Collaboration Key to Making Outcome Based Pathways

and Reimbursement a Reality Yvonne Ashford (Central CCAC)

Valerie Armstrong (North Simcoe Muskoka CCAC)

Tina Hamilton(Saint Elizabeth Health Care)

OACCAC Knowledge and Inspiration Conference

June 20th, 2013

2

Supporting Structural and Cultural Change

Kotter’s 8-Stage Process

1. Establish a sense of urgency

2. Create the guiding coalition

3. Develop a vision and strategy

4. Communicate the change vision

5. Empower employees for broad based action

6. Generate short term wins

7. Consolidate gains and producing more change

8. Anchor new approaches in the culture

Improving Care Experiences

• Patient outcomes drive care delivery

• Care decisions made by patient and care professional closest to patient

• Care based on evidence-informed best practice

• Payment for quality (outcomes)

3

Establishing a Sense of Urgency

Planning

4

Creating a guiding coalition

Service Provider and CCAC Joint Team

Cross-functional teams NSM and Central CCAC Consolidated project plans developed with SPOs & CCACs

Joint CCAC Project Team

Central CCAC Champlain CCAC North Simcoe Muskoka CCAC

Local Service Provider Internal Project Team

Cross-functional team from CCAC including frontline staff

Local CCAC Internal Project Team

Cross-functional team from CCAC including frontline staff

5

Planned Activity

Central CCAC NSM CCAC

Pathways Wound Wound / Orthopaedic

Description All new wounds All populations

All new wounds/joint replacements Short Stay population

Provider Partners

1. Bayshore 2. Closing the Gap 3. Paramed 4. Revera 5. Saint Elizabeth 6. Spectrum 7. SRT Med-Staff 8. VHA Home 9. Calea

Wound: 1. Bayshore 2. Closing the Gap 3. Saint Elizabeth

Orthopaedic: 1. Revera 2. Closing the Gap

Start Date CHRIS changes – Oct. 25 Business change – Nov. 26

CHRIS changes - Oct. 25 Business change - Nov. 26

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Developing a vision and strategy

Planning

7

CCAC

Deployment and

Testing (IT/IS)

CCAC

Contracts

CCAC

Education and

Training

CCAC

Business Process

Program Design

CCAC

Client Service

Governance

OA &CCAC

Project

Planning

CCAC

Engagement and

Communication

CCAC

Evaluation

Measurement

Reporting

WORK

BREAKDOWN

STRUCURE

SPO

Training

SPO

Business

Process

SPO

Communication

SPO

Billing

Process

SPO

Evaluation &

reporting

Detailed schedule

outlining activities

for all parties involved

CCAC

Finance

Communicating the change vision

CCAC/SPOs Joint Planning

8

VSM/Process Mapping Session

• Reviewed current state

• Identified “What will change” and “What remains the same”

• Mapped future state

• Completed gap analysis

• Demonstrated CHRIS and HPG interaction

Outcome:

• Joint action plan

• Business rules

• Revised process maps

Educational Tool Kit

1. Business process scenarios

2. Business rules document

3. Process maps

4. Q&As

5. Presentations

6. Change management material

7. User Guides – HPG / CHP

8. Guidelines for completing reports

9. Pathways

10. Video for HPG / CHP use

9

Educational Tool Kit

Change Management Resources

• Model for change analysis

• Change management exercises

• Train the trainer

10

Educational Tool Kit

Business process scenarios

• All known scenarios

• Communication

• SPO & CCAC actions

11

Scenario and technology testing

• Testing scenarios with CHP & CHRIS

• SPO & CCAC

Educational Tool Kit

Video for HPG / CHP use

Recorded instruction video

Accessible to all stakeholders

Easy to understand

Standardized instruction

12

Lessons Learned Planning

• Define Scope Early

• Risk analysis key

• Set the Stage

• Consolidated contracts, IT readiness, aligning caseloads

• Scenario Development and Testing

• Define workarounds, identify improvement opportunities

• Collaborative Approach

• Involve frontline early and often, involve cross-functional

• Resource Intensive

• Identify consistent lead, local and SPO steering committees

• Process Redesign

• Core standard processes, decisions impact local and SPOs

• Communication

• Internally and often, key messages across stakeholders

13

Implementation Strategies & Challenges

14 Empowering employees for broad based action

Implementation Strategies

CCAC

Management support for initial OBPs – confirmation of processes prior to sending out initial offers

Regular team huddles to review and provide real-time information

All managers were knowledgeable of model and available to support staff

Manager most involved to be on call initially

Ensure staff on all shifts are knowledgeable of processes

15

Empowering employees for broad based action

Implementation Strategies

Service Providers

Initial interval reports reviewed and submitted with support

Ensure IT and support staff knowledgeable and be available

Resource experts available to support a Coordination staff – real time

Internal steering committee to guide decision making

Ensure all staff on all shifts are knowledgeable of processes

16

Empowering employees for broad based action

Implementation Strategies CCAC and SPOs

1. Regular check-ins with CCAC and SPOs (first two weeks)

• Real-time problem-solving and decision-making

2. Identification of one contact person at CCAC and SPO

• For communication and escalation

3. Continue with internal committees – the “new norm”

• CCAC and SPO internal committee

• Joint CCAC/SPO committee

• CCAC and OACCAC

• Weekly provincial meetings

17

Post-Implementation Lessons Learned and Impacts

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Consolidating gains & producing more change

Anchoring new approaches in the culture

Impact on Clinical Processes

Focus on Outcomes

• Communication more focused on outcomes and less about visits

• Focus on “Clinical Management” by SPOs well received

• Shift from teach, reduce and discharge to ensuring wound is healed prior to discharge

• SPOs have more autonomy with clinical judgement – with some controls internally

SPOs monitoring patients/frequencies and best practice

• Consistency being seen

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Impact on Clinical Processes

Shift in SPO thinking

• Holistic and consideration of other services to meet gaps

• e.g. ET Nurse consults - earlier escalation to prevent delays

Some SPOs – additional work

• Lack of system integration and duplicate effort

• Increased time for orientation

Physician Practices

Challenges with physician practices

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Impact on Internal Operations

Scalability

• Model and business rules must be scalable to other populations (i.e.. Palliative, etc.) = sustainable

• Consideration of multi-disciplinary pathways

Works well with Short Stay population

• More complex, more challenging

• FFS and OBP processes complex

Shift in care coordinator thinking

• Focus on patient and patient outcomes versus frequencies

OBP reporting

• More succinct and clinically based

• Method of reporting remains a challenge - Paper

21

Impact on Technology

Lack of integration between SPO systems & CHRIS

• Duplicate entry and effort for CCAC and SPO

Workarounds until enhancements made

• Increased time and effort for staff

Tracking of enhancements and bugs

• Ongoing tracking informs improvements

Early scenario testing using CHP / HPG

• Completed early to confirm processes and limitations

• Reduces re-work

• Ensure billing codes are accurate

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Impact on Financial Processes

Revenue Reconciliation Challenges

• Not well understood or possible

• Organizational risks for CCACs and SPOs

• More intensive financial auditing processes - CCAC and SPO – new auditing processes defined

Financial risk during POC

• Best practices reports shared with SPO

Reimbursement Model

• Impact not fully understood

• Organizational risks for CCACs and SPOs

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Impact on Financial Processes

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Central CCAC

Impact on Patients

Standard approach to wound care and hips/knees

• Promotes best practice

• Focus on outcomes

Simplified referrals

• Less patient time required for completion

Reduced variation among care coordinators and SPOs

• Consistency in provider / agency

• Consistency in care coordinator

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Active Short Stay Clients with an Authorized OBP

(as of May 28, 2013)

On May 28, 2013:

• 1674 active Short Stay clients

• 19.77% (n=331) had an OB pathway currently authorized

Of the 331 clients:

• 74.3% (n=246) OB-W pathway

• 25.7% (n=85) OB-O pathway

NSM CCAC

25.68%

74.32%

OB-O OB-W

Wound Pathway Types Authorized

(November 26, 2012 – May 28, 2013)

1130 Wound pathways authorized during this 6 month period:

• 325 assessment pathways

Remaining 805 wound pathways:

• 43.9 % Surgical Wound

• 17.9% Traumatic Wound

• 32.7% All Other - Healing

• 5.6 % Non Healing

NSM CCAC

Data Note: “Non Healing” accounts for: Maintenance Wound Initial,

Maintenance Wound Recurring, Non-Healing Wound Initial and Non-Healing

Wound Recurring authorized pathway types.

“All Other – Healing” accounts for: Arterial Leg Ulcer, Diabetic Foot Ulcer, Malignant Wound Initial, Pilonidal Sinus, Pressure Ulcer and Venous Leg Ulcer authorized pathway types.

Healable Wound Pathways Discharged – Goal Met vs.

Goal Not Met (November 26, 2012 – May 28, 2013)

478 healable wound pathways have been discharged during this six month period

• 75% (n=359) discharged: pathway completed - goal met (all outcomes have been met)

• 25% (119) discharged: pathway completed - goal not met

•NSM CCAC

Data Note: Excludes all discharged assessment and non-healing/ maintenance pathways.

0%

20%

40%

60%

80%

100%

All Other SurgicalWound

TraumaticWound

75% 68% 80% 75%

25% 32% 20% 25%

Discharge: Pathway completed - goal not met

Discharge: Pathway completed - goal met

Healable Wound Pathways Discharged - Goal not Met

• 119 Wound pathways were discharged: pathway completed – goal not met.

• 19.3% (n=23) were due to supervening events (death, hospitalization, transfer)

• 56.3% (n=67) were classified as “other”

• 24.4% (n=29) service is still active

• 7 transferred to maintenance/ non- healing pathway

•NSM CCAC

19.3%

24.4% 56.3%

Supervening Events Service is still Active Other

Average LOS (in days) per Wound Pathway

Discharged: Goal Met (November 26, 2012 – May 28, 2013)

NSM CCAC

Expected

Length of

Pathway = 60

days

Expected

Length of

Pathway = 7

days

Expected

Length of

Pathway = 60

days

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

CCAC (n= 182) CCAC (n= 171) CCAC (n=78)

Surgical Assessment Traumatic Wound

38.6

7.8

41.0

Wound (OB-W) Clients with Fee for Service

(November 26, 2012 – May 28, 2013)

• 670 clients have been authorized or previously authorized for a Wound Pathway during this six month period

• 89% (595) have a outcome based wound service authorized only

• 11% (n=75) had fee for service assigned at the same time (defined as service unrelated to wound – nursing, therapy, personal support)

NSM CCAC

Top 5 Lessons Learned

1. Collaborate early and often – between and among CCACs, providers and the OACCAC

2. Investment in resources for planning will result in effective implementation

3. Adapt your business processes to new CHRIS and HPG-CHP functionalities including some workarounds.

4. Don’t underestimate change management required – fundamental shift!

5. OBP is the “right concept” – focusing on the outcomes and shared accountability

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Outstanding care – every person, every day

Outstanding care – every person, every day