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Slide 1: Designing & Delivering Whole-Person Transitional Care

Designing & Delivering Whole-Person Transitional Care
The Hospital Guide to Reducing Medicaid Readmissions

Webinar 3: Review & Update Readmission Reduction Efforts

Slide 2: Agenda

• Describe the purpose of conducting an inventory of efforts and resources relevant to reducing readmissions.
• Describe how that inventory can be used to conduct a gap analysis and identify services or partners that are needed to better meet the transitional care needs of the population.
• Describe how to use a driver diagram to design and communicate a portfolio of strategies that can be expected to achieve the hospitals’ readmission reduction goals.

Slide 3: Objectives

• Understand the utility of leveraging and coordinating all existing resources—in the hospital and the community—to strengthen your readmission reduction efforts.
• Understand the importance of knowing the gaps that exist and considering how to fill them.
• Understand the importance of designing a data-informed portfolio of strategies that can be reasonably be expected to achieve the hospital’s readmission reduction goals.

Slide 4: Table of Contents

• Introduction.
• Why focus on Medicaid Readmissions?
• How to Use This Guide.
• Analyze Your Data.
• Survey Your Current Readmission Reduction Efforts.
• Plan a Multi-Faceted Data-Informed Portfolio of Strategies.
• Implement Whole-Person Transitional Care for All.
• Reach Out to Collaborate With Cross-Continuum Providers.
• Enhance Services for High-Risk Patients.

Image: Cover of the book, Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions.

Slide 5: List of Tools

The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations.

1. Data Analysis.
2. Readmission Review.
3. Hospital Inventory.
4. Community Inventory.
5. Portfolio Design.
6. Operational Dashboard.
7. Portfolio Presentation.
8. Conditions of Participation Handout.
9. Whole-Person Transitional Care Planning.
10. Discharge Process Checklist.
11. Community Resource Guide.
12. Cross Continuum Collaboration.
13. ED Care Plan Examples.

Image: Tool icon (crossed hammer and wrench).

Slide 6: The ASPIRE Framework

Image: The Framework is a flowchart reading from left to right. On the left is a box captioned "Reduce Medicaid Readmissions"; two lines connect this box to two boxes to its right captioned "Analysis" and "Action". Three lines each extend from "Analysis" and "Action" to connect to the elements that make up the ASPIRE acronym:

• Analyze Your Data.
• Survey Your Current Readmission Reduction Efforts.
• Plan a Multi-faceted, Data-Informed Portfolio of Strategies.
• Implement Whole-Person Transitional Care for All.
• Reach Out and Collaborate with Cross-Continuum Providers.
• Enhance Services for High-Risk Patients.

Slide 7: "We run the care coordinator pilot..."

“We run the care coordinator pilot; I think nursing is working with IT on getting a high-risk flag in the record. I don’t know how that is coming.…”

Slide 8: Inventory Hospital-Based Efforts & Resources

• Readmission reduction activities have proliferated over time.
• Some efforts may have developed in isolation from one another.
• Resources or assets may exist that could be leveraged:
  • Readmission flags, high risk flags in EMR.
  • Post-discharge follow up calls.
  • Centralized appointment scheduling.
  • Pharmacists or pharmacy technicians.
  • ACO, bundled payment teams.

Slide 9: Hospital Inventory Tool

Use this tool to:

• Identify readmission reduction efforts across departments.
• Identify whether efforts are coordinated.
• Identify whether there is duplication.
• Identify gaps—in administrative support.
• Identify gaps—in clinician engagement.
• Get specific—what specifically is happening in the ED? Who leads that effort?, etc.

Image: Checklist from the Hospital Inventory Tool.

Slide 10: “You don’t understand...”

“You don’t understand, there are just no resources in the community”

Slide 11: Inventory Community Efforts & Resources

• Post-acute and community providers may offer services and supports hospital staff are unaware of.
• Health plans may offer high risk patients transitional care and/or care management.
• Resources or assets may exist that could be leveraged:
  • Practices that are patient centered medical homes: care manager.
  • Home health agencies that specialize in behavioral health.
  • Health homes offering outreach, engagement, case management.
  • Housing agencies with case management services.

Slide 12: Community Inventory Tool

Use this tool to identify:

• Peer supports?
• Navigators?
• Medical-legal advocates?
• Behavioral health providers
• Medicaid MCO care managers?
• Formal partnerships?
• Informal arrangements?
• Optimizing available resources?
• Is linkage as easy as it needs to be?
• Gaps in services and supports? 

Image: Checklist from the Community Inventory Tool.

Slide 13: Medicaid Managed Care Organizations (MCOs)

• MCOs can assist with:
  • Identify PCP.
  • Home Nursing.
  • Medication adherence.
  • Discharge planning from all levels of care.
  • Disease Management.
  • Complex Case Management.
  • Coordination of services.
• Examples:
  • Transitional care staff.
  • Complex care managers.
  • Behavioral health care managers.
  • Mobilize resources to meet basic health-related needs.

Slide 14: Living Room at Turning Point

• Living Room provides a safe, non-sterile, inviting environment.
• Developed to provide an alternative option to the ED for people experiencing a behavioral health crisis.
• Outcomes of the Living Room include:
  • $348,036 average savings from avoided Emergency Room visits in 2013.
  • 93% of people who accessed the Living Room did not proceed to an Emergency Room visit.
  • 84% of people who arrived in crisis to the Living Room report their crisis has been resolved at time of departure.
  • People who accessed the Living Room in crisis spent an average of 2 hours in resolving their crisis, which is much less than an emergency room length of stay for psychiatric presentation.

Slide 15: Adult Day Health Care

• Medical Adult Day Care is an ambulatory setting for adults with chronic physical conditions or cognitive impairments such as : Stroke, CHF, COPD, Diabetes, Dementia, Mental Illness, Developmental Disabilities and Neuromuscular Disease.
• Interdisciplinary Team consisting of a : Center Director, Registered Nurse, Licensed Social Worker, Dietician, CNA , GNA, CMA , and Therapeutic Recreational Director.
• Services: Individualized Care Plans, Daily Nurse Assessments, PT, OT, medication administration, wound care. 

Slide 16: Bon Secours Baltimore Health System

Internal Inventory:

• Peer recovery coaches in the ED.
• Outcomes Management.
• Social Work.
• Behavioral Health Program.
• Clinics provide post-discharge follow up <7-10 days for anyone.
• IT: ACO patients flagged.
• IT: Use CRISP for notifications.

Community Inventory:

• Health Enterprise Zone.
• The Coordinating Center.
• Homeless Outreach Program.
• Transitional Housing Providers.
• Home Health Agencies.
• Skilled Nursing Facilities.
• Baltimore Area Agency on Aging.
• Collaboration w UM Midtown.

What’s needed next:

• Care coordination model for high risk patients.
• Create care plans for high utilizers.
• Integrate medical and behavioral health care clinical information.
• Continue to innovate to meet need of patients.

Slide 17: Reflect on Findings to Date

• Which high-risk populations are currently served?
• Which high-risk populations are not being served?
• Are the current readmission reduction processes and/or services consistently implemented for the current target population? How do you know?
• Are the current readmission reduction processes and/or services inconsistently implemented for the current target population? Can this be improved? How?
• Do the strategies offered for the current target population effectively address the transitional care needs and root causes of readmissions? How do you know?
• Have the strategies offered for the current target population reduced readmissions for the target population? How do you know?
• Are there opportunities to better serve the current target population and reduce readmissions even more?
• Are there opportunities to serve new target populations? Which populations? With what services, process improvements, and/or partners?

Slide 18: Take a Data-Informed Approach

1. What is our aim?
2. What does our data show?
3. Who should we focus on?
4. What should we do?

Many teams start in the reverse order!

Slide 19: Create a Data-Informed Strategy

1. Specify the goal and target population
   • The goal should be data-informed and specify what will be achieved for whom, by how much, and by when.
2. Identify 3-4 primary ways by which the aim will be achieved.
   • Consider: improving hospital-based transitional care processes, collaborations with cross-setting partners, and delivering enhanced services.
   • There may be others depending on your target population and resources available.

Slide 20: Example 1: Baltimore Hospital

Image: Flowchart shows the following steps taken by Baltimore Hospital:

• Reduce hospital-wide readmissions by 20%—
  • Intervene in ED prior to (re)admit—
    • Real-time identification.
    • ED staff available to coordinate.
    • Use individualized care plans.
  • Reliably deliver inpatient transition of care practices—
    • Needs assessment.
    • Engage caregiver/"learner."
    • Customized instructions & teach back.
    • Arrange for follow up & services.
  • Provide or link to transitional care services—
    • Follow up phone calls.
    • Bedside delivery of medications.
    • Time-limited transitional care.
    • Link to community support.
  • Develop cross-setting partnerships, norms & protocols—
    • Monthy cross-continuum meetings.
    • Cross-setting readmission reviews.
    • Warm handoffs, "receiver" oriented.
    • Share use of common tools, e.g., INTERACT.

Slide 21: Example 2: Chicago Hospital

Image: Flowchart shows the following steps taken by Chicago Hospital:

• Reduce hospital-wide readmissions by 20%—
  • Create structures and capacity to drive continuous improvement—
    • Regular review of readmission data.
    • Regular review of patient/provider identified root causes.
    • Engage physician leadership.
    • Team meetings 2x/week to support rapid-cycle improvement.
  • Improve & enhance hospital-based services—
    • Deploy Social Worker in ED 40h/wk to link to services.
    • Deploy CM in ED 40h/wk to support (re)admit avoidance.
    • Interview all readmitted patients to inform ToC planning.
    • Provide bedside medication delivery.
  • Ensure linkage to follow up and services—
    • Follow up phone calls to patients and to home health agencies.
    • Schedule follow up <7 days in [hospital-owned] clinics.
    • Coordinate with on-site behavioral health providers.
    • Provide transportation assistance.

Slide 22: Driver Diagram Tool

Image: Flowchart shows Your Driver Diagram:

������ƵGuide to Reducing Medicaid Readmissions

Enter your overall readmission reduction aim statement here. Specify: what, for whom, by how much, when:

• Reduce readmissions for X population, by X%, by X date.

Identify 3-4 primary ways readmissions will be reduced for the target population:

• Driver 1.
• Driver 2.
• Driver 3.

List your current and/or planned specific actions, or strategies, to impact each readmission driver:

• Strategy 1.
• Strategy 2.
• Strategy 3.
• Strategy 4.
• Strategy 5.

Slide 23: Analyze Your Strategy: Is it Complete?

• ___Are all readmission reduction related activities captured?
• ___Will this strategy address the root causes of readmissions for your target population?
• ___What target populations have not been prioritized?  Why?
• ___What strategies have not been prioritized? Why?
• ___Are the following data-informed or high-leverage elements included? If not, why not?
  • ___Medicaid adults.
  • ___Behavioral health.
  • ___Social support needs.
  • ___High utilizers.
  • ___High risk diagnoses based on your data (sepsis, renal failure, sickle cell, etc).
  • ___Discharges to post-acute care settings.
  • ___Collaborations with: MCOs, BH providers, clinics, social services, housing services.
• ___Does this strategy align with value based /alternative payments and other incentives?
  • ___Medicare readmission penalties? Medicare value-based purchasing (total cost)?
  • ___Medicaid readmission penalties?  Medicaid MCO at-risk contracts? DSRIP goals?
  • ___Board-level goals relating to quality, patient experience, disparities, or stewardship?

Slide 24: Establish an Operational Dashboard to Track Implementation and Outcomes (Tool 6)

Image: Two screencaps display Implementation and Outcome pages from the Operational Dashboard Tool.

Slide 25: Portfolio Presentation Tool (Tool 7)

Image: A stack of screenshots displays the Portfolio Presentation Tool.

Slide 26: Summary

• Inventory readmission reduction efforts and related resources and organizational assets.
• Inventory community-based services; focus on identifying Medicaid-relevant resources.
• Reflect on findings of data and interviews; reflect on what is and is not present in the hospital and community.
• Articulate a readmission reduction strategy that leverages existing resources, fills gaps and will meet patients’ needs.

Slide 27: Thank you

Thank you for your commitment to reducing readmissions

Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
amy@collaborativehealthcarestrategies.com

Angel Bourgoin, PhD & Jim Maxwell, PhD
John Snow, Inc.
Angel_Burgoin@jsi.com; Jim_Maxwell@jsi.com