SDCCOrientation

AGENDAWelcome/Announcements – Maria Oren, Team Select

Orientation PowerPoint – Maria Oren

Overview of Tools INTERACT – Pat McBride, CLCP.A.M - Lacey McFall, Telligen

Staying Healthy at Home Binder – David Strain, CLC

Overview of Organizing Statement – Maria Oren

WELCOMESDCC is a work group to improve processes throughout the

continuum of care for our seniors.

Transparency and commitment at all meetings and to all members is vital to achieving your readmission reduction

goals as well as improving education of trends and navigating the challenges within the healthcare spectrum.

As we continue our professional relationships, a reminder

that SDCC this is not a marketing group.

Why Participate in SDCC• New CMS rules that penalize hospitals for high readmission rates began in

October, 2012.

• These rules were created by the CMS/Affordable Care Act and are designed to encourage hospitals to better coordinate the care of persons being discharged to reduce the likelihood of a return to the hospital within 30 days.

• As a result of these changes, downstream providers are now being financially impacted for these readmissions and are encouraged to track readmission rates amongst their residents/patients so they will be able to demonstrate their capabilities and outcomes to hospitals and other potential referral sources.

• The challenge is knowing how to track readmission rates in a way that allows for benchmarking against other providers/settings. Fortunately there are several sources for tracking.

PURPOSE To provide successful transitions of care for older

adults through the collaboration of the south Denver senior services community.

This is achievable by reducing unnecessary hospital readmissions, ensuring the appropriate care at the right

time, and increasing patient satisfaction in care transitions through standardized language and

processes.

HISTORY OF SDCC2011 - With changes in reimbursement from Medicare pending on

the horizon, Christian Living Communities hosted a round table discussion to brainstorm how organizations could work together.

Local hospitals, skilled nursing facilities, home health organizations, senior resource organizations and a number of others were invited

to the discussion which was held May 2011.

Through word of mouth and invitations from SDCC representatives, the group has grown to include numerous care organizations

servicing the South Denver metro senior population.

2015 OBJECTIVESPrevention of Unnecessary Rehospitalizations

• 3% relative improvement rate reduction in 30 day re-hospitalization for each organization within 12 months.

• 3% relative improvement rate reduction in 30 day re-hospitalizations in SDCC, as a group.

Member Commitment• Minimum of 75% attendance at the 18 meetings per year. • Attendance at Monthly Accountability Meetings should

be a clinician or an operation manager that can effectively discuss care transitions and impact quality improvement.

• Implement Interact Tools (for SNF, Home Health, ALF, within 6 months of joining. All other providers will have key managers trained on Interact).

• Train Key Managers on Patient Activation Tool within 6 months of joining.

TOOLS TO SUCCEEDThe following tools are “Best Practices” and vital to the

successful transitions through the continuum of care.

SDCC encourages you to implement these practices in your daily processes. The resources on the next few slides require your company take action to educate and implement these recommendations.

• SDCC encourages a maximum of 6 months timeframe from becoming a member to implementation of these tools within your organization.

• Opportunities for training are provided by SDCC

TOOLS TO SUCCEED

• “Staying Healthy At Home” Discharge Binder for Patient Engagement

• Defining your team/key representative

• Baseline of readmission rate as well as goal for 2015 end of year. (Current rate – (.03 x current rate)= Goal

TOOLS TO SUCCEED• INTERACT Tools-What Leaders Need to Knowhttps://qualitynet.webex.com/qualitynet/ldr.php?RCID=5e3c74ceb1524c1844de44cdac34bc28

• Advancing Excellence Re-hospitalization Tracking Tool

https://www.nhqualitycampaign.org/goalDetail.aspx?g=med#tab2 (then click on) AE_MedicationTrackingTool_v3.1_9-24-13.xls)

• An Introduction to Patient Activation and the PAMhttps://qualitynet.webex.com/qualitynet/ldr.php?RCID=9fc69624fad9a31d4cc4ab4238b635e9

CALCULATING HOSPITAL READMISION RATE

Hospitals calculate their readmissions based on:• all payors• all cause readmissions• all discharge dispositions• Calculate # of patients readmitted to any hospital

within 30 days of discharge (divided by) # of unique admissions

CALCULATING SNF READMISION RATE

Skilled Nursing readmissions are based on:• all payors• all cause readmissions• all discharge dispositions• Advancing Excellence provides an excellent tracking

tool• The formula for calculating the readmission rate is

also found in the organizational statement.

CALCULATING HOME HEALTH & HOSPICE READMISION RATE

• Use a 30 day window as a basis for when someone is considered "readmitted.” back into the hospital setting, following a post-acute stay.

• Track all admissions onto a log or tracking system. (all payers)

• Also create tracking log for hospital readmissions. (all payers)

• At the end of every month count the number of patients who were readmitted within the readmission window.

• Divide the number of patients who were readmitted by the total number of patients that are on your census at end of month. As an example, let's say that 33 people were readmitted to a hospital and your census is 1000 patients over a 30 day period. Using 30 days as our window, simply divide 33 by 1000 to calculate your answer of 0.033, or 3.3 percent.

CALCULATING NON-MEDICAL HOME CARE & ALF READMISSION

1. To calculate the total number of clients/residents during the time period who were discharged from a hospital within the last 30 days add the following:

• Clients/residents discharged home from hospital and start service with you: ________

• Clients/residents who start service with you from any type of referral source, and who were in the hospital within the last 30 days (this includes clients who were NOT on service with you at the time of the discharge): ________

• Existing clients/residents who were admitted to the hospital (if multiple admissions, each admission counts as 1):_______________

SUM: ____________

2. Of the list assembled above, how many were re-admitted to the hospital within 30 days of coming out of the hospital? _________________

3. Calculate the percentage:(total from #2) DVIDED BY (total from #1) = _______%

ACCOUNTABILITY MEETINGS• A monthly review of case studies presented by members.

• A clinical or operational manager shares their findings

and conclusions on how to improve transitions. Discussion and brainstorming among care providers is encouraged.

• Case studies can be success stories as well as opportunities for improvement – the emphasis is on learning and sharing.

• Full transparency is required to maximize group learning.

ADDITIONAL COLLABORATION• Work Groups: Monthly attendance and review case

studies to evaluate successes and learning opportunities. Each entity is expected to bring examples for review.

• QAPI – Discuss Process Improvement to move the needle.

• Large Bi-Monthly Meeting to receive education and share experience, successes and opportunities for improvement to receive feedback and engage.

TRANSPARENCY & CONFIDENTIALITY ARE KEY

How Does our Community Navigate Transitions?

HospitalHome

AssistedLiving Area

Agency onAging

County Social Services

CooperativeExtensionMental Health

Provider

Home HealthCare

CCRC

Rehabilitation

Nursing Home

Community ResourceCenter

Senior Center

Faith Community

County CouncilDept. of Aging Adult Day

Services

WHY INTERACT

WHY INTERACT

Goal is not to prevent all hospital transfers

Improve our capacity to safely evaluate and manage changes in our clinically complex residents in the nursing home

Provide rapid transfer of residents who need hospital care

Improved communication and care with clinical transitions

Do the right thing for our seniors

WHY INTERACT

• 17% reduction of 30 day re-admissions with in-service and use

• 25% reduction of 30 day re-admissions with full integration

P.A.M. THE PATIENT ACTIVATION MEASURE

Developed at the University of Oregon by Dr. Judith Hibbard and Dr. Bill Mahoney

Measures an individual’s skills, knowledge and confidence to manage his/her own health and healthcare

13- item survey instrument completed by the patient or caregiver

Assigns a raw score (0 – 100) and activation level (1 - 4) Higher the score/ level, higher the activation

Most individuals score between 30 and 80 and 10 to 12 points separate activation levels

Provides insight into an wide array of health-related attitudes and behaviors

Owned by Insignia Health

LOW ACTIVATION = PROBLEM & OPPORTUNITY

© Insignia Health 2012. All rights reserved.

STAYING HEALTHY AT HOMEPATIENT/RESIDENT BINDER

• Help patients/residents be more active in their care and wellness

• One location for education, red flags, and resources

IMPACT

WHAT’S NEXT?

• Organizing Statement Review

• Commitment Forms due by February 11th meeting

• Commitment to training