ma staar fall learning session engaging front-line s taff and your cross continuum team
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MA STAAR Fall Learning Session Engaging Front-Line S taff and Your Cross Continuum Team. 1:15-2:30PM Breakout Peg Bradke and Rebecca Steinfield. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations. Improved Transitions and Coordination of Care - PowerPoint PPT PresentationTRANSCRIPT
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MA STAAR Fall Learning SessionEngaging Front-Line Staff and Your
Cross Continuum Team
1:15-2:30PM Breakout Peg Bradke and Rebecca Steinfield
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Hospitals
• Perform an enhanced assessment of post-hospital needs
• Provide effective teaching and facilitate enhanced learning
• Ensure post-hospital care follow-up
• Provide real-time handover communications
Office Practices
• Provide timely access to care following a hospitalization
• Prior to the visit: prepare patient and clinical team
• During the visit: assess patient and initiate new care plan or revise existing plan
• At the conclusion of the visit: communicate and coordinate ongoing care plan
Home Care
• Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan
• Assess the patient, initiate plan of care, and reinforce patient self-management at first post-discharge home care visit
• Engage, coordinate, and communicate with the entire clinical team
Skilled Nursing Facilities
• Ensure that SNF staff are ready and capable to care for the resident patient’s needs
• Reconcile the Treatment Plan and Medication List
• Engage the resident and their family or caregiver in a partnership to create an overall place of care
• Obtain a timely consultation when the resident’s condition changes
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Transition from Hospital to Home• Enhanced
Assessment• Teaching and
Learning• Real-time Handover
Communications• Follow-up Care
Arranged
Post-Acute Care Activated• MD Follow-up Visit• Home Health Care
(as needed)• Social Services (as
needed)
• Skilled Nursing Facility Services
• Hospice/Palliative Care
Supplemental Care for High-Risk Patients *• Transitional Care
Models• Intensive Care
Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)or
IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations
* Additional Costs for these Services
Improved Transitionsand Coordination of Care
Reduction in Avoidable Rehospitalizations
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
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Vision for Cross-Continuum Teams
Understanding mutual interdependencies, the hospital-based teams co-design care processes with their cross-continuum care partners and collaborate to solve problems to improve the transition out of the hospital and reception into community settings of care.
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Cross-Continuum Improvement Teams
• One of the most transformational changes in the STAAR Collaborative
• Reinforces that readmissions are not solely a hospital problem• Need for involvement at two levels:
1) at the executive level to remove barriers and develop overall strategies for ensuring care coordination
2) at the front-lines -- power of “senders” and “receivers” co-redesigning processes to improve transitions of care
• New competencies in partnering across care settings will be a great foundation integrated care delivery models (e.g. bundled payment models, ACOs)
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Starting your Cross-Continuum Team
IHI How-to Guide, Page 6
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Starting your Cross-Continuum Team
IHI How-to Guide, Page 8
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CCT Membership Recommendation• Executive Sponsor• Day-to-day Leader• Patients and family members• Hospital clinicians and staff• Supporting staff (QI, IT, Finance, etc.)• Palliative Care• Payors• Clinical and administrative staff and/or leaders from the community
─ Skilled nursing facilities─ Office practice settings─ Home health─ Community or Public Health Services─ Area Agencies on Aging
Consider those that are part of your system but also those outside of your organization/system
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General Recommendations for CCTs
• Meet regularly to facilitate bi-directional communications and collaboration, assess progress, remove barriers to progress and support the improvement of the front-line teams in all clinical settings.
• Have members from the cross-continuum team visit each other’s sites (including accompanying a nurse on a home visit) to observe patient care processes during transitions.
• Complete periodic diagnostic reviews of patients that have been readmitted.
• Complete a gap analysis of your settings --Where to you have work going with the key changes currently?
• Add patients and family members to the cross-continuum team to enhance the focus on the patient’s experience and to harvest their suggestions for improving care processes.
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Frontline EngagementTips from Steve Spear
• Allow the frontline team interests to determine where to start.
What have you found?How have you used observation to move test of change?
• Solve a problem that really matters … When you start to score gains, your staff to take notice.
• Don’t think too much but do a lot. That’s where the real learning takes place.
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Model for Improvement
Study Do
PlanAct
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
Setting Aims
Establishing Measures
Selecting Changes
*2001 Associates in Process Improvement
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Discussion Questions for Frontline Engagement
• What stories have you used to enhance the work and move you process?
• In what way are you using data or measure results to engage your staff?
• What are your barriers to engaging your frontline?
• What are your successes in engaging frontline staff and spreading your successful practices?
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CCT’s Role in Performing an Enhanced Assessment of Post-Hospital Needs
• On admission, how can hospital clinicians and staff get timely and relevant information from community providers (e.g. medication lists, comprehensive care plans, insights about the patient’s ability to provide self-care, advanced directives).
• Other emerging best practices?
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CCT’s Role in Providing Effective Teaching and Facilitating Learning
• Develop and utilize universal patient-friendly education materials for common clinical conditions in all health care settings in a community.
• Ensure that all health care providers in the community are competent in effectively teaching and facilitating learning for patients and family caregivers utilizing health literacy principles.
• Other emerging best practices?
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CCT’s Role in Providing Real-Time Handover Communications
• Hospital team members and community providers co-design real-time handover communications (including preferred format, mode of communication and specific information about the patient’s status).
• Consider adopting a universal format for patient care plans (with information about medications, diet, treatments, signs and symptoms that require medical attention and plans for follow-up).
• Other emerging best practices?
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CCT’s Role in Ensuring Post-Hospital Care Follow-Up
• Determine who is the best clinical provider (from the patient’s perspective) to complete follow-up phone calls.
• Collaborate with payers and post-acute care providers to determine eligibility for intensive care management and best clinical provider for various patient populations (Care Transitions Intervention, APN Transitional Care, HF Clinic, Patient-Centered Medical Home, Evercare, etc.).
• Other emerging best practices?
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CCT’s Role: Review Data• Patient experience data
─ Communication with patients (Q 3,7)─ Discharge preparation (Q 19,20)
• 30-day all-cause readmission rates for:─ All conditions─ Conditions of interest
• Rehospitalization rates if available• Days between discharge and readmission• Readmission into Observation status• Patients readmitted within 30 days who had an office visit
before return to hospital
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What is one new thing you learned
today that you would like to test?