pcmh/hh webinar bringing it all together to …...upcoming webinar next pcmh and hh webinar:...
TRANSCRIPT
PCMH/HH Webinar
Bringing it All Together to Improve
Care Transitions:
Strategies & Best Practices to
Decrease Readmissions
Wednesday, July 22, 2015 7:30AM & 4:30PM
Tel. 866.740.1260, Access Code: 2520060#
Webinar Notes
To minimize background noise, all lines have been muted
To UNMUTE line and talk, press *7
To MUTE line, press *6
To ask questions or share comments:
Via Chat: Type your question or comment into the “Chat” box on the lower left-hand side of the screen
To speak via Webinar: Use “Raise your Hand” function, we’ll call on you to speak
Via Phone: UNMUTE (*7)
Please state your name when speaking
AM webinar is being recorded; materials to be posted to website
*7 to UNMUTE, *6 to MUTE Tel. 866.740.1260, ID: 2520060#
Important News & Updates
Reminder to Lead Administrators - PCMH/HH Quarterly Practice Status Report on Core Expectations is due by July 31, 2015
Save the Date – Optional Learning Opportunity:
Advancing Primary Care Summit
Wednesday, September 30, 2015 at Maple Hill Farm, Hallowell
*7 to UNMUTE, *6 to MUTE Tel. 866.740.1260, ID: 2520060#
Next Learning Session - Grab Your Ruby Slippers!
Follow the Yellow Brick Road: Implementing a Health Roadmap to Improve Care
Transitions (Last Learning Session of 2015!)
For: PCMH/Health Home Practices
Community Care Teams Behavioral Health Homes
Patient/Consumer Partners
Connect, Recharge, Collaborate, Strategize Exciting Breakout Sessions Interactive Workshops
Leave with tools, resources, connections, strategies, and an action plan to decrease admissions/readmissions and improve care transitions
Setting the Stage: Strengthened Focus Going Forward
Reflecting back on the transformation work so far…
Range of practices as PCMH/HH Learning Collaborative grows
Great progress achieved implementing the medical home model
And looking ahead to 2015/2016…
Leverage the successful implementation of the medical home model to achieve measureable reductions in 30 Day All Cause Readmissions
Stated goal of PCMH and Health Home work already
Aligns with practice and system outcomes
Major quality and safety issue for patients, families, caregivers
Major healthcare cost driver
* 6 to MUTE, *7 to UNMUTE Tel. 866.740.1260, ID: 2520060#
Webinar Objectives
Identify key elements of the PCMH/HH Core Expectations that can help practices impact readmissions and improve care
Review the PCMH/HH Primary Care Roadmap for Change as a
tool to help practices decrease readmissions and improve care transitions
Highlight some best practices that successful teams are using
to improve care transitions Identify specific quality improvement strategies and tools
available to practices in order to help decrease readmissions and improve patient care
Improving Transitions of Care
Focus on Decreasing Hospital Readmissions
Decrease ACSC Admissions
Ambulatory Care Sensitive Conditions:
Conditions for which appropriate ambulatory care prevents or reduces the need for admission – AHRQ
Grand mal status and other epileptic convulsions
Chronic obstructive pulmonary diseases
Asthma
Heart failure and pulmonary edema
Hypertension
Angina
Diabetes
May also impact Emergency Department Visits
* 6 to MUTE, *7 to UNMUTE Tel. 866.740.1260, ID: 2520060#
Care Transitions Roadmap for Change
Exploring Solutions: Care Transitions Roadmap for Change
Summarizes key roles for primary care practices (and CCTs, BHHs) to promote effective care transitions
Developed by PCMH Pilot from review of best practices, expert opinion, and consensus - including yours!
Primary Care Roadmap: 7 Key Elements
1. Reduce readmissions by preventing avoidable admissions, with focus on high-risk conditions
2. Develop systems for timely, two-way communication re: patients admitted/ discharged from hospital, SNF/Rehab, Specialty Care
3. Conduct telephonic outreach within 24-48 hrs of discharge, including medication reconciliation
Primary Care Roadmap: 7 Key Elements
4. Patient-centered, timely access to follow-up care (i.e. office visit within 3-7 days)
5. Connect with community resources to optimize patient & family/caregiver supports
6. Facilitate patient and family-centered discussions regarding palliative and/or end of life care
7.Build relationships across your medical neighborhood
Poll
On the Roadmap for Change, what areas of change implementation does your practice team need the most help with? Reducing readmissions
Preventing avoidable admissions
Timely, two-way communications about patients admitted or discharged
Telephonic outreach to all patients within 24-48 hrs of discharge, including med rec
Patient-centered, timely access to follow-up care
Connect with community resources to optimize supports
Facilitate patient and family-centered discussions regarding end of life care
Build personal relationships across your medical neighborhood
Tel. 866.740.1260, ID: 2520060#
*7 to UNMUTE, *6 to MUTE
Hospital Readmissions: The Facts
For hospitalized Medicare patients*: 20.3% readmitted within 30d
35.1% readmitted within 90d
Within 1 year:
53.0% (surgical), 68.9% (medical) pts. readmitted
64.6% of all HF pts. readmitted
Most frequent diagnoses for re-hospitalization:
HF, Pneumonia, COPD, Septicemia
Many hospitalized pts have 1+ previous ED visits
*Jencks et al, NEJM, 2009
Hospital Readmissions: An Opportunity!
90% “potentially avoidable” = $17 Billion - 20% of all Medicare $’s spent on hospitalizations
At least 50% of patients readmitted had no claim for physician visit within previous 30 days
Current trends raise risks for readmits: Shorter hospital stays
More people involved in care; less coordination
More complex illnesses
Critical link = transition of care across settings!
Reducing Avoidable Hospitalizations: What the Evidence Tells Us
HRET Action Guide to Reduce Avoidable Admits:
During Hospitalization: Establish communication with PCP, family, home care Use teach –back education about dx & care
At Discharge: Comprehensive d/c planning; schedule & prepare for f/u appt Help patient manage meds
Post-Discharge: Follow up phone call within 2-3 days Conduct patient home visit Promote patient self-management
HRET, Health Care Leader Action Guide to Reduce Avoidable Readmissions; January 2010
16
17
Primary Care Roadmap for Transitions of Care Foundational Core Expectations
1. Reduce Admissions 1 – Ongoing & active leadership support 4 – Risk stratify and address unique needs 6 – Identify & refer for behavioral health needs 7 – Include patient & family 9 – Value this as reduction of waste in medicine 10 – Use health IT to help with this work
Typical Transition Failures* Best Practices/Strategies for
Improvement** 1. Discharge planning process too
hurried, not inclusive of patient, family and community supports
2. Unrealistic plans 3. Roles of caregivers not clearly
defined
A. Assess self-care ability prior to D/C B. Plan follow-up care with pt/family C. Include diet, activity and wt. plans
18
4. Patient-centered access to care
2 – Match patient needs to care team skills 3 – Identify what works for THIS patient 5 – Set up patient-specific risk mitigation plans 6 – Match behavioral health needs & resources 7 – Make sure the family is optimally involved
1. Failure to involve the patient and family/caregivers 2. Lack of understanding of patient’s physical & cognitive health function 3. Lack of understanding of patient’s health literacy 4. Lack of backup or emergency plans the patient can use
A. Develop a comprehensive care plan using shared decision-making
B. Verify understanding of symptom recognition and management
C. Name and provide contact info for community resources pt. needs
D. Educate about condition thru the care continuum
Typical Transition Failures* Best Practices/Strategies for
Improvement**
Primary Care Roadmap for Transitions of Care
Foundational Core Expectations
Stories from the Field
* 6 to MUTE, *7 to UNMUTE Tel. 866.740.1260, ID: 2520060#
A new day.
Transitional Care Management Winthrop Family Medicine
PCMH webinar 7/22/15
A new day.
Starting the process
• Initial meeting with care managers, coders and nurse manager together
• Introduced TCM concept and WHY it was important
• Discussed and addressed concerns
• Shared information and planned next steps
A new day.
Developing the workflow
Planning meetings with care managers and coders addressed:
Who, what, when, where
Roles defined, communication and documentation ironed out
Spreadsheet developed to enter and track TCM patients
A new day.
TCM Spreadsheet
A new day.
A new day.
TCM Workflow
A new day.
TCM Tracking spreadsheet
More Resources and Tools
Find on our website, under the ‘Care Transitions Tools & Resources’ tab!
Examples of post-discharge follow-up telephone scripts, tool for identifying intervention areas for patients at high-risk of admission/readmission, checklists for post-hospital follow-up visits…
And more! http://www.mainequalitycounts.org/page/2-947/care-transitions
* 6 to MUTE, *7 to UNMUTE Tel. 866.740.1260, ID: 2520060#
Getting Compensated for Care Transitions Work
Transitional Care Management Services
Services provided to patient whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during care transitions
Services also include non-face-to-face care
TCM Codes will pay more than billing an office visit
Find more info about TCM Codes on our website! http://www.mainequalitycounts.org/page/2-947/care-transitions
FAQ about TCM Codes
Questions and answers about billing for TCM services
Upcoming Webinar
Next PCMH and HH Webinar:
Wednesday, August 26, 2015
7:30 a.m. or 4:30 p.m.
Topic: Strengthening Partnerships with Community Care Teams to Improve Care Transitions
*7 to UNMUTE, *6 to MUTE Tel. 866.740.1260, ID: 2520060#
Join Us! Become a Maine Quality Counts Member
• Networking events • Webinars with national experts • Discounted registration for QC 2016
mainequalitycounts.org/join
A special QC Members-only web event Thursday, July 30th
Noon to 1PM
A Conversation with Laudan Aron, Co-Editor of the Institute of Medicine’s Shorter Lives, Poorer Health Report
Laudan Aron, Study Director and Co-Editor – IOM’s U.S. Health in International Perspective: Shorter Lives, Poorer Health
Contact Info/Questions for PCMH/Health Home Practices
PCMH/HH Quality Improvement (QI) Specialist
Maine Quality Counts website
www.mainequalitycounts.org
Maine PCMH/HH webpage
(See “Programs” Maine PCMH/HH Learning Collaborative)
(can also go to “What We Do” “Helping Practices Improve Quality” Maine PCMH/HH)
*7 to UNMUTE, *6 to MUTE Tel. 866.740.1260, ID: 2520060#