care navigation affinity group session five€¦ · comprehensive care for joint replacement model...

Care Navigation Affinity Group

Session Five: Communication and Collaboration with Post-Acute Care Providers and Community

Organizations

January 18, 2018

Comprehensive Care for Joint Replacement Model

Audio available by dialing (800)832-0736Conference Room:*4934891#

Access Code: 011818#

Welcome

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Laura Maynard, M.Div.CJR Learning System Team

The Lewin Group

Hilarea Amthauer, MPH, BSN, RNCJR Learning System Team

The Lewin Group

Webinar Agenda

• Welcome & Logistics• Overview of Affinity Group Goals• Review of the Care Navigation Driver Diagram• Introduction to the QIN-QIO Program • Group Discussion• Announcements & Reminders

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Meeting Logistics

• All telephone lines are muted and will be unmuted during the discussion session

• Please dial in using a telephone to enable open discussion• We encourage comments, questions, and reactions via Chat• Participate!

– Chat– Polls– Telephone (During Open Discussion)– Post-Event Survey

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Download Available Resources

Closed Captioning

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To Ask Questions

or Send Messages

To Dial In Via

Telephone

To Raise Your Hand

Introduction to Adobe Connect

To View the Video

Introduction to Adobe Connect (Cont.)

• Use the Chat pod to submit any questions or comments

• Please use “@” if your question/comment is directed to a specific participant

• Submit your question/comment by clicking the chat bubble icon

• Please share in Chat now:– Organization– One success or challenge you have

had related to care navigation this month

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Care Navigation Affinity Group Goals

Convene on a monthly basis to:– Share care navigation and care coordination

tools and resources– Discuss successful strategies, challenges, and

lessons learned– Learn from each other

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Care Navigation Driver Diagram: Primary Driver #1

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Care Navigation Driver Diagram: Primary Driver #2

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Poll 1

Do you have any strategies that should be added to the driver diagram? [Select one option]• Yes• No• Maybe

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Questions to Consider

• What successes and challenges has my hospital had in collaborating with post acute care providers and community organizations?

• How can we build better partnerships in the community?

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QIN-QIO Program

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QIO Program Timeline

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1965 – Medicare and Medicaid signed into law1972 – To oversee quality – Medicare Professional Standards Review Organizations (PSRO) are formed1982 – PSROs become Peer Review Organizations (PROs) to protect beneficiaries from under-use of necessary services1984 – PROs begin to review medical records to protect beneficiaries so they are not discharged from hospitals too early1996 – PROs launch first quality initiative to improve hospital care for beneficiaries who suffered a heart attack2002 – PROs become Quality Improvement Organizations (QIOs)2002 – 2008 – QIOs start working with nursing homes, home health agencies and physician offices2011 – Align with National Quality Strategy 2014 – QIO program is structured to regionalize care and reduce duplication

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Map

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• 14 QIN QIOs• Each state and territory has a QIO that helps providers:

– reduce healthcare associated infections, – reduce readmissions and medication errors, – work with nursing homes to improve care for residents, – support clinical practices in using interoperable health information technology to enable

the exchange of essential health information to improve the coordination of care,– promote prevention activities, – reduce cardiac disease and diabetes, – reduce health care disparities,– improve patient and family engagement, and– increase CMS value based purchasing programs, including the physician value based

modifier program.

Quality Innovation Network – Quality Improvement Organization (QIN-QIOs)

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• Use community organizing tactics to engage providers and community members to work collaboratively together towards a common goal.

• Perform a root cause analysis to determine the main drivers of the identified problem.

• Select an evidence based intervention to address the drivers identified.

• Collect and monitor data to track progress and outcome measures.

Coordination of Care Task Tactics

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• Poor communication and information transfer between providers and/or practitioners at the transition of care.

• Lack of standard or known processes for providers and practitioners to use in transitioning beneficiaries across settings.

• Low patient engagement and activation.

Common Drivers of Readmissions

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Cohort A: August 1, 2014 - December 31, 2014

Cohort B: January 1, 2015 - December 31, 2015

Cohort C: January 1, 2016 - December 31, 2016

Recruitment

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Recruited and In Progress QIN-QIO Care Coordination Communities

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Visit the QIO Program Website: http://qioprogram.org/contact

Find Your QIN-QIO

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Contact Your QIN-QIO to Join a Recruited Care Coordination Community

Poll 2

Do you participate in a Quality Improvement Network -Quality Improvement Organization (QIN-QIO) coalition or Learning and Action Network (LAN)? [Select one option]• Yes• No• I Don’t Know

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Let’s Discuss!

• Use the Chat pod to submit any comments, questions, or reactions

• Please use “@” if your question/comment is directed to a specific participant

• Submit your comment/question/reaction by clicking the chat bubble icon

• “Raise your Hand” or speak up to share verbally

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Discussion

• How do you work with your community partners?

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Care Navigation Driver Diagram: Primary Driver #2

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Poll 3

Do you have regular meetings with your PAC providers? [Select one option]• Yes• No• I don’t know

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Poll 4

Do you share data with PAC providers? [Select one option]• Yes• No• I don’t know

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Let’s Discuss Further!

• Use the Chat pod to submit any comments, questions, or reactions

• Please use “@” if your question/comment is directed to a specific participant

• Submit your comment/question/reaction by clicking the chat bubble icon

• “Raise your Hand” or speak up to share verbally

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Discussion Questions

• How have you engaged with Post-Acute Care providers?

• How do you determine your preferred provider list?• What are the benefits of good relationships with PAC

providers?• How has your work with PAC providers and

community organizations helped your patients?

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Sharing Locally

• Do you collaborate with other care navigators in the CJR program, outside these affinity group meetings?

• Do you collaborate with other care navigators in your community?

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Announcements & Reminders

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Leaving in Action

• Please type into chat:– Something that you will do or try based on today’s

discussion (i.e. contact your QIN-QIO to join a recruited community, join the QIN-QIO Learning and Action Network, start meeting with your post-acute care providers).

– Based on the presentations from this Care Navigation Affinity Group, what specific actions, enhancements, or changes have you made at your organization?

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Poll 5

Do you have an effective way of using Risk Stratification tools to enhance Care Navigation? [Select one option]• Yes• No• I don’t know

(Please type in chat what Risk Stratification Tool you use)

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Continue Discussion on CJR Connect

• Request to join the “Care Navigation” groupo Go to the “Groups” tab on CJR Connecto Click on the green plus sign to join the “Care Navigation”

group • Post a comment in the group, share resources with your peers,

or just respond to others!• To request a CJR Connect account, go to:

https://app.innovation.cms.gov/CJRConnect/CommunityLoginand click “New User? Click Here”

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Upcoming Events & Reminders

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• If you have any questions about these events or related to the Care Navigation Affinity Group, send an email to LS-CJR@lewin.com.

• Send any technical or programmatic questions to CJRSupport@cms.hhs.gov.• Please take a few minutes to complete the Post-Event Survey.