MA STAAR Fall Learning SessionEngaging Front-Line Staff and Your

Cross Continuum Team

1:15-2:30PM Breakout Peg Bradke and Rebecca Steinfield

Hospitals

• Perform an enhanced assessment  of post-hospital needs

• Provide effective teaching and facilitate enhanced learning

• Ensure post-hospital care follow-up

• Provide real-time handover communications

Office Practices

• Provide timely access to care following a hospitalization

• Prior to the visit: prepare patient and clinical team

• During the visit: assess patient and initiate new care plan or revise existing plan

• At the conclusion of the visit: communicate and coordinate ongoing care plan

Home Care

• Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan

• Assess the patient, initiate plan of care, and reinforce patient self-management at first post-discharge home care visit

• Engage, coordinate, and communicate with the entire clinical team

Skilled Nursing Facilities

• Ensure that SNF staff are ready and capable to care for the resident patient’s needs

• Reconcile the Treatment Plan and Medication List

• Engage the resident and their family or caregiver in a partnership to create an overall place of care

• Obtain a timely consultation when the resident’s condition changes

Transition from Hospital to Home• Enhanced

Assessment• Teaching and

Learning• Real-time Handover

Communications• Follow-up Care

Arranged

Post-Acute Care Activated• MD Follow-up Visit• Home Health Care

(as needed)• Social Services (as

needed)

• Skilled Nursing Facility Services

• Hospice/Palliative Care

Supplemental Care for High-Risk Patients *• Transitional Care

Models• Intensive Care

Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)or

IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

Vision for Cross-Continuum Teams

Understanding mutual interdependencies, the hospital-based teams co-design care processes with their cross-continuum care partners and collaborate to solve problems to improve the transition out of the hospital and reception into community settings of care.

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Cross-Continuum Improvement Teams

• One of the most transformational changes in the STAAR Collaborative

• Reinforces that readmissions are not solely a hospital problem• Need for involvement at two levels:

1) at the executive level to remove barriers and develop overall strategies for ensuring care coordination

2) at the front-lines -- power of “senders” and “receivers” co-redesigning processes to improve transitions of care

• New competencies in partnering across care settings will be a great foundation integrated care delivery models (e.g. bundled payment models, ACOs)

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Starting your Cross-Continuum Team

IHI How-to Guide, Page 6

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Starting your Cross-Continuum Team

IHI How-to Guide, Page 8

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CCT Membership Recommendation• Executive Sponsor• Day-to-day Leader• Patients and family members• Hospital clinicians and staff• Supporting staff (QI, IT, Finance, etc.)• Palliative Care• Payors• Clinical and administrative staff and/or leaders from the community

─ Skilled nursing facilities─ Office practice settings─ Home health─ Community or Public Health Services─ Area Agencies on Aging

Consider those that are part of your system but also those outside of your organization/system

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General Recommendations for CCTs

• Meet regularly to facilitate bi-directional communications and collaboration, assess progress, remove barriers to progress and support the improvement of the front-line teams in all clinical settings.

• Have members from the cross-continuum team visit each other’s sites (including accompanying a nurse on a home visit) to observe patient care processes during transitions.

• Complete periodic diagnostic reviews of patients that have been readmitted.

• Complete a gap analysis of your settings --Where to you have work going with the key changes currently?

• Add patients and family members to the cross-continuum team to enhance the focus on the patient’s experience and to harvest their suggestions for improving care processes.

Frontline EngagementTips from Steve Spear

• Allow the frontline team interests to determine where to start.

What have you found?How have you used observation to move test of change?

• Solve a problem that really matters … When you start to score gains, your staff to take notice.

• Don’t think too much but do a lot. That’s where the real learning takes place.

Model for Improvement

Study Do

PlanAct

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

Setting Aims

Establishing Measures

Selecting Changes

*2001 Associates in Process Improvement

Discussion Questions for Frontline Engagement

• What stories have you used to enhance the work and move you process?

• In what way are you using data or measure results to engage your staff?

• What are your barriers to engaging your frontline?

• What are your successes in engaging frontline staff and spreading your successful practices?

CCT’s Role in Performing an Enhanced Assessment of Post-Hospital Needs

• On admission, how can hospital clinicians and staff get timely and relevant information from community providers (e.g. medication lists, comprehensive care plans, insights about the patient’s ability to provide self-care, advanced directives).

• Other emerging best practices?

CCT’s Role in Providing Effective Teaching and Facilitating Learning

• Develop and utilize universal patient-friendly education materials for common clinical conditions in all health care settings in a community.

• Ensure that all health care providers in the community are competent in effectively teaching and facilitating learning for patients and family caregivers utilizing health literacy principles.

• Other emerging best practices?

CCT’s Role in Providing Real-Time Handover Communications

• Hospital team members and community providers co-design real-time handover communications (including preferred format, mode of communication and specific information about the patient’s status).

• Consider adopting a universal format for patient care plans (with information about medications, diet, treatments, signs and symptoms that require medical attention and plans for follow-up).

• Other emerging best practices?

CCT’s Role in Ensuring Post-Hospital Care Follow-Up

• Determine who is the best clinical provider (from the patient’s perspective) to complete follow-up phone calls.

• Collaborate with payers and post-acute care providers to determine eligibility for intensive care management and best clinical provider for various patient populations (Care Transitions Intervention, APN Transitional Care, HF Clinic, Patient-Centered Medical Home, Evercare, etc.).

• Other emerging best practices?

CCT’s Role: Review Data• Patient experience data

─ Communication with patients (Q 3,7)─ Discharge preparation (Q 19,20)

• 30-day all-cause readmission rates for:─ All conditions─ Conditions of interest

• Rehospitalization rates if available• Days between discharge and readmission• Readmission into Observation status• Patients readmitted within 30 days who had an office visit

before return to hospital

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What is one new thing you learned

today that you would like to test?