![Page 1: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/1.jpg)
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#
![Page 2: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/2.jpg)
Welcome
2
Laura Maynard, M.Div.CJR Learning System Team
The Lewin Group
Hilarea Amthauer, MPH, BSN, RNCJR Learning System Team
The Lewin Group
![Page 3: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/3.jpg)
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
![Page 4: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/4.jpg)
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
![Page 5: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/5.jpg)
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
![Page 6: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/6.jpg)
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
![Page 7: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/7.jpg)
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
![Page 8: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/8.jpg)
Care Navigation Driver Diagram: Primary Driver #1
8
![Page 9: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/9.jpg)
Care Navigation Driver Diagram: Primary Driver #2
9
![Page 10: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/10.jpg)
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
![Page 11: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/11.jpg)
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
![Page 12: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/12.jpg)
QIN-QIO Program
12
Comprehensive Care for Joint Replacement Model
![Page 13: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/13.jpg)
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
![Page 14: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/14.jpg)
Map
14
![Page 15: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/15.jpg)
• 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
![Page 16: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/16.jpg)
• 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
![Page 17: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/17.jpg)
• 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
![Page 18: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/18.jpg)
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
![Page 19: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/19.jpg)
Recruited and In Progress QIN-QIO Care Coordination Communities
19
![Page 20: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/20.jpg)
Visit the QIO Program Website: http://qioprogram.org/contact
Find Your QIN-QIO
20
Comprehensive Care for Joint Replacement Model
![Page 21: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/21.jpg)
Contact Your QIN-QIO to Join a Recruited Care Coordination Community
![Page 22: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/22.jpg)
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
![Page 23: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/23.jpg)
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
![Page 24: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/24.jpg)
Discussion
• How do you work with your community partners?
Comprehensive Care for Joint Replacement Model 24
![Page 25: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/25.jpg)
Care Navigation Driver Diagram: Primary Driver #2
25
![Page 26: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/26.jpg)
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
![Page 27: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/27.jpg)
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
![Page 28: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/28.jpg)
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
![Page 29: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/29.jpg)
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
![Page 30: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/30.jpg)
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
![Page 31: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/31.jpg)
Announcements & Reminders
31
Comprehensive Care for Joint Replacement Model
![Page 32: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/32.jpg)
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
![Page 33: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/33.jpg)
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
![Page 34: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/34.jpg)
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
![Page 35: Care Navigation Affinity Group Session Five€¦ · Comprehensive Care for Joint Replacement Model • If you have any questions about these events or related to the Care Navigation](https://reader036.vdocuments.us/reader036/viewer/2022071301/609a0080256d1a40f46b3ad5/html5/thumbnails/35.jpg)
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.