In Search of What Works:

Presented by Ms. Ann Rodriguez-McConnell, R.N.

Re-Defining Post Acute Partnerships to Reduce Readmissions,

Using the Integrated Chronic Disease Care

at Home Model

Faculty Disclosure Statement

The faculty have no conflict of interest with regard to any information presented, and will not endorse any specific products or specific

service vendor.

ObjectivesDiscuss Current Healthcare SystemDescribe Wagner’s Integrated Chronic Care

ModelDescribe the Care Delivery PracticeDefine Self Management SupportDiscuss Principles of Adult LearningDiscuss Health LiteracyDiscuss the Principles of Motivational

InterviewingDiscuss Goal Setting

Re-defining Post Acute Partnerships to Reduce Readmissions

2/3 of the nations hospitals will be penalized in Medicare's campaign to reduce the number of patients

admitted in one month. 1

Medicare identified 2,225 hospitals that will have payments reduced for one year starting October 1, 2013. 2

Hospitals that treated large number of low income patients were more likely to penalized than those treating the fewest impoverished people. 3

Averting 1 out of every 10 of those returns [Re-Admissions] could save Medicare $1Billion dollars. 7

Solutions involve a coalition of post-acute providers to work collaboratively, breakdown silos, and get patients to the right care setting. 4

Are We Doing the Right Thing in Healthcare?

Meet Harold…

Frontline Reality Check: Our Patients Needs

Fragmented health system Increasing incidents of chronic diseaseComplexity of careAcute based systemPoor transitionsLanguage barriersChanging healthcare landscapePatient labeled “non-compliant”What a patient does at home is different than what

the doctor orderedUncoordinated care

ConsequencesPoorly controlled disease Increased avoidable Re-Hospitalizations

and ED visitsUnnecessary changes in treatment Increase incidences of Chronic DiseaseMiscommunication and ConfusionMedication mismanagementNon Adherence and non-compliance Lack of follow up/Missed MD Visits

Our Patients Healthcare Experience…

3%

16%

26%

23%

15%

6%

11%

No Physician1 Physician2 Physicians3 Physicians4 Physicians5 Physicians6+ Physicians

Source: Anderson, G: Chronic Conditions: Making the Case for Ongoing Care, Johns Hopkins University; November 2007@2010 Penta Health (All Rights Reserved)

Uncoordinated Care

Complexity: Medication Mismanagement

50

40

30

20

10

0 1 2 3 4 5

3.7

10.4

17.9

24.1

33.3

49.2

Number of Chronic Conditions

Source: Anderson, G; Chronics Conditions: Making the Case for Ongoing Care; Johns Hopkins University ; November 2007

Improving Medication ManagementPatients understanding and adherence to medication

instructions is a key factor in avoiding a return to the hospital 8

The Home Health Quality Improvement (HHQI) National Campaign helps home health stakeholders and multiple health care settings improve medication management and reduce avoidable re-hospitalizations. 9 www.homehealthquality.org

The campaign offers free Best Practice intervention packages (BPIPs)“Fundamentals of Reducing Acute Care Hospitalizations”“Improving Management of Oral Medications”

Insanity: doing the same thing over and over again and expecting different results.

The Right Thing to Do:IOM Quality Chasm Report Conclusions

“Quality problems occur typically not because of failure of goodwill, knowledge, eff ort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized.”

The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work; Changing systems of care will! 10

Our Change Vision:Doing the Right Thing

Person Centered

Goals Drive Care

Member of Team

Dignity & Respect

Person Centered

Goals Drive Care

Member of Team

Dignity & Respect

Evidence Based·Clinical

·Engagement/Self Managing Support

·Transitions

Evidence Based·Clinical

·Engagement/Self Managing Support

·Transitions

Coordinated·Time

·Settings

·Providers

Coordinated·Time

·Settings

·Providers

Better Care, Better Health, Lower Cost

Wagner’s Chronic Care Model:

“Patients can undo a month’s worth of expensive and intensive care just going home and going about their normal routines.”

Complexity: Behavior Change Required

John Charde, MD, VP Strategic Development, Enhanced Care Initiatives, Inc. (April 2006)

Bottom Line: Across the Healthcare Continuum

•Healthcare systems are designed for short-term acute rather than long-term chronic care

•Chronic care management models must support the individual in the environment where they face the their daily challengesSource: “Improving Primary Care for Patients with Chronic Illness”, Bodeheimer, Wagner,

Grumbach, Jama, October 9, 2002, Vol. 288, No.14

WE CAN DO THIS!

Care Delivery PracticesRelationships/ Patient Centered:• Holistic Assessments• Trust Building• Patient Engagement• Face to Face Visits

Self-Management support:• Patient specific SMART

goals• Motivational Interviewing• Facilitation of behavior

change• Problem Solving

Care Delivery PracticesExpertise/Coordination:• Patient is “expert” of self• Evidence based care

delivery• Interdisciplinary team• Learning Environment• SBAR Communication

Technology/Decision Support:•Early Identification of Exacerbation•Positive reinforcement & SMS•Meaningful data exchange•Make “right thing to do the easy thing to do”

Five Key Clinician RolesBuild trustIdentify barriersFind relevanceBuild confidencePlan for action

Goal: Keep patient safe and out of the hospital

The Search for What WorksSelf Management Support– a systematic

provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem solving support

Self Management SupportPatient Centered FocusPatient-Clinician RelationshipAssessment and TailoringCollaborative Goal SettingProblem Solving

What is “Patient-Centered”?Putting the patient’s needs first above all

else and at the center of everythingGiving patient choices and enabling

them to make decisions about their health

An emphasis on patient goals coupled with evidenced based care

Things we can do wrongLecture to patientsAssume they are ready to changeAdvice action for them to takeSolve problems for the patientSet goals for patients that aren’t

meaningful for them Threaten dire consequences for not

taking care of themselves

Behavior Change is KeyEstablishing trustDetermine barriersConnecting the dotsBuilding self-confidencePlan of actionThink of a new attitudeThink of a new communication style

Learning is KeyLearning is enhanced with feedback and

reinforcementNew information is insufficient – getting

right is satisfyingPositive reinforcement is keyMust be integrated and connectedLink new information with oldRelevant prior knowledge must be

acknowledgedUse of analogies

Learning is KeyIts enhanced by activity - patients remember

what they doActive involvement learning and problem solving

is integrated by “doing”Coherency and structureIts enhanced by relevance: How does this affect

me?Goals, information rewards must be relevant Memory must not be overloadedUse visualsMap out a planTeach back method

HEALTH LITERACY NEEDSVisual, information and numericalHomecare population most affected by

poor health literacy skillsEffects are manyApproximately half of Medicaid/Medicare

Patients have below fifth grade level

FACTORS AFFECTING HEALTH LITERACYAge related sensory disabilitiesCognitive abilitiesDepressionDisease complexityMedication effectsIt is often overlooked by cliniciansPatients won’t tell you

PROBLEM SOLVINGTeach patient how to monitor

symptomsEnsure patient knows their red flag

symptoms and how to report themHelp the pt problem solve how to

address barriers for needed self management behaviors

Problem solving skills are vital

Motivational Interviewing (MI)Enhances pt motivation to changePt centered style for eliciting change by

helping patients explore and resolve ambivalence

Helps activate patient’s own motivations to change

Guides rather than badgerEncourages rather than shameNegotiate rather than dictate

MI PrinciplesExpress EmpathyDevelop DiscrepancyRoll with ResistanceSupport Self Efficacy

SkillsListen, listen and listen some moreListen by reflecting Ask open ended questionsSilenceUse affirmationsElicit and reflect back change talkActivities

Patient / Nurse Relationship•Maximize engagement•Empathic•Non-authoritarian•Supports patient autonomy•Collaborative •Non-argumentative•Non-judgmental•Curious

Set Stage for ActionAsk pt about their long term goalWhat is the most important thing they

want to achieve related to their disease or ailment

Maintain that connection with the long range goal at every encounter

Connect disease management behaviors with long term goal

Increase their self efficacy

El Paso Healthcare Community Unites to Reduce Hospital Re-AdmissionsProvides an avenue for health care

professionals from various disciplines to meet and discuss issues and best practices for reducing hospital readmissions. 5

It breaks down barriers by giving health care providers a look into what's involved in other providers’ roles and a view of the complete information needed to achieve well-coordinated, patient–centered care. 6

Examples: University Medical Center RHP 15 Sierra Providence Post Acute Coalition Committee (PACC) Mano y Corazon Conference 2013 Southwest Association for Healthcare Quality (SWAHQ) Project Amistad (Community-based Care Transitions Health

Coaches)

Patient SMART Goals•Must be achievable and realistic•Help pt visualize•Identify barriers and obstacles•Find ways to minimize•Reinforced at each encounter•Specific and measureable•Assessed accordingly

Shared Goals = Shared Success•Engage the Patient - Ask what is pressing for the patient – what do they want to address first. •Explain that you have information that is important to address but only after addressing their concerns•Ask for permission to give information •Provide choice of information topics such as charts or pictures•Ask – what do you already know about the subject •Ask – how do you think the information is relative to you•Ask what would you like to discuss at next visit

“Life is a pond. We are all pebbles. Never underestimate the difference one pebble can make.”Hardwiring Excellence

Quint Studer

Questions?