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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]
Sherri Klotz 720-639-2200, [email protected]
Next Meeting will be November 2nd at 3:00 PM PowerBack in Lafayette
329 Exempla Circle, Lafayette
Meeting are the 1st Wednesday of each month from 3:00 – 5:00 PM
Questions?
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