ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for...
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ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health? Presented by: Susan Carmichael MS, RN, CHCQM, COS-C, ICM, FAIHQ EVP, Chief Compliance Officer SELECT DATA
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ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health?
Transcript of ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for...
ACOs Transitions of Care Patient Centered Medical Homes Care Transitions What Do
They Mean for Home Health
Presented by
Susan CarmichaelMS RN CHCQM COS-C ICM FAIHQ
EVP Chief Compliance OfficerSELECT DATA
Objectives
Patients are receiving disjointed care in the present expensive system Changing the model
ndash Identifying the components of The Transformed System affordable accessible seamless and coordinated plus high quality person and family centered and clinically supportive
ndash Listing ways to develop partnerships that create strong symbiotic teams
ndash Creating Care and Operation Interventions that integrate with Care Transitions Guided Care in the PCMM(H) and ACO models
THE STATE OF HEALTH CAREScary Expensive and Inconsistent
The Scary Safety is an issue
ndash Airline Safety gt 99999999bull Airline Baggage Handling gt 99999bull B-Blocker p MI 70 ndash 99bull Immunization 55 ndash 94bull MD Hand Hygiene in ICU 3 ndash 40 REALLY
Quality Safety Efficiencyndash Imagine
bull Imagine an industry (or a company within an industry) with poor quality (or safety) would you invest
ndash Categories of Poor Quality (Safety) in Healthcarebull Underuse Vaccines Beta-Blockersbull Overuse Spine Surgeries Cardiac Proceduresbull Misuse Calcium Channel Blockers as First-Line for Hypertensionbull Safety Healthcare Associated Infections Medication Errors
ndash Inefficiencies may mean different things to payors providers and patients due to misaligned incentives
ndash High Performance Safer Care most efficient for all especially in the emerging ldquolimited warrantyrdquo environment of healthcare
INTRODUCTION
As a percentage of GDP health care expenditures are about 18 By 2019 the national health care expenditures will be 193 and approaching an unsustainable level
Innovative approaches to quality healthcare must be found
Letrsquos discuss these new Chronic Care Models in general and Transitions in Care ACOs and the Patient Centered Medical Model in particular
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Objectives
Patients are receiving disjointed care in the present expensive system Changing the model
ndash Identifying the components of The Transformed System affordable accessible seamless and coordinated plus high quality person and family centered and clinically supportive
ndash Listing ways to develop partnerships that create strong symbiotic teams
ndash Creating Care and Operation Interventions that integrate with Care Transitions Guided Care in the PCMM(H) and ACO models
THE STATE OF HEALTH CAREScary Expensive and Inconsistent
The Scary Safety is an issue
ndash Airline Safety gt 99999999bull Airline Baggage Handling gt 99999bull B-Blocker p MI 70 ndash 99bull Immunization 55 ndash 94bull MD Hand Hygiene in ICU 3 ndash 40 REALLY
Quality Safety Efficiencyndash Imagine
bull Imagine an industry (or a company within an industry) with poor quality (or safety) would you invest
ndash Categories of Poor Quality (Safety) in Healthcarebull Underuse Vaccines Beta-Blockersbull Overuse Spine Surgeries Cardiac Proceduresbull Misuse Calcium Channel Blockers as First-Line for Hypertensionbull Safety Healthcare Associated Infections Medication Errors
ndash Inefficiencies may mean different things to payors providers and patients due to misaligned incentives
ndash High Performance Safer Care most efficient for all especially in the emerging ldquolimited warrantyrdquo environment of healthcare
INTRODUCTION
As a percentage of GDP health care expenditures are about 18 By 2019 the national health care expenditures will be 193 and approaching an unsustainable level
Innovative approaches to quality healthcare must be found
Letrsquos discuss these new Chronic Care Models in general and Transitions in Care ACOs and the Patient Centered Medical Model in particular
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
THE STATE OF HEALTH CAREScary Expensive and Inconsistent
The Scary Safety is an issue
ndash Airline Safety gt 99999999bull Airline Baggage Handling gt 99999bull B-Blocker p MI 70 ndash 99bull Immunization 55 ndash 94bull MD Hand Hygiene in ICU 3 ndash 40 REALLY
Quality Safety Efficiencyndash Imagine
bull Imagine an industry (or a company within an industry) with poor quality (or safety) would you invest
ndash Categories of Poor Quality (Safety) in Healthcarebull Underuse Vaccines Beta-Blockersbull Overuse Spine Surgeries Cardiac Proceduresbull Misuse Calcium Channel Blockers as First-Line for Hypertensionbull Safety Healthcare Associated Infections Medication Errors
ndash Inefficiencies may mean different things to payors providers and patients due to misaligned incentives
ndash High Performance Safer Care most efficient for all especially in the emerging ldquolimited warrantyrdquo environment of healthcare
INTRODUCTION
As a percentage of GDP health care expenditures are about 18 By 2019 the national health care expenditures will be 193 and approaching an unsustainable level
Innovative approaches to quality healthcare must be found
Letrsquos discuss these new Chronic Care Models in general and Transitions in Care ACOs and the Patient Centered Medical Model in particular
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Scary Safety is an issue
ndash Airline Safety gt 99999999bull Airline Baggage Handling gt 99999bull B-Blocker p MI 70 ndash 99bull Immunization 55 ndash 94bull MD Hand Hygiene in ICU 3 ndash 40 REALLY
Quality Safety Efficiencyndash Imagine
bull Imagine an industry (or a company within an industry) with poor quality (or safety) would you invest
ndash Categories of Poor Quality (Safety) in Healthcarebull Underuse Vaccines Beta-Blockersbull Overuse Spine Surgeries Cardiac Proceduresbull Misuse Calcium Channel Blockers as First-Line for Hypertensionbull Safety Healthcare Associated Infections Medication Errors
ndash Inefficiencies may mean different things to payors providers and patients due to misaligned incentives
ndash High Performance Safer Care most efficient for all especially in the emerging ldquolimited warrantyrdquo environment of healthcare
INTRODUCTION
As a percentage of GDP health care expenditures are about 18 By 2019 the national health care expenditures will be 193 and approaching an unsustainable level
Innovative approaches to quality healthcare must be found
Letrsquos discuss these new Chronic Care Models in general and Transitions in Care ACOs and the Patient Centered Medical Model in particular
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Quality Safety Efficiencyndash Imagine
bull Imagine an industry (or a company within an industry) with poor quality (or safety) would you invest
ndash Categories of Poor Quality (Safety) in Healthcarebull Underuse Vaccines Beta-Blockersbull Overuse Spine Surgeries Cardiac Proceduresbull Misuse Calcium Channel Blockers as First-Line for Hypertensionbull Safety Healthcare Associated Infections Medication Errors
ndash Inefficiencies may mean different things to payors providers and patients due to misaligned incentives
ndash High Performance Safer Care most efficient for all especially in the emerging ldquolimited warrantyrdquo environment of healthcare
INTRODUCTION
As a percentage of GDP health care expenditures are about 18 By 2019 the national health care expenditures will be 193 and approaching an unsustainable level
Innovative approaches to quality healthcare must be found
Letrsquos discuss these new Chronic Care Models in general and Transitions in Care ACOs and the Patient Centered Medical Model in particular
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
INTRODUCTION
As a percentage of GDP health care expenditures are about 18 By 2019 the national health care expenditures will be 193 and approaching an unsustainable level
Innovative approaches to quality healthcare must be found
Letrsquos discuss these new Chronic Care Models in general and Transitions in Care ACOs and the Patient Centered Medical Model in particular
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Chronic Illness in the USndash The ACA Improving Chronic Illness Care is dedicated to the
idea that United States health care can do betterndash Over 145 million people - almost half of all Americans - suffer
from asthma depression and other chronic conditions ndash Over eight percent of the US population has been diagnosed
with diabetes ndash All of this is possible by transforming what is currently a
reactive health care system into one that keeps its patients as healthy as possible through planning proven strategies and management
We must find new meaningful REAL interventions
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Experts Sayhellip
ndash That in 10 years hospitals will essentially focus as ICUsndash Med Surg will basically be provided in the homendash Expect costs to be bundled into episodes from
hospital admission to post acute to home carendash Expect costs to be measured in full care of clinically
defined episodesndash Clinical continuums will replace length of stay based
carendash Agencies will be measured by care transition
capabilities and the value of their outcomes
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
THE REASON FOR CHANGEHere is
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Overview
bull T
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Mrs Ruth Smith
bull 77 year old widow alert oriented bull Retired school teacher lives alonebull Receives pension SS Medicarebull 4 chronic conditionsbull Three physiciansbull Son lives 12 miles away with wife and 3 childrenbull Mrs Smith is a part of a disjointed healthcare
system
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Mrs Ruth Smith In 2012
bull 14 prescriptions 9 medsndash 10 physician and clinic visitsndash 1 hospital admitndash 1 23 hour observationndash 4 weeks sub acute carendash 2 nursing homesndash 6 months home health carendash 2 home health agenciesndash Overseen by 7 physicians 6 social workers 5 PTs 3 OTs
42 nursesndash Who is coordinating her care
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Mrs Ruth Smith
ndashMedicare ndashPaid $89000 for this risky fragmented care
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Everyone is in a Hurry
ndash No one individual sits with her
and hears her concerns and needs ndash Hurried one problem physician visitsndash Discharges from each level of care with
discontinuity through the transitions of care
ndash As a nation it is felt that we can do better and it is expected that we will
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Letrsquos Look at Care Another Waybull Presently here is what is driving healthcarebull Policy and Regulation What do you think of when the surveyor arrivesbull Payment Methodology meansbull Provider Care = The Patientrsquos Health Care bull bull Future Delivery of Care Must be Driven in the Following Order bull Patientrsquos Health Needsbull Provider Carebull Payment Methodologybull Policy and Regulationbull bull
bull
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Research Showinghellip
ndash Current Healthcare Delivery System is ineffective and Riddled with Gaps
ndash Trying Harder Using the Present System will Change Little
ndash THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM
ndash Technology is Not the Solution It is a Tool for the New Care Delivery Systems
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Chronic Care Needs
ndash Almost half of all Americans - suffer from asthma depression and other chronic conditions such as Heart Failure COPD CAD and over eight percent of the US population has been diagnosed with diabetes
ndash All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning proven strategies and management proactive
ndash The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
What we do knowhelliphellip
bull Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care
bull Care Complexity will Risebull Poor Transition between Levels of Carebull Poor Coordination between Levels of Carebull Poor Use of Evidenced- Based Carebull Care is Provider Directed not Patient Centeredbull Clinicians Attempt to ldquoTeachrdquo Patients with Poor
Understanding of How Individuals Learn
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
CMS Mandates Quality Initiatives
The CMS ldquoTriple Aimrdquo Goals1 Better Health for the Population
2 Better Care for Individuals
3 Lower Cost through Improvement of
Care Delivery
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Institute of Medicine 2012
ndash Need to improve re Falls Medication Reconciliation Pressure Ulcers Depression and NUTRITION Yes NUTRITION
ndash Medicare Patients now see average of 7 physicians including 5 specialists amongst 4 different practices (Pham et al 2008)
ndash Multiple providers means poor coordination confusion as to care and poor accountability
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Transformed System must be
Affordable
Individual and Family Centered
Accessible
Seamless and Coordinated
Quality of Care delivered
Support to Patients and Clinicians yes Clinicians
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
CMS Created the INNOVATION CENTER
The purpose is to ldquotest innovative payment and service delivery models to reduce program expenditureshellipwhile preserving or enhancing the quality of care furnishedrdquo
Coordination is emphasized
Funding FY2011 - 2019 is $10 Billion
The goal is to take successful project models and move them to the national level
httpwwwhealthcaregovcenterprogramspartnershipjoininindexhtml
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Method of Payment
F Fee-for Service- For a specific volume of service there will be a negotiated fee
Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount
Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs quality and
patient experience
Risk ndashSharing- Sharing of savings and losses
Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
TO SHARE THE RISKBe Prepared
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Innovations
Federal Coordinated Care 15 State Demonstrations
Acute with Post Acute Bundled Payment Episodes for Care
Pre Hospital Assessments
Health Information Exchange
Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting
Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Several Innovative Projects
Community-based Care Transitions Program (CCTP) and 6 models
= 1Care Transitions Programs
= 2Patient-Centered Medical Home
= 3Guided Care Nurse-Physician Models
= 4Comprehensive Care Coordination Models
= 5Innovative Academic Partnerships
= 6Coaching Role Skill Transfer
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Shift is
ndash Moving from Volume to Valuendash Knowing Your Numbers such as the cost to deliver
home care fro each diagnostic category with an expected outcome
ndash Knowing how to operate at the granular levelndash To post acute care within 12-24 hoursndash Moving toward Self care managementndash Data Integration with specific outcomes
measurementndash Specific education in home care
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
inadequate information and training at discharge were themes that spanned all groups
ndash Transitions ndash To home
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
CARE TRANSITIONS MODELSWhat might work best for your agency
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Care Transition Model
ndash Where did the model originate Colorado 2000ndash Dr Eric Coleman wrote extensively and validated research
regarding the model It has solid aimsbull Support patients and familiesbull Increase skills among healthcare providersbull Enhance ability of health information technology to promote health
information exchange across care settingsbull Implement system level interventions to improve quality and safetybull Develop performance measures and public reporting mechanisms
and bull Influence health policy at a national levelbull DO YOU RECOGNIZE MANY OF THESE MEASURES
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
American Geriatrics Society defines Transitional Care ashellip
ndash A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location May include (but not limited to) hospitals sub acute and post acute nursing facilities the patientrsquos home primary and specialty care offices and long term care facilities Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patientrsquos goals preferences and clinical status It includes logistical arrangements education of the patient and family and coordination among the health professionals involved in the transition
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Coleman Model
ndash Heavily funded by both the John A Hartford and Robert Wood Johnson Foundation this is a patient-centered interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Four Pillars of the Model
ndash 1 Medication self management Patient is knowledgeable about their meds and has a med management system
ndash 2 Uses a dynamic patient-centered record Understands and uses their record to facilitate communication and ensure continuity
ndash 3 Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions
ndash 4 Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Sample items on Discharge preparation checklist
I have been involved in decisions about what will take place after I leave the facility
I understand where I am going after I leave the facility and what will happen once I arrive
I have the name and phone number of a person I should contact if a problem arises during my transfer
I understand the potential side effects of my medications and whom I should call if I experience them
I understand how to keep my health problems from becoming worse
And there are a few morehellip
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Transitional Care ishellip
ndash The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete
ndash Within settings Primary Care to Specialty Carendash Between Settings Acute to Sub-acute facilities to
Ambulatory clinics ndash Across Health Care Settings Curative Care to Palliative
Care to Hospice to Home to Assisted Living
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Obtain more information
Dr Eric Coleman on Transitional Coaching
httpwwwcaretransitionsorg
Dr Chad Boult on the Guided Care Nurse
httpwwwguidecareorg
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Care Transition(TM) Coach
ndash This is a proprietary Training Program on the Care Transitions Program
ndash Many programs using these concepts are also using a coach
ndash If working with a Certified Care Transitions Program one will use the 15 item uni-dimensional measure to assess quality of the care transition This measure has had psychometric testing to validate findings from one location to another level
ndash Medication Discrepancy Tool
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Care Transitions Interventions
ndash Recognized by Dr Eric Colemanndash One day course in Aurora Condash To become Trainer to Train othersbull Must complete CTI trainingbull Be employed in Healthcarebull Complete app to become trainer and submit w DVD
conducting home visit using CTIbull Take trainer coursebull Complete another 30 CTI and second home visit DVD
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Another transitional care type training ICM
ndash Integrated Care Management provided by Sutter Center for Integrated Care
ndash 1 day course ndash To be qualified as Train the Trainer Must complete 1 day course Must complete 4 on-line modules on
Heart failure Diabetes COPD DepressionMust Complete online Exam and pass within 80+
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
National Transitions of Care Coalition
bull Resources to assist to establish a Transitional Care Program
bull NTOCC provides tools and resources bull wwwntoccorg
bull NTOCC reports ldquoYesterday May 22 2012 the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make
better-informed health decisionsrdquo
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
NTOCC Seven Essential Intervention Categories
1 Medication Management
2 Transition Planning
3 PatientFamily EngagementEducation
4 Information Transfer
5 Follow-up Care
6 Healthcare Provider Engagement
7 Shared Accountability across Providers and Organizations
HttpwwwntoccorgToolboxbrowseattributes=61
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Partnership for Patients
Secretary Sebelius has launched a nationwide public-private partnership to improve care transitions
By the end of 2013 goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20 compared to 2010
Achieving this goal would mean more than 16 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge Potential savings $35 B over 3 yearsrdquo
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Expect
ndash To retrain the Workforce to Move to a Strategic Outcome Focus
ndash If your Program is not Evidence Based or Best Practice driven expect not to be considered
ndash Residual and Preventive Care will be the focusndash Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Community-based Care Transition Program (CCTB)
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Vanguard Health Systems
ndash Already actively involved with fixed episodic payment charges for knee and hip replacements
ndash Have obtained physician buy inndash Home health must provide evidenced based
programs with proven outcomes or not considered
ndash Expect home care rehab in 3-7 visitsndash Patients pay $15000 co-pay to be a part of the
programndash Use of Care Navigating Nurse
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
CCTB
ndash For more information and guidance on starting programs visit
httpwwwcmsgovDemoProjectsEvalRots MDitemdetailaspitemID-CMS1239313
ndash Direct questions to CMS regarding Care Transition Programs at
ndash CareTransitionscmshhsgov
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Websites you may wish to explore
httpcaretransitionsorg
httpwwwiproorgindexct-care-transitions
httpwwwcfmcorgintegratingcaretoolkithtm
httpinnovationscmsgovinitiativesPartnerships-for-PatientsCCTPindexhtml
httpnextstepincareorg
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
A PRACTICAL APPROACH
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Dominican Sisters Family Health Service
ndash Looked at their Care Transition Intervention Program
ndash They looked at reducing rehospitalizationsndash 1 in 5 hospitalizations occur within 30 days of
hospital dischargendash 64 post acute care patients need visits sooner and
need to be at self-management levelndash 1 in 4 hospitalizations are avoidable ndash JAMA April 10 Commonwealth Fund 2009
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
They Looked at the Patient Perspective
From the AARP Report on Chronic Care A Call to Action
Nearly 1 in 4 reported a medical error
Nearly 1 in 7 received no follow up appointment post hospital discharge
Nearly 1 in 5 said their transitional care was not well coordinated (IPRO 2011)
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Dominican Sisters Family Health Program
Looked at
Effective Medication programs the PHR PCP follow up appointment any Red Flags and results
They looked at the reconciled Med list Goals if the patient brought the PHR to all physician programs any wt gains because of the patient DX and patient satisfaction
They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR
They used a Home Visit Transition Nurse Coach
Look at the common theme a COACH
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The Dominican Sisters Family Health Service
Identified Goal To ldquoempower patients and caregivers to have the skills knowledge and confidence to manage
their care and to communicate their needs effectively to their health care teamrdquo
Per Eric Coleman MD MPH there were 20-40 decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Care Transition Programs w Coaches
University of Colorado Transition Coaches Annual cost savings $300000
At St Lukersquos Hospital in Iowa Enhanced assessment of post discharge needs on admission Rate of compliance for Med reconciliation increased 75
Louisiana Health Care using a Health Coach day hospital readmission rates from 19 to 4
Is there an opportunity for your home health agency if coaches are being considered at the hospitals ARE they being considered
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
PATIENT CENTERED MEDICAL HOME (PCMH)
Perhaps you want to work with Physicians
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Care Coordination Barriers
ndash Practitioner level barriers such ashellip
ndash System level barriers such ashellip
ndash Patient level barriers such ashellip
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Many Physicians Believe
bull There is a better wayhellipThey are looking to transform their
primary care practices into Patient Centered Medical Homes
What does that mean
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
CMS and PCMH rests on five pillars
1 Patient-centered orientation directed toward their unique needs culture values and preferenceshellip
2 Comprehensive team-based care that meets the majority of each patientrsquos physical and mental health needshellip
3 Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
4 Superb access to carehellip
5 A systems approach to quality and safetyhellip
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Improving Care Transitions through PCMH
PCMH is intended to result in more personalized coordinated effective and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location byndash Taking collective responsibility for patient carendash Providing for the patientrsquos health care needs and ndash Arranging for appropriate care with other qualified
cliniciansrdquo
httpwwwncqaorgPortals0PCMH
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Back to Mrs Smith The Patient and the Family
Mrs Smith has no one plan to stay healthy and no one plan of care
She is confused by the care and the meds
She is concerned about the cost
Her son is uncertain who to call for a global view of her care
He has called three pharmacists regarding her meds
He is upset and getting angry
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Mrs Smith and Disjointed care Mrs Smith has no main contact no single practice monitoring her
condition
Has harried single problem office visits poor follow up on labs
Discontinuity through transitional levels of care
Limited guidance for self-management
No support for families
Mrs Smith is at risk for care fragmentation resulting in an error or poor care
Mrs Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The PCMH
Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare
ndash Requires an interdisciplinary team to take responsibility to improve access continuity and coordination of care
ndash Patients and family members are engaged through education and supporting self-care and disease management
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Mrs Smith is referred to a PCMH
ndash The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person
ndash This program is comprehensive team based primary care reducing cost geared toward a collaborative model easy to implement capable of providing excellent care to patients with multiple chronic conditions
ndash The physician applies to become a PCMHndash The application is indepth and patient centered
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care
ndash Specially trained RNs based in the PCMH physician offices as Guided Coaches
ndash The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions
ndash The nurse and her ldquoback-uprdquo RN partners with the patient for the rest of the patientrsquos life
ndash This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guide and Coach are the words
RN will converse assess and create an evidence-based Care Guide (notice they chose ldquoguiderdquo not ldquoplanrdquo)
The Guided Care RN coordinates care with other care providers HH providers clinics and hospitals
The Guided Care RN educates and supports family and caregivers
This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care Training John Hopkins
ndash A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs
ndash An online course for nurses This six-week 40-hour web-based course prepares registered nurses to become Guided Care Nurses It features self-paced modules live webinars and support from expert faculty After passing an online exam nurses receive a ldquoCertificate in Guided Care Nursingrdquo from the American Nurses Credentialing Center (ANCC) The course is offered by the Institute for Johns Hopkins Nursing
ndash An implementation manual titled ldquoGuided Care A New Nurse-Physician Partnership in Chronic Carerdquo provides detailed practical information and advice on assessing practice readiness preparing to launch providing and managing Guided Care
An orientation booklet for patients and families titled Transformation A Familys Guide to Chronic Care Guided Care and Hope that describes what Guided Care is and how it can help them
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Physicians planning Guided Care
Free Technical assistance is available at
wwwGuidedCareorgadoptionasp
Online courses from John Hopkins Nursing available for RNs
There are also Physician and family courses
Order the free Implementation Manual
Guided Care A New Nurse-Physician Partnership in Chronic Care
There are also free books and material for families
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
NCQA GUIDED CARE PROGRAMAnother option
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
NCQA PCMH Program
ndash Physician and Nurses become Patient-Centered Medical Home Certified Content Experts
ndash Already 5000 recognized practices nationwidendash Provides deliberate strategies and efforts to transform a
practice into a medical home with PCI content expertsndash Must attend 2 seminars 212 daysndash NCQA Facilitating Patient Centered Medical Home
Recognition (15 days covering standards)ndash NCQA Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
NCQA PCMH Program
ndash Complete online application after completion of the seminars
ndash Prepare for and schedule your exam $395ndash Prepare for the survey of the practicendash Keep up to date with NCQA PCMH Standards and
Guidelinesndash Last Advanced Topics in PCMH Mastering NCQArsquos
Medical Home Recognition was in New Orleans 113
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
NCQA PCMH CONTENT EXPERTAND JOHN HOPKINS GUIDED
CARE NURSE COACH
You may want to become certified as an
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
NCQA PCMH CONTENT EXPERT
ndashCan receive certified status and work with physicians in this modelndashReview more on NCQA ndashwwwncqaorgProgramsREcognition
PatientCenteredMedicalHomePCMHaspx
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care at John Hopkins
bull Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002 In creating the Guided Care model the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management disease management self-management transitional care geriatric evaluation and caregiver support models into primary care Guided Care integrates these successful innovations into primary care to make evidence-based state-of-the-art chronic care available from professionals the patient trusts
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care
ndash With Guided Care a registered nurse who is based in a primary care office works closely with 3-4 physicians and health information as well as
technology to provide state-of-the-art care for 50-60 chronically ill patients In partnership with the primary care physician the Guided Care Nurse Coach is responsible for the following clinical processes
ndashAssesses the patient at home this will be completed by the physician practice Guided Care Nurse
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care Continuedndash Create an evidence-based comprehensive ldquoCare Guiderdquo (a tool
for providers that summarizes the patientrsquos conditions and medications care providers family members and other important data in a succinct and professional format) and ldquoAction Planrdquo (a patient-friendly version of the Care Guide)
ndash Monitor the patient monthlyndash Promote patient self-managementndash Smooth the patientrsquos transitions between sites of carendash Coordinate the efforts of all the patientrsquos health care providersndash Assess educate and support family caregivers
Facilitate access to community resources
ndash What is the role for home health
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care
ndash The Guided Care nurses used a secure web-based EHR that was created to support Guided Care The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions The Guided Care nurses used the EHR to do the following
ndash Enter new information about their patients such as initial assessment data changes in health status and medications laboratory test results specialistsrsquo reports and reminders for future events
ndash Check patientsrsquo medications for possible adverse interactionsndash Generate new and revised evidence-based Care Guides for providers
and Action Plans for patientsndash Document contacts with patients families and health care providersndash Check for reminders of events or actions scheduled for each day
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Guided Care Training John Hopkins
ndash Go to httpwwwijhnjhmieduImagesDocumentsFAQGuidedCareNursingpdf
ndash The course is 40 hours and costs $190000
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Home Health Should
Be willing and available with leadership and clinicians to ldquoup-skillrdquo Be flexible Be rapid in response
Be willing to work COLLABORATIVELY
Agree to have certain clinicians trained in PCMH constructs
The HH agency should see improvements in goals attained
The HHCAHPs should reflect the patient satisfaction
Are you preparing the patients for the HHCAHPS survey
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
PCMH and Your Agency
Look for innovative partnerships NOW
Offer same day access and response
Look at creative tools needed specialized programs like heart failure MI follow up
Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs
and consistent communication methods and processes
Establish proactive prepared practice teams
Be willing to break away from the traditional Medicare m Model of care
Consider having Guided Coach Nurses
Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
ACCOUNTABLE CARE ORGANIZATION (ACO)
What about the
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
The ACO
ndash The Coker Group (2012) defined the ACO as an ldquointegrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targetsrdquo
ndash If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals
ndash ACOs will choose who they will work with to deliver care You need to have programs and outcomes they need
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Looking for Excellence in Healthcare
bull The Final Rule requires CMS to ldquoassess the ACOrsquos quality and financial performance based on a populationrsquos use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark populationrdquo(CMS Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP)bull What excellence can your agency demonstrate
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
ACO Count
ndash There were 35 ACOs nationwide in June 2012 over 50 in California As of 11013 there were 106 New ACOs announced by Medicare As of 414 over 360
ndash There are 33 quality measures that an ACO must report on to CMS These measures are collected by Patient surveys (7 measures) data calculated using claims (3 measures) determined via EHR (1 measure) and via Group Practice Reporting Option Web Interface (22 measures) These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks
ndash There are now over 300 +ACOs nationwide and growing
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Risk TRACKS
Various CMS approved risk programsIn Track 1 the one sided model ACOs will h have an upside shared savings opportunity with no downside risk but the shared savings opportunity is less with this modelndash Track 2 is a two sided model requiring the
ACO to share in 60 of both savings and
losses with a cap
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
ACOs
ndash At HomeCare 100 in January 2013 there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups The landscape is changing and changing fast
ndash You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed what you plan to do what resources you have and what resources you need Then make a plan choose the strategy and BEGIN BEGIN
ndash ndash
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
ACOs
ndash Tim Rowan Editor of Home Care Technology Report stated at HomeCare 100 ldquo Through lower reimbursement rates and more aggressive Z-PIC audits CMS seems to be trying to reduce the number of certified HHAs from the current about 11000 to as few as 6000 Survival will largely depend on ACO partnerships but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their areardquo (January 2013)
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Be Proactive
ndash It was stated at HomeCare100 that ldquoas a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your areardquo
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
What other leaders are sayinghellip
ndash Bob Fazzi recently stated ldquoAs a home health leader you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must
ndash Initiate strategies that position your agency to be one of the chosen in your areardquo (February 2013)
ndash Donrsquot be passivehellipstart gathering data Be proactive BEGIN
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Leaders say
ndash Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders
ndash Hospitals are being financially penalized for having excessive rehospitalization rates
ndash Home Health can provide excellent care in the home at a variety of levels
ndash We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified
ndash You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
HOSPITAL READMISSIONREDUCTION PROGRAM
Focus is Quality
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Hospital Readmissions Reduction Program
ndash Payment reduction to hospitals capped at 1FY 2013 2 FY2014 3 FY 2015
ndash Readmission measures apply first tondash Acute MI 30 day risk standardized readmission
measurendash Heart failure 30 day risk standardized readmission
measurendash Pneumonia 30 day risk standardized readmission
measure
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Readmission Measures
ndash Readmission measures are National Quality Forum endorsed measures
ndash CMS began counting the specific readmissions 112012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Home Health Responses
ndash MI post acute follow up programs evidenced-based as well as collaborative prevention oriented programs
ndash Heart Failure post acute follow up programs evidenced-based as well as prevention oriented programs
ndash Pneumonia as abovendash Be certain agency coding is at highest level of
specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code not just the primary diagnosis
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Transitioning into Homecare
ndash Letrsquos look at Heart Failurendash Hospitals are motivated to have patients
discharged to post acute care with a commitment to quality positive outcomes and maintaining patient in the home safely
ndash That means a strong post acute heart failure program at your home health agency
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Visualize the Value
ndash Donrsquot throw out the great things you are doing nowhellipJust show the stats in a stronger manner
ndash Med reconciliation what was found What interventions What outcomes Share the info
ndash Show the powerful holistic evaluation of the patient in their home 2 floors 4 dogs son-in-law who smokes and lives there Physical Social Emotional Environmental challenges and supports need to be shown
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Visualize the Value
ndash Keep the Focus on programs that supportndash The Quality Measures Ambulation and transferring as
well as med managementndash All outcome measures at or above 85ndash The Process Measures The Heart Failure Program The
Wound Care Program ndash The Pressures Ulcer Prevention Program The
Medication Teaching Program ndash The Falls Risk Program The Depression Risk Program
The Immunization Program The Diabetic Foot Care Program or the DiabeticSystemic Care Program
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Visualize the Value
ndash The Patient Experience (HHCAHPS) Make certain clinicians are talking about Pain Medications (What they are What they do When to Take What symptoms are green yellow red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Initiate an Accelerated Strategic Plan
bull You must be strategically focused Gather your team together Brainstorm bull Conduct the community gap analysisbull Note augmented programs that you can make
possiblebull You have choices Create new programs that
reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
IT IS AN EXCITING TIMEIt is a Time of Opportunities
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Things to DO
ndash Assess your community What is needed Where candoes your agency fit
ndash Assess your agency What are the strengths operationally compliance wise financially HR wise
ndash Assess the gap between need and have List the assets and those needed
ndash Assess Technology and Touch Now look at gaps again
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Integrated Chronic Care Managed Model Four Pillars
ndash Build Relationships in community with patients and personnel High Touch Care is achieving High Results
ndash Change Behavior Supporting Patient Self Management means few smart not many goals
ndash Accessing Expertise Means Coordinating Care Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies)
ndash Maximizing Technology such as telemonitoring
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Exciting Changing Times
ndash Hospitals need Home Care but they need to see your value Visit the CEOs COOs CNOS
ndash Demonstrate Your Valuendash Be Prepared for their changes
Be Creative assertive with new programs that augment theirs with TRUE VALUE
ndash Do you know that over 30 of clinicians are expected to be certified in Integrated Chronic Care Management by end of year Will you employ some of those
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Self Management
Will you be able to state and prove you promote self management of patients and that you
Assess PatientFamilies forCurrent level of self management for health literacy for
readiness to change and for problem solving abilityTeach and coach on needed strategies and activities such
asCommunity support groups provide written material
based on EBP Life style modifications and health promotion maintenance needs
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Be PROACTIVE
ndash Care Transition Patient Centered Medical Models ACOs and Home CarehellipIt is an exciting time Be a proactive part of the exciting time
ndash Look at the new seamless coordinated quality personfamily-centered model with your administrative and clinical teams Where does your agency fit now Where will it fit in the future
ndash You must BEGIN
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Q and A
ndash Questionsndash Thoughtsndash Comments
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
Thank you
ndash Contact Susan at ndash susancselectdatacomndash Call 7145242500x235 or 9495846296 cellndash Thank you
- ACOs Transitions of Care Patient Centered Medical Homes Car
- Objectives
- The State of Health Care
- The Scary Safety is an issue
- Quality Safety Efficiency
- INTRODUCTION
- Chronic Illness in the US
- The Experts Sayhellip
- the Reason for Change
- Overview
- Mrs Ruth Smith
- Mrs Ruth Smith In 2012
- Mrs Ruth Smith (2)
- Everyone is in a Hurry
- Letrsquos Look at Care Another Way
- Research Showinghellip
- Chronic Care Needs
- What we do knowhelliphellip
- CMS Mandates Quality Initiatives
- Institute of Medicine 2012
- The Transformed System must be
- CMS Created the INNOVATION CENTER
- Method of Payment
- To Share the risk
- Innovations
- Several Innovative Projects
- The Shift is
- inadequate information and training at discharge were themes th
- Care Transitions Models
- Care Transition Model
- American Geriatrics Society defines Transitional Care ashellip
- The Coleman Model
- The Four Pillars of the Model
- Sample items on Discharge preparation checklist
- Transitional Care ishellip
- Obtain more information
- The Care Transition(TM) Coach
- Care Transitions Interventions
- Another transitional care type training ICM
- National Transitions of Care Coalition
- NTOCC Seven Essential Intervention Categories
- Partnership for Patients
- Expect
- Community-based Care Transition Program (CCTB)
- Vanguard Health Systems
- CCTB
- Websites you may wish to explore
- A Practical Approach
- Dominican Sisters Family Health Service
- They Looked at the Patient Perspective
- The Dominican Sisters Family Health Program
- The Dominican Sisters Family Health Service
- Care Transition Programs w Coaches
- Patient Centered Medical Home (PCMH)
- Care Coordination Barriers
- Many Physicians Believe
- CMS and PCMH rests on five pillars
- Improving Care Transitions through PCMH
- Back to Mrs Smith The Patient and the Family
- Mrs Smith and Disjointed care
- The PCMH
- Mrs Smith is referred to a PCMH
- Guided Care
- Guide and Coach are the words
- Guided Care Training John Hopkins
- Physicians planning Guided Care
- NCQA Guided Care Program
- NCQA PCMH Program
- NCQA PCMH Program
- NCQA PCMH CONTENT Expert and John Hopkins Guided Care Nurse
- NCQA PCMH CONTENT EXPERT
- Guided Care at John Hopkins
- Guided Care (2)
- Guided Care Continued
- Guided Care (3)
- Guided Care Training John Hopkins
- Home Health Should
- PCMH and Your Agency
- Accountable Care Organization (ACO)
- The ACO
- Looking for Excellence in Healthcare
- ACO Count
- Risk TRACKS
- ACOs
- ACOs (2)
- Be Proactive
- What other leaders are sayinghellip
- Leaders say
- Hospital Readmission Reduction Program
- Hospital Readmissions Reduction Program
- Readmission Measures
- Home Health Responses
- Transitioning into Homecare
- Visualize the Value
- Visualize the Value (2)
- Visualize the Value (3)
- Initiate an Accelerated Strategic Plan
- It is an Exciting Time
- Things to DO
- Integrated Chronic Care Managed Model Four Pillars
- Exciting Changing Times
- Self Management
- Be PROACTIVE
- Q and A
- Thank you
-
