Boulder County Care Transitions Collaborative · PDF file 2017-10-08 · Boulder...

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Transcript of Boulder County Care Transitions Collaborative · PDF file 2017-10-08 · Boulder...

  • Boulder County

    Care Transitions

    Collaborative 2016 Age Well Conference

  • What is BCCTC

     Boulder County Care Transitions Collaborative started

    March 2012

     CMS Grant

    Goal to reduce Readmission in Boulder County

     Partnership between Area Agency on Aging and Quality

    Improvement Organization (QIO)/Colorado Foundation

    for Medical Care (CFMC) with community involvement

  • Foundation

     Small Think Tank – March, 2012

     Quickly realized all stakeholders needed to be at the table to make real

    change

     Community Coalition– June, 2012

     Expanded into a community coalition primarily identifying struggles to

    readmissions and discussing solutions in an ideal world

     Collaboration – August, 2014

     CMS Grant ended

     Community run group with leadership team guiding direction and helping to

    ensure progress

  • Quantitative Accomplishments

    30 Day Readmission Rate (All Cause)

    2014

    Boulder County Colorado

    Medicare Only 6.68% 10.15%

    Private Insurance Only 5.76% 5.28%

    Medicaid Only 7.81% 10.10%

    All Current Payers 6.75% 8.51%

    2012

    17.6% of Medicare beneficiaries

    nationwide were re-hospitalized.

  • Qualitative Accomplishments

     Improved partnerships between providers

     Understanding each other’s businesses

     Providers (who)

     Organizational structure

     Regulations

     Clinical/provider capabilities

     Sharing of best practices

     Local Resources: involve over 75 organizations throughout Boulder County

     Similar struggles/systems developed within providers

     Development of county wide templates/expectations

     Teamwork

     Less of a competitive mentality

     Focus on the right thing for the patients/people of Boulder County, no longer about the individual organization

  • Establishing Peaks

     Formation of leadership team

     Community Lead

     Representing a variety of types of organizations

     Hospital, SNF, ALF, Home Health, Home Care, PCP

     Creation of mountain top goals

     Established timeline

  • Mountain Top Goal 2011-2017

    2011

  • Peak 1

     Goal: Reduce hospitalization between hospital to skilled nursing facility

     Local Involvement/ Resources

     First time the hospitals and SNF’s sat down together

     4 meetings between Fall 2013 and Fall 2014

     Identified barriers and discovery of capabilities of both sides of the patients care

     SNF Regulations: Acceptable discharge plans, restraints, psychotropic medications, labs, medication

    delivery

     Best Practices:

     Re-evaluated necessary information on transfer forms and report call

     Improved partnership between providers

     Organizational contacts

     Sharing of best practices

     Transitional care nurses follow patients closely

    Peak 1

    Hospital-SNF

    protocol/set

    of

    information

    has been

    established

    and

    implemented

  • Peak 2

     Goal: Reduce hospitalization between hospital to skilled nursing facility by involving/educating the PCP and

    educating hospitalists

     Local Involvement/ Resources

     Transitional care nurses, PCPs, Specialist and Hospitalist involvement

     Identified barriers and discovery of capabilities of more sides of the patients care

     Educated PCP’s, specialists and hospitalist on SNF clinical capabilities

     Misconceptions identified, i.e. stat labs, ability to do certain procedures

     Assumptions addressed, relationships built, respect established

     Best Practices:

     Expectation of improved communication and collaboration between all providers involved

     Improved partnership between providers

     Organizational contacts

     Hospital informed PCP of discharge from hospital to SNF

     SNF provided discharge information to PCP upon leaving SNF

     Specialty education within SNF’s

     Transitional care staff follow patient closely while at SNF and schedule specialty appointments during SNF stay and PCP appointments within 1 week of discharge

    Peak 2

    Hospital-PCP &

    specialists &

    hospitalists

    protocol/set of

    information has

    been established

    and

    implemented

  • Peak 2

     Trial and Best Practices--discharge information being sent to all parties involved when leaving a SNF

    Your Patient_________________________is being discharged from our facility on

    _______________. A follow up appointment will be made prior to discharge with the Primary Care Physician, and a copy of the discharge orders will be faxed to all following physicians for review.

    Primary Care Physician_____________________Follow up appointment_______________

    Orthopedic physician_________________________

    Nephrologist________________________________

    Cardiologist_________________________________

    Other______________________________________

    Home Health________________________________

  • Peak 3

     Goal: Reduce hospitalizations. By this point we have hospital to skilled

    nursing facility by involving/educating the PCP and educating hospitalists and

    bringing in Home Health and Home Care agencies.

     Local Involvement/ Resources-over 10 local Home Health’s and a handful of

    non-medical agenesis joined our collaboration

     Identified barriers and discovery of capabilities of more sides of the patients

    care:

     Who orders what and when do they arrive:

     Wound Care Supplies, DME

     O2 orders, Medications, INRs

     Medication Management– getting Rx’s to patients home, setting up pill boxes, watching for side

    affects, reporting errors to who and when?

     Psyc- Social Issues and Support

     Family Dynamics

    Peak 3

    Hospital- Home

    Health

    protocol/set of

    information has

    been

    established and

    implemented

  • Nurse-to-Nurse Handover Pilot Program

     Goal: determine if Nurse to Nurse Handovers were valuable in the communication piece of reducing rehospitalziations for complex/ at risk patients

     3 SNF’s participated and 3 Hospitals and 5 Home Health agencies

     76 patients were tracked in a 60 day window.

     Feedback: average Quality of Call -4, most were LC, comments included-

     ‘Very valuable! From paperwork, I would never had know what the nurse was able to share in the phone call.’

  • Peak 3

     Best Practices:

     Expectations- time frame for SOC, supplies and communication

     Communication points-Nurse to Nurse Hand-Over

     Education

  • Peak 4

    Peak 4

    Hospital-ALF

    protocol/set of

    information has

    been

    established and

    implemented

    Over 55

    licensed ALF’s

    in Boulder

    County

  • Peak 4

     Goal: Reduce hospitalization between hospital to skilled nursing facility by

    involving/educating the PCP and educating hospitalists and bringing in Home

    Health and Home Care agencies for individuals living in Assisted Livings

     Local Involvement/ Resources-over currently have over 15 active assisted livings in

    our collaboration

     Identified barriers and discovery of capabilities of more sides of the patients care:

     When a resident can return to home: regulations, each community is different, time frames

     How can a resident get home?

     Family involvement

     Local Involvement

     COMMUNICATION between ALF, EMT, ER

  • Peak 4  Area Agency on Aging developing a quick reference on their website.

     Trial currently in progress, through end of 2016: TRANSFER SUMMARY TEMPLATE

     Goal of having better communication as to why resident is being sent out by ALF and how fast can

    they get back home and stay.

    Slums 15, Alert and oriented

    Very confused last 2 hrs

    Alz

  • Reduce Rehospitalzations in Boulder County

     65 days until 2017

     Our mission will never be fully completed

     It is an ever changing industry

     Needs are ever changing

     Rules and Regulations are ever changing

     But our goals remain the same…

     Improved partnerships between providers

     Sharing of best practices

     Utilize and work successfully with Local Resources, Teamwork

     Development of county wide templates/expectations…Best Practices

    Mountaintop Goal

  • If you want to get involved:

     Please contact a member of the BCCTC Leadership Team  Julie Nash303-440-9100, [email protected]