The Value Proposition for Transitioning to a New Model of Operations

1. The Value Proposition for Transitioning to a New Model of Operations

2. How to Improve Performance • Regulations • Public reporting • Reimbursement

3. ACA’s Three Aims • Better patient experience • Better outcomes • Lower costs

4. Medicare/Medicaid >> Managed Care • Goal – encourage coordinated care • Reward providers that meet three aims – • Safe, efficient transitions • Low rehospitalization rates • Excellent outcomes

5. Reimbursement Based on Outcomes and Value Safe Transitions Institutional Care Individualized Care Reimbursement Based on Volume Fragmentation

6. Reduce Rehospitalization Rate • Publically State the Goal • Enhance clinical competencies • Improve care transitions • Involve physicians

7. Percentages are People Risks for Geriatric Patients • Disorientation • Hospital-acquired infections • Falls • Skin breakdown • Adverse drug effects • Atrophy • Transfer trauma Ouslander, 2011

8. Good to Great Confront the brutal facts • Good decisions • Distinctive process • Collected data • Seek deep understanding • Determine the truth • Right decisions self-evident Collins, J. 2001

9. Climate Where the Truth is Heard Four key practices: • From data to knowledge to action • Conduct autopsies without blame • Engage in dialogue, not coercion • Lead with questions • Root-Cause Analysis Collins, J. 2001

10. Uncover the Root Causes • Identify all possible causes • Brainstorming • Keep asking - what else? What have we missed? Are there other factors? • Arrange these causes along “bones” • Avoid discussing solutions • Vote on the most influential

11. Cause and Effect Diagram Policies People High Rehospitalizations Environment Equipment/Supplies

12. Root Cause Analysis Leadership Paradigm • Causes are many • Solutions multi-faceted • Root cause analysis - a path to knowledge • Stakeholders involved • Need cooperation

13. Identify High Risk Elders • History • Failed teach back • Longer stay than anticipated • Dual-eligible • High risk diagnosis OnShift, 2013

14. STOP and WATCH Challenges • Clinical: • Competence of follow-up • Time to follow-up • Physician or NP available • Getting physician or NP to respond with more than “just watch” to mild symptoms • Noticing the change in the elder too late • Organizational: • Staff instability • Only a few use tool • No system to review together • Steep hierarchy stifles sharing information • Lack of team approach

15. Measurement Components • Structural measures – • the capacity to prevent avoidable re-hospitalizations • Process measures – • performance necessary to prevent avoidable re-hospitalizations • Outcome measure – Re-Hospitalization Rate

16. Structural Measures • Staffing ratios • Total nursing hours per day • Total RN hours per day • # of vacant positions = 0 • # of shifts worked by agency staff = 0 • # of shifts understaffed = 0

17. Structural Measures • Staff turnover • Total departures/average number of staff = 30% • Staff retention • Staff with one year of service/avg. number of staff = 80%

18. Structural Measure • Staff Satisfaction • Overall satisfaction = 90% “Excellent/Good” • Recommendation to others = 90% “Excellent/Good”

19. Power of Staff Satisfaction Influences • Staff turnover • Quality of life • Relationships - co-workers, residents, families • Quality of care • Regulatory compliance Castle et al., 2007

20. Process Measures • The% of new admissions with risk assessments complete and care plan initiated within the first 24 hours = 100% • Presence of physicians or NPs = 5 hours per week • Consistent Assignment = 95%

21. Process Measures • Employee absenteeism = less than 30 call-outs per month per 100 staff • Call light response time = 3 minutes • The % of new admissions seen by their attending physician or NP in the first 24 hours = 90%

22. Process Measures • The % of new admissions readmissions with an updated POLST form in the chart within 24 hours • The % of new admissions or readmissions who meet with the social worker and confirm the POLST with 3 days

23. Rehospitalization Data Dashboard Outcome Measures Process Measures Structural Measures

24. Measurement Triggers Action • What are we going to change? • How will we know if it works? • When will it start? • How can I assist? • When will we get people involved? • How will we keep people informed?

25. CMS Estimates – In year 2… • Applies to – • 65 Years-Old • Diagnosis of – acute myocardial infarction, heart failure, pneumonia • 2,225 Hospitals will be penalized $227 million because of excess readmissions • 34% No Penalty • Hospitals serving low-income are twice as likely to be penalized

26. Contributing Factors of Readmissions • Patients’ socioeconomic status • Access to social supports • Dual-eligibility • Race • English proficiency • Access • Number of chronic conditions Center for Healthcare Strategies, 2009

27. Case Management • Expert on local resources and services • Learn to navigate the entitlement maze • Logistics involve complex interactions: • Home health • Durable medical equipment (DME) • Oxygen • Formal and informal caregivers

28. Follow-Up Calls Conduct post discharge follow-up calls • Ask about visit from HHA • Reinforce medications and treatments • Reinforce follow-up visits with physicians • Speak to both the patient and the family caregiver

29. Focus on New Admissions • The most dangerous day of admissions • High risk in first 24 hours • Frontload your interventions • Risk of readmission declines each day • Know who is critically ill • Everyone focus on high risk and new admits

30. Adopt a Physician Relations Strategy • Improve perceptions • Efficiencies • Communication • Presence and Involvement • Teaching

31. The Value Proposition of Transitioning to a New Model of OperationsThe GREEN HOUSE® Model

32. Green House Transformation • Shift within current regulatory and organizational structures • Transformation: • Physical Design: Real Home • Organizational Redesign: Empowered Staff • Philosophy: Meaningful Life

33. Real Home

34. Real Home • Assisted Living and SNF • Similar to surrounding community • Private rooms and baths • Residential Finishes • Intentional Community

35. Real Home • Home to 10 – 12 elders • Small scale, intimate spaces • Internally organized for public to private progression • Good sight lines • Lots of natural light • Exterior space immediately accessible

36. Urban Green House

37. Typical Residential Floor Plan

38. “I want to go home.” “Often when a resident says - “I want to go home” - they are not necessarily referring to the house they came from, but rather to a state of being that was comfortable, ordered, and fundamentally orienting.” Caulkins, M. 2003

39. Key Elements: Hearth Open plan Living, Dining, & Kitchen

40. Kitchen • Open access to elders except at busiest times • Elders can prepare food with supervision • Built-in safety features allow open kitchen to be part of elder’s life

41. Living Room Living Room

42. Private Bedrooms • Elders encouraged • to bring own furniture • Provide a sanctuary Bedroom: 210 NSF

43. Private Baths

44. In-Room Medication Cabinets • Key locked • Key with nurse • Refrigerated meds • and narcotics • locked in office • All meds prepared • in room

45. Easy Access to Outdoors

46. Office • Qualifies as nurses’ • station • Paper and electronic • charting location • Open to elders and family

47. Life & Fire Safety Meets institutional life safety standard, including: • Automatic Sprinkler System • Emergency Lighting • Exit doors/smoke compartments • Comprehensive staff training • Generator • Emergency egress door lock releases

48. EmpoweredStaff

49. Organizational Redesign

50. Organizational Redesign • Elder at the heart of the organizational chart • Shahbazim – versatile worker • Prepare meals, housekeeping, laundry • Additional education hours = 128 • Redefines roles and responsibilities of the direct care worker, nurses and the clinical support team