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Integrated Care Management (ICM): Positioning Home Care as a Value Added Partner Better Health Better Care Lower Cost © 2014 Sutter Health Learning Objectives 1. Provide an overview of healthcare reform and the urgency for change in our care delivery model 2. Provide an overview of Integrated Care Management (ICM) and key best practices , competencies, and tools 3. Review a leadership best practice to lead transformational change and clearly communicate Home Health as value added partner . © 2014 Sutter Health What is the Sutter Center for Integrated Care (SCIC)? SCIC supports health care organizations, leaders and clinicians through the provision of educational programs, consultation, best practice tools, and model hardwiring of the Integrated Care Model (ICM). SCIC team seeks to transform healthcare delivery nationwide by guiding the way for those seeking to achieve better health, better care, and lower costs for individuals and populations. Those trained include: hospital executives, case managers, home health and hospice clinicians, care navigators/managers for hospitals and insurers, telehealth nurses, social workers, pharmacists, therapists, and physicians © 2014 Sutter Health Meet the Team Beth Hennessey, RN, MSN Executive Director Paula Suter, RN, BSN, MA Clinical Director Jennifer Pearce, MPA Health Literacy Program Manager © 2014 Sutter Health Sutter Health at a Glance One Sutter: Patient Experience Operational Excellence Market Growth Future Innovation • • • • 5,000+ physicians 55,000+ employees 24 acute care hospitals Home Health, Home Infusion, Hospice, DME • Long-term care services • Health care research, development and dissemination program © 2014 Sutter Health 5 Sutter Center for Integrated Care (CIC): Facts About Who We Serve Sutter CIC SCAH Northern California 28 Locations • 11 Home Health • 7 Hospices • 2 Infusion • 2 HME • 1 Private Duty & Geriatric Care Management 1,800 Employees 770 Volunteers 20,000 Average Daily Census Sutter Health: Transitions of Care, Complex Case Management, Advanced Illness Management, PCMH, Patient Experience, Population Health Outside SCAH/SH: 7000+ Providers (49 States and 3 Countries: US, Canada & Singapore) © 2014 Sutter Health Urgency for Change STAR CoP revisions Value Based Payments © 2014 Sutter Health Star Ratings: Pay Close Attention to Patient Experience Patient Satisfaction – Did you like what I did? Versus Patient Experience – Did we do what you expected /what met your needs? © 2014 Sutter Health 8 New COP’s and ICM Practices/ Tools COP ICM Tool Continuous, integrated care process based on a patient-centered assessment Risk assessment at referral/intake, Stoplight tools, Med Risk tool, High Risk med teaching tools, Personal Health record- “Always event” Patient-centered, interdisciplinary approach that recognizes the contributions of various skilled professionals Weekly case conferencing, Personal goal listed in EMR, case conf discussion of goals, use of SBAR template, SMART action plans Outcome-oriented, data-driven quality assessment and performance improvement program Metric tracking bi-weekly, client friendly med list, ARC program as an example of an improvement Eliminate the focus on administrative process requirements that lack adequate consensus or evidence OASIS not completed at first visit for high risk TOC patients, High alert medication teaching Safeguard patient rights Universal precautions approach to HL, Clientfriendly Medication list © 2014 Sutter Health Medicare Payments Will Significantly Change: Bold Goals Are Set 1) Alternative Payment Models ( ACOs & bundled payments) 30% by 2016 50% by 2018 2) Tied to quality or value 85% by 2016 90% by 2018 © 2014 Sutter Health Living in Two Worlds at the Same Time is Challenging Value Based Population Reimbursement Fee for Service Urgency for change to survive and thrive in both worlds calls providers to … consistently provide exceptional high quality care for ALL patients © 2014 Sutter Health Evolving “World” of Payment Reform: Impacting “Transitions of Care” FFS World Penalties World Value Based World • Decrease acute care length of stay • Decrease acute care length of stay • Avoid readmissions e.g.: HF, MI, COPD, pneumonia • Focus on quality and patient experience outcomes across providers, settings and time, starting with high risk patients • Better health, better care, lower cost © 2014 Sutter Health Integrated Care Management (ICM): Where it started Journey Towards Excellence In Homecare & Healthcare: Improving Experience and Outcomes of Care © 2014 Sutter Health The Right Thing to Do: IOM Quality Chasm Report • Current healthcare systems cannot do the job • Trying harder will not work • Changing care systems will work • Make the right thing to do the easy thing to do © 2014 Sutter Health The Right Thing to Do: IOM Quality Chasm Report ALL health care providers should pursue six major aims: 1) 2) 3) 4) 5) 6) Safe Effective Patient Centered Timely Efficient Equitable “Providing care that is respectful of and responsive to individual patient preferences, needs, & values & ensuring patient values guide all clinical decisions.” “ A New Health System for the 21st Century” (IOM, 2001) © 2014 Sutter Health 15 Integrated Care Model (ICM): What is it? • A person-centered care delivery model • Based on Wagner’s Care Model • Integrates care transitions best practices • Integrates health literate care All patients All providers All settings © 2014 Sutter Health Integrated Care Management (ICM): A Care Delivery Model for Improved Outcomes Person-Centered Evidence-Based Coordinated Care - Care with dignity and respect - Clinical best practices - Seamless transitions across providers, settings and time - Patient Engagement: - Values, needs and preferences drive care Self-management support - Patient as partner Health literate care - Meaningful and timely information exchange Improved outcomes leading to better health, better care and lower cost © 2014 Sutter Health Patients Values, Needs and Preferences Guide All Care “We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive […] those reasons matter all along the way.” Atul Gawande, MD, MPH, Author of Being Mortal: Medicine and What Matters in the End © 2014 Sutter Health Person-Centered Care Person-Centered - Care with dignity and respect - Value, needs and preferences drive care - Patient as partner Goal Before: Manage signs and symptoms of HF exacerbation, low sodium diet, and fluid restrictions adhered to by ---- Goal Now: Able to join ROMEO (Retired Old Men Eating Out) group for lunch once a week © 2014 Sutter Health Person-Centered Care Person Centered - Care with dignity and respect - Values, needs, & preferences drive care - Patient as partner Goal Before: Safely ambulate 100 feet with or without assistive devices by time end of episode. Goal Now: Be able to walk on my own to the activity center in the next month. © 2014 Sutter Health Asking questions to understand persons preferences These are some things you can work on that will help you return to gardening. Lets go over these options together. What would you like to work on? © 2014 Sutter Health Use Shared Decision Making Approach to Goal Setting Walk 15 minutes each day Starting tomorrow Walk around my house for 15 minutes after lunch daily for the next week I may feel too tired to do it “I would like to exercise” Ask my husband to encourage me Will improve my enegy level so I can work in my garden again March 2nd © 2014 Sutter Health Power Point Template 3 22 Quality of Life Tools As a persons condition changes, their needs and preferences change. Shared decision making with patient and caregivers is facilitated with person-centered health literate tools. © 2014 Sutter Health Evidence-Based Care Step 3 Leads to Empowerment Promotes Engagement Evidence-Based - Clinical best practices Step 2 Start with Plain Language - Patient Engagement: Self-management support Step 1 Health literate care Source: Blue Shield California Foundation. (2012). Empowerment and engagement among low-income Californians: Enhancing patientcentered care. © 2014 Sutter Health Patient Engagement is “The Right Thing To Do” Evidence reveals that patients who are actively involved in their health and healthcare: Achieve better clinical outcomes Have lower healthcare costs Are more satisfied with their care experience © 2014 Sutter Health How Can You Start Engaging Patients? The Cycle of Patient Engagement Leads to Empowerment Promotes Engagement Start with Plain Language Source: Blue Shield California Foundation. (2012). Empowerment and engagement among low-income Californians: Enhancing patient-centered care. © 2014 Sutter Health This Approach is Appropriate for All Individuals Regardless of: Reading ability Education level Universal Precaution Approach Socio- economic status Source: Smith, Sandra A. (2001). Patient Education and Literacy in Labus, A. & Lauber, A. (Eds.) Preventive Medicine and Patient Education. Philadelphia: WB Saunders, 266-290. © 2014 Sutter Health To Improve Understanding and Engagement Use a universal precautions approach to health literacy with verbal and written materials © 2014 Sutter Health Universal Precautions Oral Communication Self Assessment Found in AHRQ Universal Precautions Tool Kit © 2014 Sutter Health Enhancing Provider Competencies: Make “the right thing to do, the easy thing to do” © 2014 Sutter Health 30 Power Point Template 3 Verify Understanding Teach-Back Competency Check List You get to hear in the patients own words : • their understanding • what is important • how to best “connect” new information © 2014 Sutter Health To Improve Understanding and Engagement Use a universal precautions approach to health literacy with verbal and written materials © 2014 Sutter Health Evidence: Easy-to-read is Preferred! College educated readers’response to health information written at 5th grade level: Recall of key messages Satisfaction Sources: Smith SA. Information giving: Effects on birth outcomes and patient satisfaction. Int Electronic J Health Educ 1998:;3:135-145. Online at http://www.beginningsguides.net/content/images/stories/info-giving.pdf © 2014 Sutter Health 33 Health literate stoplight tool with universal precaution approach applied ClearMark Award of Distinction Center for Plain Language Washington, D.C. © 2014 Sutter Health Moving toward Health Literate Care: Stoplight form before • Third person • Zones drive navigation • Graphic does not support text • Font, layout, graphics not consistent with health literacy principles © 2014 Sutter Health Stoplight after: supports patient and family engagement • First person • Patient daily assessment drives navigation • Font, layout, graphics consistent with health literacy and plain language principles • Supports patient and caregiver engagement • Supports teach back with content ready for “chunk and check” © 2014 Sutter Health 36 Universal Precautions Approach in Action: Patient Friendly Medicine List Medication and Route Dose Frequency Reason Instructions Font size increased to 14 pt © 2014 Sutter Health 37 Coordinated Care There and Home Again Safely (AMA) Joint Commission 7 Foundations Coleman, Naylor, RED, Boost Taking the Best of the Best Coordinated Care - Seamless transitions across providers, settings and time - Meaningful and timely information exchange © 2014 Sutter Health ICM Alignment with TJC Foundations For Safe Transitions TJC Foundation ICM Practice/ Tool/competency Patient/ family action/ engagement Universal precautions approach to HL, id of pt goals and preferences through open-ended questions and reflective listening, teach-back Early identification for “at risk” patients Look for common barriers: low self rating of health, depression, low literacy, cognitive deficits, lack of social support, etc. Transitions planning Protocols to guide care delivery for high risk pts Medication management Thorough medication reconciliation, medication risk assessment, assistance with medication adherence Multidisciplinary collaboration and transfer of information Broad use of SBAR in provider and patient communication, team review of high risk patients Leadership support Creating a learning environment and reviewing © 2014 Sutter Health readmissions for improving practice 39 Person-Centered Care “Always Event”: Starting in Hospital “I have four areas we need to focus on to help prepare you and your family for discharge, but before we start on my list can you tell me what you are the most concerned or worried about when you leave here and go home?” Then transitions of care focus areas …. 1. Medication Management Post-Discharge 2. Early Follow-up 3. Symptom Management 4. Personal Health record © 2014 Sutter Health Person-Centered Care “Always Event”: Starting in Hospital Open ended questions in hospital and continued in the home • What are you most concerned about at this time? • What would you like to have happen as a result of our care? • How would you like to feel? • What is one thing that is most important to you that you want to be able to do again? Feeling lonely as I live alone. © 2014 Sutter Health Risk for Re-admission: IHI Two Question Rubric High Risk Criteria A • 2 or more hospitalizations in past year Criteria B • Low confidence with self-care, or fails teach-back © 2014 Sutter Health Person Centered Assesment Tool Personal assessment of health, “In general would you say your health is… poor (1) fair (2) good (3) very good (4) excellent (5) ?” © 2014 Sutter Health Single Item Self-Rating and One Year Event Rates Source: DeSalvo, et.al., Health Services Research, August 2005 © 2014 Sutter Health ICM Transitions of Care: 9 “Touch-Points” in First 2 Weeks Week 1 •Home Care Coordinator in-hospital patient visit •Patient Assessments: Risks for readmission •Patient Concerns/ Goals •Stoplight teaching •MD Follow-up appt •PHR 3 home visits or virtual visits Week 2 • Focus on patient engagement, med management, barriers and confidence-building Remote monitoring Home visits Pre-discharge •1st visit w/in 24 hrs •2nd visit w/in 72 hrs by same clinician •3rd visit same week •Focus on patient concerns, med rec, signs & symptoms, MD f/u, personal health record Remote monitoring • Remote monitoring with focus on patient engagement & selfmgt support • Remote monitoring to detect signs of exacerbation and build confidence in SMS Additional interventions • Case conference • Patient –friendly med list • Medication Management and adherence • SBAR communication Home visits continue based on need © 2014 Sutter Health High Alert Medication Stoplight Tools A recent study found that four agents were responsible for 2/3 of all drug related hospitalizations: 1. Plavix 2. Coumadin 3. Insulin 4. Oral Hypoglycemics Source: Budnitz, et al. NEJM, Nov 24, 2011. © 2014 Sutter Health 46 Health Literate Tools: Across Providers and Settings © 2014 Sutter Health Cohesive Care Delivery Promotes Efficiency, Safety, and Access © 2014 Sutter Health SBAR for Patients in PHR © 2014 Sutter Health What “key lesson” would I share with Home Health Leaders …. Source: Vocera Experience © 2014 Sutter Health Innovation Network 50 Accelerators for Execution and Committment Leadership buy-in and commitment to transforming care to be person-centered care Process to ensure hardwiring best practices Outcome metric tracking to demonstrate value Success stories in all case conferences, leadership & management meetings, and in employee news letter “Clinical Connect” Clear communication to stakeholders about the value add of Home Care : Elevator speech © 2014 Sutter Health 51 Leadership but-in and commitment to person-centered care • Tie to organizational strategic objectives with focus on the patient and employee experience • Identify ALWAYS event • Track progress over time to maintain focus • Engage all employees in the value of providing person centered - care © 2014 Sutter Health 52 Communicating ALWAYS event to Providers Infographic •Featured at the 2015 Sutter Health Management Symposium • In plain language describes how to engage patients with every encounter •Applies to all staff in all settings © 2014 Sutter Health 53 ALWAYS Event Incorporated into Standard Work Across System A I D E 54 T ACKNOWLEDGE “Hello Mrs. House, I am Georgia, the homecare nurse from Sutter Care at Home. We spoke on the phone yesterday about my visit this morning. INTRODUCE “Your nursing case manager, John, was not able to visit today, but he gave me an update about your wound, and after my visit today I’ll let him know how the new treatment is going for you” DURATION “I think my visit will be about 45 minutes; is that going to work for your schedule? EXPLANATION “In addition to doing the wound care, I’d like to review your medications with you to make sure our list of medications is up to date and see if you have any questions or concerns regarding your medications. Before we get started, what questions or concerns do you have? I want to make sure we take time for what is most important to you.” THANK “Thank you Mrs. House, I will be giving John an update on how good your wound looked today. Do you have any questions for me or for me to pass © 2014 Sutter Health along to John? I have time. Communicating Value-Add • Have an elevator speech ready • Know your statistics • Understand the strategic objectives of new payment models and which your partners are considering • Embed information about how your agency will help meet strategic objectives © 2014 Sutter Health Home Health: Experience as High Value/ Low Cost Provider Experience caring for complex patients Demonstrated improvement in outcomes Lowest cost post acute provider • 4 out of 5 HH pts have 3 or more chronic diseases • 62% have incomes < 25K/yr • 60% are older than age 75 • 65% improvement in breathing • 89% improvement in wound healing • 68% report less pain • 8K less on average than all other PAC settings • Home is the venue of choice for care amoung older Americans Source: Lee, t and Schiller J. HHN, Feb. 2015 © 2014 Sutter Health 56 Know Your Numbers 10% Your Agency Your State © 2014 Sutter Health Home Care as a Value Added Partner ACROSS Healthcare Continuum Valued Hospital Partner Valued Physician Practice Partner Valued Home & Community Partner © 2014 Sutter Health “Life is a pond. We are all pebbles. Never underestimate the difference one pebble can make.” Hardwiring Excellence. Quint Studer © 2014 Sutter Health What questions do you have, I have time? Contact Information Beth Hennessey, RN,BSN,MSN Executive Director Sutter Center for Integrated Care [email protected] © 2014 Sutter Health