Care Transitions and Patient Navigation Learning Collaborative January 29 th , 2014

1. LEARNING SESSION NUMBER IJanuary 29th & 30th, 20148:00 AM – 4:15 PMThe Riley Center at Southwestern Seminary1701 W. Boyce Avenue, Fort Worth, Texas 76115Room 150

2. Care Transitions and Patient Navigation Learning CollaborativeJanuary 29th, 2014

3. Learning Session Welcome and Introductions Aubrie Augustus, RN, BSN, MHA; Senior VP Network Quality, JPS Health Network and Administrative Director, Learning Collaborative

4. Agenda 8:30-8:40 Welcome and Introductions 8:40-8:50 Learning Session Overview 8:50-9:00 The Case for Improvement in Care Transitions and Patient Navigation in Region 10 9:00-9:10 Intersection Between the Learning Collaborative and DSRIP 9:10-9:20 Introduce Story Board Gallery Walk 9:20-9:30 Break

5. Agenda 9:30-10:15 Storyboard Gallery Walk: Meet the other Provider Teams 10:15-10:40 Model for Improvement, Part 1 Aim Statements, Monthly Measures, Run Charts 10:40-11:10 Team Meeting#1: Revise Aim Statement, Data Collecting Planning 11:10-noon The Model for Improvement, Part 2: The Plan- Do-Study-Act Testing Cycle Noon-1:00 pm Lunch 1:00-1:20 Overview of Change Package for Care Transitions: What do we know that works?

6. Agenda 1:20-2:00 Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide our Work 2:00-3:15 Introduction to Motivational Interviewing to Behavior Change 3:15-3:25 Break 3:25-3:55 Team Meeting 2 Planning for High Impact Change 3:55-4:10 Teams Share Their Plans for Action Period 1 4:10 Evaluation 4:15 Adjourn

7. Learning Session Overview Gillian Franklin, M.D., MPH Clinical Effectiveness & Integration Specialist Project Manager & Performance Improvement Specialist, Learning Collaborative

8. Learning Collaborative Model (Breakthrough Series Model)

9. Learning Session Overview The Learning Session

10. Goals And Objectives Goal: Participants will learn about the Model for Improvement . Objective: Participants will understand the various aspects of the Model for Improvement and their functions. Instructional Objective: Participants will work on parts of the Model for Improvement (Plan-Do-Study-Act Testing Cycle) to test change.

11. Learning Outcomes Model for Improvement • Full engagement as early adopters Strategies • Process Improvement NOT Research Elements • “Best Practice” Changes • Learning Collaborative Change Methodology • Aim Statements; PDSA Testing Cycle; Monthly Measures; Run Charts etc. Action Period 1

12. Inquiry-driven

13. Formative Feedback

14. The Take Away Knowledge New skills Immediate changes Steal Shamelessly Share Relentlessly

15. Wait, Wait Don’t Tell Me!!! What is a proven way to test potential changes without disrupting your organization’s day-to-day operations?

16. Answer Model for Improvement&Plan-Do-Study-Act Cycle

18. The Case for Improvement :Care Transitions and Patient Navigation Elizabeth Carter, MD Senior Vice President for Population Health Director, Care Transitions Learning Collaborative

19. The Case for Improvement Inadequate case coordination including care transitions responsible for $25-45 Billion in wasteful spending • “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful” IOM report “Crossing the Quality Chasm”

20. Medicare Cost Per Beneficiary and 30 Day Readmission by State

21. All Cause 30 Day Readmission Rates

22. Sickle cell anemia- 31.9% Gangrene- 31.6% Hepatitis- 30.9% Disease of white blood cells-30.6% Chronic renal failure- 27.4% Conditions with Highest Readmission Rates

23. The Case for Improvement Root Causes per Robert Wood Johnson: Hospital computers don’t interface to community providers- less reliable hand-off Current payment policies may create disincentives for hospitals to invest in care transitions Medicaid low payment incentivizes NH to send patient back to the hospital to qualify for a more generous Medicare payment rate Half of Medicare patients admitted within 30 days have not been seen by a physician in the interim

24. Reducing Readmissions for Value-Based Healthcare

25. Texas in the 4th quartile Medicare 30 day readmission NH admissions and readmissions Home health admissions Texas in 3rd quartile Admissions for Pedi asthma Asthmatics with ED visit Medicare admission for ACS Avoidable Hospital Use and Costs

26. Carrot Oct 2012, increase in Medicare payment if achieve or exceed performance (help at home, warning signs/symptoms, discharge instructions) Medical Home- pay providers for care transition services Demonstration projects- Monthly payments or per beneficiary per month for transitions processes/coordination Stick Oct, 2012 reduced payments 1% readmission for CHF, AMI, pneumonia exceed target Transparent Physician level quality data Affordable Care Act

27. The Intersection of DSRIP and the Learning CollaborativeMallory JohnsonManager RHP 10

28. According to the PFM…. Our Learning Collaborativesshould… Regional plans should recognize the importance of learning collaboratives in supporting continuous quality improvement, RHPs will provideopportunities and requirements for shared learning among the approved DSRIP projects in the region. Learning collaboratives should strongly be associated with Performing Provider’s projects and demonstrate a commitment to collaborative learning that is designed to accelerate progress and mid-course correction to achieve the goals of the projects and to make significant improvement in the Category 3 outcome measures and the Category 4 population health reporting measures.

29. What does the Learning Collaborative mean to Region 10 DSRIP Projects? The continuation of the journey we have all been on together! Over the last two years we have all experienced together…

30. What can the Learning Collaborative mean to your DSRIP Projects? • A networking opportunity to learn how other similar projects are doing and best practices occurring in our community • Focus on specific issues where multiple providers will collaborate to see improvement for all • An opportunity to bring performance improvement practices (CQI) to your projects • Recognition that it’s not just about the milestones, but the broader impact of participation in the Waiver, willingness to collaborate with peers, and show improvement at the individual, regional, and state levels

31. TEAM ME

32. Storyboard Gallery Walk Hunter Gatewood, MSW, LCSW

33. Break

34. Storyboard Gallery Walk: Meet the Other Provider Teams

35. Model for Improvement: Part 1 Aim Statements, Monthly Measures, Run Charts Hunter Gatewood, MSW, LCSW

36. Team Meeting #1: Revise Aim Statement, Data Collection Planning

37. The Model for Improvement, Part 2: The Plan, Do-Study-Act Testing Cycle Hunter Gatewood, MSW, LCSW

38. Lunch

39. What do we know that works for Care Transitions and Patient Navigation Overview of Change Packet

40. Context for Transitional Care Acute Care Episode Trajectory 1 (T1) Relatively healthy adult with onset of new chronic illness Population At Risk Acute Phase Post Acute/ Rehab Phase Secondary Prevention Trajectory 2 (T2) Adult with multiple chronic conditions Trajectory 3 (T3) Adults at end of life Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of an episode of illness and sets forth a vision to guide ongoing and future efforts.

41. IHI’s Blueprint for Improving Transitions and Reducing Avoidable Re-hospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Re-hospitalizations Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

42. What do we know that works?What do patients want? Very helpful interventions • Speaking with a pharmacist about their medications especially true if patient had low literacy • Receiving a phone call 1-4 days after discharge • receiving these two interventions made them more comfortable with talking to their outpatient provider after discharge . Courtney Cawthon, Sheena Walia, et al (2012) Improving Care Transitions: The Patient Perspective, Journal of Health Communication: International Perspectives, 17:sup3 312-324

43. Change Concepts Optimum Hospital Discharge Planning and Process Deliver Timely Access to Care Prior to the First Post-Hospital PCP: Prepare Patient and clinical team During the First Post-Hospital PCP visit: Assess Patient and Initiate New Care Plan At the conclusion of the First PCP Visit: Communicate and coordinate ongoing care plan

44. Navigation Navigation is often necessary because of the fragmented and complex health care system New accreditation standard for navigation process to address health care disparities and barriers to care by the American College of Surgeons’ commission on Cancer Multiple approaches to problem-solve, educate, define next steps

45. What Works? Systematic Review 36 randomized, controlled trials of Inpatient to Outpatient Hand-offs Multiple components ( 94% of trials) Significant improvement in outcomes (69% of trials) Strategies before and after discharge (>50% of trials) Transition managers employed (72% of trials) • Care coordination • Patient education • Assessment of social and functional needs Hesselink G et al. Improving Patient handovers from hospital to primary care: A Systematic Review. Ann Intern Med 2012 Sept 18; 157-417

46. Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide Our Work

47. Scott Walters, PhD University of North Texas Health Science Center School of Public Health Introduction to Motivational Interviewing to Behavior Change

48. Break

49. Team Meeting #2: Planning for High-Impact Change, Drafting a PDSA Test

50. Teams Share Their Plans for Action Period 1