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Community Partnerships Part 2 Partnering with Home Health to improve Care Coordination and Lower Readmissions. Eve Esslinger - eesslinger@wvmi.org. Objectives. At the completion of this webinar, the participant will be able:
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Community Partnerships Part 2Partnering with Home Health to improve Care Coordination and Lower Readmissions Eve Esslinger - eesslinger@wvmi.org
Objectives • At the completion of this webinar, the participant will be able: • Identify and select tools and resources from the HHQI Cross Setting 1 BPIP to bridge gaps in patient care between care settings. • Describe how to advance communication between providers • Recognize the benefits of using health coaching as a tool to strengthen and support a care transition program.
BPIP Contents • Introduction • Leadership • Tools, Ideas, Focus Section, Checklists, Organizational Culture, Ideas for working with physicians • Tools • Primary (in the BPIP) • Associated Resources • Weblinks • Discipline Checklists "The early bird might get the worm, but the second mouse gets the cheese." –Unknown
Cross Setting I: Care Transitions • Improved Care Transitions: • Improved patient satisfaction • Less adverse drug events • More efficient health care providers • Fewer hospital readmissions
Home Health Compare • How often patients had to be admitted to the hospital (End Result Outcome Measure) • Georgia: 27% National 27%
Evidence-based practice • Evidence-based clinical decision making • External evidence from research, theories, opinion leaders, expert panels • Clinical expertise • Patient preferences and values Melnyk and Fineout-Overholt, 2011, p. 4
Care Transitions Models • Transitional Care Model • Care Transitions Program: Care Transitions Intervention • Project Red • Project BOOST
Planning Approach • Know your community of providers • Be prepared to speak a common language • Consider innovative approaches to improving care across settings "Give me six hours to chop down a tree and I will spend the first four sharpening the axe." -Abraham Lincoln
How to improve? • Organizational Commitment • Just Culture • Learning from errors or potential errors • Ongoing staff education • Identify opportunities • Learning how to reduce hospitalizations by examining patient hospitalizations or rehospitalizations is a step toward improvement.
Improving Communication • Between disciplines • Between other providers • With patient/caregiver/family “Examine what is said, not who speaks.” --Proverb “It is greed to do all the talking but not to want to listen at all.” --Democritus
Applying Best Practice Interventions as a Community Develop relationships with your referral stream • Where do your patients come from and where do they go next? • Develop standard referral, communication and transfer processes • Develop mechanisms for accountability to those processes • Explore web-based sharing instruments to drive improvement (Brock, 2010, HHQI Cross Setting (CS) I BPIP: Focus Section)
Coaching • Health Coach/Navigator: • Clinician acts as a health coach through active listening, working for the patient’s agenda, and identifying patient beliefs and values to activate a patient’s own motivation for change and adherence to treatment. (Huffman, 2007)
Coaching: Telephone support • Customer: My keyboard is not working anymore. • Tech support: Are you sure it's plugged into the computer? • Customer: No. I can't get behind the computer. • Tech support: Pick up your keyboard and walk 10 paces back. • Customer: OK • Tech support: Did the keyboard come with you? • Customer: Yes • Tech support: That means the keyboard is not plugged in.
Six Telephone Coaching Tips • Schedule the call • Work from an agreed upon agenda • Use active listening skills to enhance call effectiveness • Location, location, location • Call just because… • Avoid using a speaker phone (Huffman, 2010, HHQI CS I BPIP: Focus Section)
What a motivated provider can do: • Adopt evidence-based models • Assess strengths and what you can add to community based strategies • Understand value-based strategies • Build a community of practice • Develop relationships with your referral system • Review readmissions with those partners (Brock, 2010, HHQI CSI BPIP: Focus Section)
Teach Back “The only way to know for sure whether patients understand is by asking. One technique to do just that is the “teach-back,” in which providers ask patients to state in their own words (i.e. teach back) key concepts, decisions, or instructions just discussed.” Helen Osborne, M.Ed., OTR/L President of Health Literacy Consulting
Focus Section • Pages 13-38 • Coaching • Motivational interviewing • Updates on national and state care transitions projects
To-Do List – Week 1 • To do by week 1: • Download the BPIP • Break it apart (e.g., circulate discipline tracks) • Know your readmission rate (and by hospital) • Evaluate hospitalizations and ED visits through record reviews and staff discussion "Great things are not done by impulse, but by a series of small things brought together." Vincent Van Gogh
To-Do List - Wk. 2 • To do by week 2: • Ask staff for input on care transitions • Include barriers and solutions • Use staff meetings, post-it boards, etc • Plan immediate adoption some tools/practices • SBAR, Teach Back • Patients see PCP within 7 days of hospital discharge • Medication Reconciliation
To-Do List – Wk. 2 continued • Analyze every: • Hospitalization • ED visit • Medication discrepancy • Reach out to other providers • Evaluate Transitions models • Staff Education
References • Barlow, J., Wright, C., Sheasby, J., Turner, A, & Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: A review. Patient Education and Counseling, 48, 177-187. • Hernandez, A.F., Greiner, M.A., Fonarow, G.C., Hammill, B.G., Heidenreich, P.A., Yancy, C.W., Peterson, E.D., and Curtis, L.H. (2010). Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. The Journal of the American Medical Association, 303,1716-1722. • Home Health Quality Improvement, Cross Setting I BPIP, October 2010 • Huffman, M., (2007). Health Coaching: A New and Exciting Technique to Enhance Patient Self-management and Improve Outcomes. Home Healthcare Nurse,25, 271-276. • Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. The New England Journal of Medicine, 360, 1418-1428. • Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins
www.homehealthquality.orghhqi@wvmi.orgThis material was prepared by the West Virginia Medical Institute, the Quality Improvement Organization supporting the Home Health Quality Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication Number: 10SOW-WV-HH-BK-061912. App. 6/2012.
