care navigation affinity group session five€¦ · comprehensive care for joint replacement model...
TRANSCRIPT
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
2
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
3
Comprehensive Care for Joint Replacement Model
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
Comprehensive Care for Joint Replacement Model 4
5
Download Available Resources
Closed Captioning
Comprehensive Care for Joint Replacement Model
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
6
Comprehensive Care for Joint Replacement Model
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
Comprehensive Care for Joint Replacement Model 7
Care Navigation Driver Diagram: Primary Driver #1
8
Care Navigation Driver Diagram: Primary Driver #2
9
Poll 1
Do you have any strategies that should be added to the driver diagram? [Select one option]• Yes• No• Maybe
Comprehensive Care for Joint Replacement Model 10
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?
Comprehensive Care for Joint Replacement Model 11
QIN-QIO Program
12
Comprehensive Care for Joint Replacement Model
QIO Program Timeline
13
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
Comprehensive Care for Joint Replacement Model
Map
14
• 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)
15
Comprehensive Care for Joint Replacement Model
• 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
16
Comprehensive Care for Joint Replacement Model
• 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
17
Comprehensive Care for Joint Replacement Model
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
18
Comprehensive Care for Joint Replacement Model
Recruited and In Progress QIN-QIO Care Coordination Communities
19
Visit the QIO Program Website: http://qioprogram.org/contact
Find Your QIN-QIO
20
Comprehensive Care for Joint Replacement Model
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
Comprehensive Care for Joint Replacement Model 22
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
23
Comprehensive Care for Joint Replacement Model
Discussion
• How do you work with your community partners?
Comprehensive Care for Joint Replacement Model 24
Care Navigation Driver Diagram: Primary Driver #2
25
Poll 3
Do you have regular meetings with your PAC providers? [Select one option]• Yes• No• I don’t know
Comprehensive Care for Joint Replacement Model 26
Poll 4
Do you share data with PAC providers? [Select one option]• Yes• No• I don’t know
Comprehensive Care for Joint Replacement Model 27
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
28
Comprehensive Care for Joint Replacement Model
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?
Comprehensive Care for Joint Replacement Model 29
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?
Comprehensive Care for Joint Replacement Model 30
Announcements & Reminders
31
Comprehensive Care for Joint Replacement Model
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?
Comprehensive Care for Joint Replacement Model 32
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)
Comprehensive Care for Joint Replacement Model 33
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”
34
Comprehensive Care for Joint Replacement Model
Upcoming Events & Reminders
35
Comprehensive Care for Joint Replacement Model
• If you have any questions about these events or related to the Care Navigation Affinity Group, send an email to [email protected].
• Send any technical or programmatic questions to [email protected].• Please take a few minutes to complete the Post-Event Survey.