. visible Represent the agency, nt just yurself Be prepared fr each visit i frm start f care (SOC) t discharge, and invlve the patient, family, and caregivers in the plan f care. HOW are clinicians ging t d this??? Mve all yur persnal prblems t the back burner Enter the hme attentive and present t the patient and caregiver(s) Methdical: knw WHY yu are making the visit! Review last visit nte, care plan, MD rders, and cmmunicate with ther prviders. Knw and cmmunicate t the patient/family what needs t be accmplished at the visit t include the anticipated length f the visit (Manage the visit!) 8
Prvide Case Management Knw where yu are in the care f the patient, the gals, and the interventins anticipated at the visit Anticipate the patient s needs: cmmunity resurces, supplies, MD visits, ther discipline visits Knw what is ging n fr the patient and what will impact the care psitively Use the EMR PPS Tab EMR Prvides Actinable Insights Analysis: viewing caselad acrss varius metrics (by dx, MD, therapy) Understand benchmarks fr care delivery; utilize metrics t drive prcess imprvement Address utliers 9
Reprts will assist in measuring quality care, prductivity, it and satisfactin Utilize yur EMR alerts, tabs, etc. t guide yu Practive POC slutin helps t drive cmpliant clinician behavir KPIs Team Supervisrs/Managers review with staff Key Perfrmance Indicatrs (KPIs) Clinicians knw patient s utcmes: pain, dyspnea, bathing, ambulatin, etc. Track persnal/team prductivity weekly 10
The Patient s Schedule When d yu cnfirm yur appintments? Patient s have plans t, even if they are hmebund Arrival time: 30 min. windw ntify patient if yu re running late! Directins Verify address and directins (Cnsider a GPS) If yu ll be making the first visit and the directins were incrrect crrect in the EMR Supplies: Knw what supplies are needed based n Dx and rders. Equipment: Knw what is need and hw t use it! OPEN yur cmputer after intrducing gyurself and take a mment t establish rapprt with the patient: At time f admissin explain what the cmputer is fr; review as needed Integrate the cmputer int yur visit Avid the cmputer becming a barrier Cmplete yur dcumentatin as part f the visit, r at the end f each visit = POS Dcumentatin! 11
Cnducting visits in a standardized way that is well develped with the understanding that all patients require individualized care. Hmecare Intelligent Disease Pathways, HiWays Adjusting t issues, radblcks, c-mrbidities Evidence- and standards-based Utilizes cntent frm leading authrities t guide decisin-making Cntextual Tls Drive Predictable Outcmes Intelligent medicatins Intelligent rders Intelligent cding Cllabrative Risk Management Tls CRM ACO cnnectivity Cntinuus care dcuments 12
Demnstrate: Cnfidence and knwledge f the patient s status and situatin Cmpetence, Cmpassin Capability in cnnecting with the patient Maintain apprpriate prfessinal bundaries Deliver: The specific care required and rdered d Cmmunicate with MD., ther resurces, and the care team. Des the patient have what they need? Functin within yur scpe f practice Dcument: Use the EMR as an integrated tl Balance skillful dcumentatin with active listening Cmplete signature dcuments timely Dcument bjectively and avid yur wn subjective cmments Read yur wn and peer dcumentatin as if yu were an utsider: des it say what it shuld? 13
We must be bth effective and efficient! Educate the patient/caregiver abut: Disease management Skills with teach back Pain and symptm management Cping and ways t imprve quality f life What an agency can and cannt d fr them Ensure skilled care is prvided per MD rders Evaluate: Effectiveness f interventins Patient satisfactin Prgress tward gals Patient needs and cncerns Efficiency f the visit and make plans t address what may be impeding this At the end f each visit ask: Have I been helpful t yu tday? r I have sme clinical gals fr ur next visit, what wuld yu like t fcus n at ur next visit? 14
Listen: Actively listen t the patient/family/caregivers Lead: Manage the visit, time, cntent, gals, skills Assess yur visit Did it g as yu hped? What can yu imprve next time? Lve and Leave: Leave the patient/family/caregiver(s) feeling well cared fr and lved Leave n a psitive nte knwing: Yu were an inspiratin, empathized, and yu were memrable in a prfessinally psitive way. Leave n time being respectful f: The patient s time and energy level The requirement t meet the needs f many patients in a given day 15
Full day ypresentatin Time fr emplyee cllabratin: Lunchen Hnring the past: what we d well Timeline f agency histry Vide interviews with lng standing staff Slide shw set t music M.O.D.E.L. presentatin The stry and slide shw yu just heard Patient panel Referral surce panel Discussin f the M.O.D.E.L. Visit resulted in ther key prjects t supprt the MODE M.O.D.E.L. Visit. i Prjects: Clinical The Visit Cmmunicatin Scheduling Case Management Data/Reprts Pint f Service Dcumentatin Administrative: Web develpment, I.S. Internal Custmer Service, Vlunteer cmmunicatin/dcumentatin 16
Using LEAN prcesses, identify: Executive Spnsrs (buy in frm tp dwn) Team Leaders Cre Members Prvide training fr the teams t include: Hw t run a meeting Dcuments t use Reprting structures Gals and timelines Fllw-up is key! Assess the situatin - what is the current state? Yu ll ` Identify the key prblem (dn t slutin jump) Prblem statements are nt simple! 17
Cmmunicatin: (8) frms f tw-way cmmunicatin (each reaching less than 50% f staff) Canceled visits: >3,000/m. fr multiple reasns (we were stunned by this data pint!) What time d yur clinician s i i really start t their day? Reprts t many t cunt. Identify measures: Prcess Measures: Did the staff fllw the prcess? Outcme Measures: Did the prcess wrk? Analyze using the 5 whys: (why, why, why, why, why?) Identify a future state (nt slving wrld hunger) 18
Prpse a test f change what is yur prpsal t reach the future state (hw d yu get frm y t z?) Plan, plan, plan Implement the plan PLAN, DO, CHECK, ACT (Make it, Break it, Fix it) T set the stage fr the M.O.D.E.L. Care 19
SCHEDULING PROJECT: Functinal Assessments (FA) Current State Hlding 30 90 visits (20-70K/week wrth f visits) frm billing Unable t bill: n qualifying FA One team assistant managing FA lists Analysis: Multiple canceled visits by patients Scheduler nt checking FA t d list as instructed Instructins nt as helpful as initially thught Therapists nt re-assigning visits when they were ut. Cntent f FA ntes nt up t par Interim plan: tw prject leads managed the Functinal Assessments Increase the number f TAs managing the FA lists Flw charts develped t assist TAs fllw prcess Cmpetency develped t assess Team Assistants Develp audit tl t ensure TAs is reviewing the list accurately DRUM ROLL results: 20
100 90 Nn Billable Therapy Visits it 80 70 60 50 40 30 Ttal ST OT PT 20 10 0 Meaningful Organized Develped Effective/Efficient Lasting Quality 21
Meaningful Organized Develped Effective/Efficient Lasting Quality Fr further infrmatin cntact: Andrea LeBlanc, COO, Andrscggin Hme Care & Hspice Rb Pahlavan, CEO, HealthWyse 207-777-7740 andrea.leblanc@ahch.rg 877.777.9973 rpahlavan@healthwyse.cm 22