Download Journey to Strategic Quality Improvement…

Coordination of Care:
The Patient’s Journey
Improving Community
Health Care Systems
Annette Kritzler, RHIT, CPHQ
Minnesota Rural Health Conference
July 18, 2006
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Objectives
 Define “coordination of care” and its
significance to quality improvement
 Describe barriers and frustrations for health care
providers and patients/families in transitioning
and navigating care among health care settings
 Understand the significance of communication
in building patient-centered communities of
care
 Summarize learnings of a rural health
coordination of care mini-collaborative
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Dr. Eric Coleman
University of Colorado
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Dr. Eric Coleman
University of Colorado
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Coordinating the Patient’s Journey
Emergency Care
Information/orientation
Access to care
Person in need
Assessment
Satisfaction
Continuation/coordination
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Treatment
Admission
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Care Coordination
?
Discharge

Physician
Social Work
Nursing
Physical Therapy
Pharmacy
Nutrition
Karen Zander, The Center for Case Management
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Institute of Medicine’s Six Aims
QIOs support the Institute of
Medicine’s six aims that
challenge us to provide
health care that is:
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Safe
Timely
Effective
Efficient
Equitable
Patient Centered
___________________________________________
Coordination of Care?
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Coordination of Care: The Goal
Patient
Centered
Safe
Equitable
Timely
Efficient
Effective
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Coordination of Care: The Reality
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What is Coordination of Care?
 Known by many different
names…
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Throughput
Discharge planning
Care management
Transitioning care
Improving access to care
Continuity of care
Optimizing patient flow
Process and system redesign:
otherwise known as
quality improvement
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Why Focus on Coordination of Care?
 Increasingly complex systems and processes of care
 Growing elderly population with multiple chronic
illnesses
 Pressure from regulators and payers
 Pay for reporting has placed an emphasis on
improving quality and patient safety
 Coordination of care is vital to achieving the IOM
aims
 Coordination of care equates to the patient’s
experience of care
 It’s the right thing to do!
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Why is Coordination of Care a Problem?
 Older adults with complex care needs frequently
require care in multiple settings
 Health care professionals in these settings often
function independent from one another
 As a result, care is fragmented
 Patient safety and quality are compromised
 Caregivers become frustrated
 Patients are left to fend for themselves
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Challenges at Multiple Levels
 Patient
 Health care provider
 Health care organization
 Health information technology
 Performance measurement
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Patient Centered Care?
SNF
Hospital
Skilled
Nursing
Facility
Emergency Services
Ambulatory
Care Clinic
Home
Hospice
Rehabilitation
Facility
Hospice
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Patient
 Unprepared and uncertain about their role
 Institutions foster dependency and
complacency
 This changes abruptly on transfer/discharge
when expected to assume major role in selfcare
 Rising prevalence of cognitive impairment
intensifies this challenge
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Health Care Provider
 Rare for one clinician to orchestrate care
across multiple settings
 Rise of hospitalists and SNFists
 Many health care providers have never
practiced in settings to which they transfer
patients
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Health Care Organizations
Hospital
HHC
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LTC
Dr. Eric Coleman
University of Colorado
Health Information Technology
 Health information technology infrequently
extends from emergency transport to the hospital
or clinic into post-acute care settings
 Electronic health records do not have
interconnectivity
 Vendors do not have a product that meets both
inpatient and outpatient needs
 Settings do not have a shared and standard
language
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Performance Measurement
 Lack of measurement for coordination of care is a
significant barrier to quality improvement
 Proxy or outcome measures do not adequately capture
the process of transitioning care
 Each setting has a different quality improvement
infrastructure
 Monitoring care and the transition across
settings is a challenge!
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Minnesota’s Work with
Coordination of Care
 Focus on rural Minnesota communities
– 2003-2005 initiative
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Why Focus on Rural?
 Need first arose in a rural community
 Rural health care community was conducive to the
proposed initiative:
– A large rural provider and senior population
– Strong health care networks and systems
– A collaborative Rural Flex Program office
 Positive past experience with rural collaboratives
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Why Focus on Rural? (cont.)
 Rural Minnesota has 30% of state’s population
– 40% of those are 65+
 Minnesota has one of the highest per capita rates
of hospitals, nursing homes, and home health
agencies, largely because of small rural providers
 Two-thirds of Minnesota hospitals are Critical
Access Hospitals
– Associated LTC, clinic, home care
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Elderly 60+ in 2000
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Coordination of Care
“Mini-collaborative”
 Adapted the nationally known IHI
Breakthrough Series collaborative model
to focus on coordination of care in rural
Minnesota communities
– Stratis Health worked cooperatively with partner
organizations to develop and implement the
collaborative regionally, providing subject matter
experts, QI education and consultation, venues for
sharing, and facility support
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Coordination of Care
“Mini-collaborative” (cont.)
 Stratis Health partnered with:
– MDH’s Office of Rural Health and
Primary Care
– Minnesota Association of Area
Agencies on Aging
» Hospitals
» Nursing homes
» Home care
» Public health
» Parish nurses
» Other health care providers
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Coordination of Care
“Mini-Collaborative” (cont.)
 Presented in six
regions of the state,
aligning with the
rural AAA
geographical areas
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Coordination of Care
“Mini-Collaborative” (cont.)
 Five month duration in each region
 Two learning sessions
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Discharge planning models
Case management overview
Health literacy
Generational communication
Community sharing
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Unique barriers
Community models of excellence
Networking and learning from each other
AAA resources
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Coordination of Care
“Mini-Collaborative” (cont.)
 Three expert speaker conference calls
– HIPAA, UR, transitional care models
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Resources
www.stratishealth.org
 Discharge Planning Quality
Resources Kit:
– Data collection
– Policies and procedures
– Assessment/reassessment tools
– Staff education, patient/family education
– Bibliography
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Resources (cont.)
www.caretransitions.org
 Care Transitions Intervention
– Manual
– Video clips/order DVD
– Tools for patients and caregivers
 Medication Discrepancy Tool
 Care Transitions Measures
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Care Transitions Measures
 When I left the hospital, I had a good understanding
of the things I was responsible for in managing my
health.
 When I left the hospital, I clearly understood the
purpose for taking each of my medications.
 The hospital staff took my preferences and those of
my family or caregiver into account in deciding
what my health care needs would be when I left the
hospital.
www.caretransitions.org
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Key Issues Identified From
Collaborative Work
 Communication
– Lack of information most commonly cited issue
– Lack of communication among settings, as well as with
patient and family
 Patient control
– Patient and family preference on care transitioning not
taken into consideration
– Patient confusion about insurance coverage and
reimbursement
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Key Issues Identified from
Collaborative Work (cont.)
 Health care services
– Nursing homes don’t admit residents on the weekend
– Lack of available psychiatric services
 Measurement
– Process measures across settings?
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QIO Lessons Learned
 Partners
– Re-alignment of AAA regions
– Regional AAA engagement varied
 Planning
– Content evolved over time
– All regions are not the same (flexibility)
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QIO Lessons Learned (cont.)
 Measurement
– Accustomed to data driven initiatives
– “Soft” science
 Communicating with participants
– List of participants was enormous
– Listserve was not effective
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Success Stories
 Qualitative vs. Quantitative in nature
 Success across the state:
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Within organizations
Between settings of care
Community wide
Regionally
Statewide
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Vignette: Listening to Helen
 The first step to wisdom is
silence. The second is
listening . . .
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Take-Away Lesson:
The Power of Hearing the Patient
Listen to Helen’s story . . .
 Do you hear her concerns?
 What is she telling you about coordination of
care?
 How could her transition have been improved?
 What barriers exist in your organization that
prevent you from hearing your patients?
 How do you learn to hear our patients?
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Vignette: Listening to Helen(s)
 If you are interested in using these stories for education at
your facility, please send an email to:
[email protected]
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The Work Continues
 Quarterly coordination of care conference
calls/WebEx
– Highlight best practices and new approaches
– Share national speakers
– Maintain the focus
 Coordination care section of e-newsletter
 A Patient’s Guide to Leaving the Hospital
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A Patient Centered Approach to Care
 Institute of Medicine’s 2001 report:
Crossing the Quality Chasm: A New Health
System for the 21st Century
– Patient centeredness
“We are guests in our patients’ lives
instead of hosts in our health care
organizations.”
- Donald M. Berwick, President and CEO
Institute for Healthcare Improvement
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Vision without action is merely a dream.
Action without vision just passes the time.
Vision with action can change the world
-Joel Barker, The Power of Vision
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Questions and Comments
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Contact Information
 Annette Kritzler, RHIT, CPHQ
Hospital Project Manager
Stratis Health
952-853-8590
[email protected]
www.stratishealth.org
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Stratis Health is a non-profit
independent quality improvement organization
that collaborates with providers and consumers
to improve health care.
This material was prepared by Stratis Health under a contract with the Centers for Medicare & Medicaid Services (CMS),
an agency of the U.S. Department of health and Human Services. The contents presented do not necessarily reflect CMS policy.
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