1

Improving Care for Multi Visit Patients: An Introduction to the MVP MethodPartner Learning Webinar

August 16, 2019

2

Click the arrow to expand or collapse this pane

Click the hand to “raise your hand”

Click Questions to expand or collapse the Questions box

Messages and links from staff will appear here

To share a comment or question with staff, type here and click Send. (Please keep in mind: at our discretion staff may address your comment/question publicly during the webinar, privately during the webinar, or privately at a later time.)

Webinar Logistics: Asking Questions

3

If you plan to speak, join the webinar via computer or the GoToWebinar smart phone app.

If joining audio by dialing the number (not the IOS or Android app), you will need to enter your “Audio PIN” to speak. Otherwise, you will be in listen-only mode.

“Raise your hand” in the GoToWebinar control panel when you want to talk; the meeting organizer can unmute your line.

Check that your computer or phone is not muted, and talk.

Webinar Logistics: Speaking

If you would like to ask a question directly please ‘raise your hand’ and we will unmute you to ask your question

Improving Care for Multi Visit Patients

An Introduction to the MVP Method

Sue Bergmann, MBA, BSNSenior Director, Safety and Quality

sueb@wsha.org

Washington State Hospital Association

Objectives

Describe the Multi Visit Patient Method and it’s role in reducing readmissions

Outline the steps for implementing the MVP Method

Review Harborview Medical Center’s experience in a Multi Visit Patient Acceleration Network

Explain Harborview’s learnings and barriers identified in their implementation

Whole Person Transitional Care (AHRQ ASPIRE)

A patient-centered approach to addressing the medical, social and behavioral needs of patients.

Medical BehavioralSocial

Designing and Delivering Whole-Person Transitional Care. Content last reviewed June 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html

Amy Boutwell, MD, MPPPresident, Collaborative Healthcare Strategies

Developer, the ASPIRE Guide and MVP Method

Washington Hospitals Coached on MVP

Confluence Health

Harrison Medical Center

PeaceHealth Southwest

Providence Regional Medical

Center Everett

Skagit Valley Hospital

Harborview Medical Center

Multi Visit Patient (MVP)A patient with four or more inpatient admissions within twelve months.

High Utilization Complex Medical Conditions

MVP’s in Washington State

Source: CHARS Washington State Comprehensive Hospital Abstract Reporting System (CHARS)- Timeframe: July 2016 – July 2018

CADHypertension

DiabetesCHF

COPD

DepressionAnxietyBipolar

Post Traumatic Stress Disorder

Substance Use Disorder

HomelessnessSocial Isolation

PovertyEducation Violence

Medical Behavioral Social

MVP Contributing Factors

MVP’s have unmet needs driving their utilization.

Utilization is a symptom of that unmet need.

Driver of utilization: The person-centered root cause of utilization

Driver of Utilization

Not the admitting diagnosis

Not the chief complaint

Not the problem list

Why is one patient an MVP and the other isn’t?

Mr. Smith42 year old male

DMCADHTNAfibARF

Mr. Johnson42 year old male

DMCADHTNAfibARF

MVP Not an MVP4+ admits/year 1 admit/year

Mr. Smith42 year old male

DMCADHTNAfibARF

MVP 4+ admits/year

Whole Person Transitional Care for MVP’s

Identify Assess Develop a Plan Link Plan for Return

Identify• Reliably identify MVP’s currently

in the hospital

• Start with a daily MVP report

• Work to build a real-time notification or alert in your EMR

Assess• Assess your MVP’s at the

bedside, while in the hospital

• Not a chart review, let the patient lead the conversation (motivational interviewing)

• Identify the driver of utilization

Develop a Plan• Develop a plan to address the

unmet need driving utilization

• Co-developed with the patient and/or caregivers

• The plan is feasible and gives clear guidance

Link • Link to outpatient and/or

community resources that will address the MVP’s unmet needs

• Warm hand-off, in-person meeting while the MVP is in the hospital

• Not a paper referral

Plan for the return • Prepare the ED for when MVP

returns

• ED Care Plans: • Summary for the ED

provider to inform care in the ED

• Link the patient back to community resources

It may take several attempts to successfully engage an MVP.

Identify patients that “refuse” services as an opportunity to try something different!

Harborview Medical CenterMVP Pilot Project Experience

HMC MVP Team Members

Mona Chambers, RNProject Operations SpecialistInpatient Care Management

Kari Nasby, SWSocial Work Supervisor

Ambulatory CareEllen Robinson, PTClinical Analyst

Quality Improvement

HMC Baseline Analysis

MVP defined as >= 4 IP Visits in 12 months240 patients ~ 1300 IP encounters

• 60% White, 22% Black, 10% Asian, 4% American Indian/Alaska Native• 47% patients with Mental Health condition • 41% patients with Housing Insecurity• 53% patients with Substance Use Disorder• 25% have all three conditions• 70% Male, average age 56 years old• 15% Non English Speaking• 51% Medicare, 43% Medicaid, 6% Commercial• 90% Home Discharges

MVP IdentificationReal Time Web Based Report

A day in the life…• ##/2019 - 25 MVPs • 16 patients > 4 (4-21 visits) • 9 patients current encounter = 4th visit • 7 Non English speaking • 4 Housing Insecurity• 15 Medicaid, 8 Medicare, 2 Commercial

Typical Daily List - 3-5 New patients5-15 minutes per patientTracking cases to expedite linkages

Harborview MVP InterviewsMedical One Liner:• Try to keep to one sentence and include the main reason for this admission.

Utilization history and pattern:• Include ED visits, Admits over the last 3 months, etc.

The Driver of Utilization:• Try to elicit from patient the underlying reason for return to the hospital. “Why do

you think you are needing to come back to the hospital so much?” “What can we do differently for you?” What can you do differently to be able to avoid coming back to the hospital?”

• Summarize in a short paragraph of what is driving this readmission with a holistic lens, looking at the specific medical, social and psychosocial status and needs of the patient which is causing them to seek medical help frequently.

Weekly Team Huddles

• Multidisciplinary Team allows us to look at the issues from all angles

• Brainstorming linkages for individual cases provided knowledge transfer across care settings

• Reviewed the services we “thought” the patient was getting and what they “were” getting

“There is no such thing as a referral for a MVP” – Dr. Amy Boutwell

Driver of Utilization Response SystemDrivers (Root Cause) Response System (Linkage) Primary Care Engagement Enhanced ACC, outreach to patient at bedside, make warm and helpful

connection, work on flexible scheduling, encourage patient to make connection (or re-connection) with community provider;

Chronic Symptom Management(HF, COPD, Renal, DM)

Describe chronic unstable baseline; identify maneuvers that provide rescue/relief; Develop strategies to deploy maneuvers as part of a known plan of care in-home, in urgent care, or in ED. Reconnect patient with specialty care providers already in place;

Inadequate Housing Assess patient level of need, determine if community resources are already in place or have begun application process, link to housing liaison PRN

Navigator/Coach/Cultural Mediator/Case Manager

Link to PCP with notification of additional wrap around services that might be required; Develop system for electronic notification and warm handoff Neighborhood Clinics connections

SUD Treatment Link patients with inpatient SBIRT services for transition to community care

Communication Challenges• Care Team roles/contacts don’t cross systems• Notification of MVP ED arrival is not visible • EDIE care plans not always complete and not integrated into all ED

providers work flow• Inpatient/ambulatory care plans not integrated• Warm handoffs optimal - - but challenging

Data Tracking

“More FTE’s is not the answer”

“Cross Continuum Care Management requires a reduction in gaps/duplication across system resources”

HMC Ongoing Work • Care Management Steering Committee• Review job roles and responsibilities across Care

Management teams• Inpatient and Outpatient IT integration • Considering how to facilitate “team huddles” across

care settings – including community partners

MVP Project Team

• Paula Minton-Foltz – Executive Sponsor• Dr. Nancy Sugg – Physician Champion• Mona Chambers – Care Co-ordinator RN (Inpatient)• Kari Nasby – Social Work (Ambulatory)• Curt Muhammad – COPD Care Manager (Inpatient)• Lea Ann Miyagawa (Cultural Mediators)• Kim Rezentes – Nursing (Ambulatory)• Ellen Robinson – Quality Improvement Support

MVP Training OpportunityWSHA and HealthierHere are offering

FREE MVP training for King County Hospitals

Late 2019: In person MVP Boot Camp for hospitals to work on their MVP Implementation Plans

WSHA will provide monthly coaching calls to support MVP Implementation

Early 2020: In person MVP Boot Camp for hospitals and community partners to work on MVP linkage

For more information on MVP Training, contact Sue Bergmann: sueb@wsha.org

Questions?

To implement MVP and/or

Whole Person Transitional Care at your facility:

Contact Sue Bergmannsueb@wsha.org