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Welcome Community
PartnersMichelle Nelson
Welcome Agenda Community Partner Binders Focus Groups 2014 Survey Results Community Partner Web-site
http://www.unitedregional.org/community-partners
QUALITYAcross the Continuum
Shelley Moser
Today’s Objectives Review the Affordable Care Act Discuss need to align patient care to
ensure the highest level of quality, safety and value are delivered to all that we serve
Discuss 2015 Quality and Safety Goals Discuss the importance of transparency
Affordable Care Act
Affordable Care Act The Affordable Care Act was passed by
Congress and then signed into law by the President on March 23, 2010
On June 28, 2012 the Supreme Court rendered a final decision to uphold the health care law
The Bill 10 Titles of the Affordable Care Act, with
amendments to the law called for by the reconciliation process TITLE III--IMPROVING THE QUALITY AND
EFFICIENCY OF HEALTH CARE TITLE VI--TRANSPARENCY AND PROGRAM
INTEGRITY
Health Care Reform Federal health care reform requires and
rewards significant investments in comprehensive, accessible reliable and more “seamless” health coverage and encourages “seamless” systems of care transitions and transparency
Medicare Spending per Beneficiary per episode ACA requires use of efficiency measures
in FFY 2014 and thereafter
Must include total Part A and Part B spending per beneficiary
Must include Medicare spending per beneficiary adjusted for age, sex, race, severity, and other factors as determined
Value (Efficiency) Measure
Efficiency Measure
Inpatient Stay
Pre-op lab
work
Dr. Visi
t
Three Days Prior:
Dr. Visit
ED Visit
Post Acute
30 Days Post:
Dr. Visit
Dr. Visit
One Episode
National Vision Smooth Transitions between Care
Settings – Hospitals, communities, patients and families will devote new attention to making sure that transitions out of the hospital are well coordinated
2015 Quality and Safety Focus
2015 Quality and Safety Focus Patient Safety is number one! Discharge Planning Medication Reconciliation Reducing Patient Harm
Surgical Site Infections Catheter-Associated Urinary Tract Infection - CAUTI Central Line-Associated Bloodstream Infection-
CLABSI Surgical Site Infection Pressure Ulcer Stage
Transparency
Interest in Transparency We are at a critical juncture in the evolution of our
health care system Growing government interest in performance
measurement and reporting, the adoption of value purchasing models keyed to measured performance, implementation of standards-based EHRs, disease registries, and health information exchange, and greater consumer exposure to health care decisions – including through the new insurance Exchanges – will all rest upon a foundation of publicly reported quality measures
Today’s Objectives Review the Affordable Care Act Discuss need to align patient care to
ensure the highest level of quality, safety and value
Discuss 2015 Quality and Safety goals Discuss the importance of transparency
Questions?
Internal Transitions
TeamJody GregoryKim LawsonChristi Cook
Michelle Nelson
2014 Accomplishments Utilized the Boost Implementation Guide
to improve care transitions:
Boost: Better Outcomes for Older Adults through Safe Transitions
What is BOOST? Project BOOST provides resources to
optimize the hospital discharge process in an effort to mitigate and prevent known complications and errors that occur during transitions.
2014 Accomplishments Standardized the patient education format –
Teach Back Module Incorporated risk assessment screenings into
the electronic medical record targeting the risk factors/diagnoses most associated with readmission for senior adults
Developed an automatic referral process for patients at risk for readmission
Enhanced education materials for high risk diagnoses
Risk Factors Problem Medications – anticoagulants, insulin, aspirin
& plavix dual therapy digoxin, narcotics Polypharmacy – 5 or more routine medications Principal Diagnosis – cancer, stroke, DM, COPD, heart
failure Poor Health Literacy – inability to do Teach Back Prior Hospitalizations – non-elective hospitalization in
the last 6 months Patient Support – absence of a care giver/assistance at
home Palliative Care – Does this patient have an advances or
progressive illness?
Risk Factor Referral Process Problem Medications & Polypharmacy – patients taking 10
or more medications combined with a high risk medication receive medication education from pharmacist
Principal Diagnosis – cancer, stroke, DM, COPD, heart failure – developed quick reference discharge materials focused on disease management and specialized discharge calls
Poor Health Literacy – inability to do Teach Back – generates referral for social services
Prior Hospitalizations – non-elective hospitalization in the last 6 months – generates referral for case management
Patient Support – social services referral Palliative Care – Does this patient have an advances or
progressive illness? - generates referral for palliative care
Next Steps Review top readmission DRG to identify
opportunities to prevent readmission during prior hospitalization
ER bounce backs – gain a better understanding of the cause of excessive/over use of the ER and develop/coordinate resources to prevent ER return visits
Ongoing enhancement of patient education materials
Care Transitions Document
Questions?
Facility Dashboard&
Rural ED Case Managers
Christi Cook
2014 AccomplishmentsFacility Dashboard Developed and
Distributed Home Health Hospice Nursing Home Rehabilitation
Facility Dashboard Used to identify readmissions Chart review for readmitted patients Improve processes Decreased readmission
Facility Dashboard Used to identify readmissions Chart review for readmitted patients Improve processes Decreased readmission
Readmission Information
2014 Case Manager and Referral Training ED Case Managers
Electra Wilbarger
Standardize Referral and Work-up Guidelines Electra Iowa Park Seymour
Case Manager Duties Assess, plan, implement, coordinate, monitor
and evaluate options and services to meet the complex patient's individual health needs
Connect un-insured and under-insured populations with community health and social service resources and benefits; Medical - mental health - dental homes links with providers completes eligibility applications addresses barriers to access provides follow-up
Benefits Assuring that this population can
benefit from, and become knowledgeable regarding, the best community resources for their individual needs
This practice extends into the community through communication of available resources to promote quality cost-effective outcomes
Next Steps Train ED Case Managers and Referral
Guidelines Bowie Clay Faith Community (Jacksboro) Nocona
Questions?Christi Cook, MBA, BSN, RN, ACMDirector of Case Management and
Social Work
Voice:(940) [email protected]
Medication Reconciliati
onDoan Noe, PharmD, BCPSPharmacy Operations and
Medication Safety ManagerUnited Regional Health Care System
Agenda A Deceptively simple process The steps to appropriate Medication
Reconciliation at United Regional Challenges Questions
A deceptively simple process Reconciliation is a simple 5 step process:
A.) List of patient’s current medications is developed (BPMH or PML)
B.) List of medications to be prescribed during current treatment is developed
C.) Comparison of the two lists is performed D.) Clinical decisions made based on
comparison to consolidate and create new list E.) New list is communicated to appropriate
caregiver and patient
A deceptively simple process The process becomes difficult due to:
Combination of clerical and cognitive tasks I.E. Metoprolol: Lopressor vs Toprol XL
Patient’s unreliability in providing information
Multiple disciplines involved Workflow Computer system and knowledge
regarding it
The steps to appropriate Medication Reconciliation at United Regional Medication history is collected by
nursing or pharmacy and entered into the OMR (Outpatient Medication Record) and saved as COMPLETE
Once this is done, the physician is able to perform medication reconciliation with inpatient/ admission orders
The following alert will fire upon order entry when it is time for the physician to perform admissions medication reconciliation
The physician will not see this alert at order entry UNTIL the OMR has been saved as Complete by the nurse or pharmacy technician.
The physician will continue to the medication reconciliation Icon and choose Admission reconciliation.
The reconciliation process is to be performed in one sitting and should ALWAYS be saved as COMPLETE despite need on waiting for more information, or desire to continue medications at a later time.
If the OMR has not been saved as “COMPLETE” and the physician tries to perform Admissions Reconciliation, the following alert will fire
The alert states “CAUTION!! The Home Medication List has not been collected or verified.”
MD must enter a comment in the Red star field supporting the decision of going ahead with the reconciliation process PRIOR to a Completed OMR to proceed OR can back out to cancel and wait until OMR is finished
The steps to appropriate Medication Reconciliation at United Regional Med history obtained Home meds entered and saved as complete in OMR
Admission Reconciliation Physician or RN on behalf of physician compares patients
home medications against orders for inpatient use
Transfer Reconciliation Medications are compared again when level of care
changes
Discharge Reconciliation Medications are reviewed and orders created on
discharge appropriate for patient to continue at home
Challenges we Face Medications carry forward from prior admissions in
OMR; makes med list muddled and confusing
Staffing limited to dedicate only to Med Rec Process; time in obtaining most accurate history is insufficient
Physicians perform admission reconciliation too quickly (prior to med history being obtained)
Inconsistent reporting to understand the impact of errors/ potential harm in Med Rec Process, especially upon discharge
Community Partners: External
Team
Robin Moreno
2014 AIM Review Develop Physician/PCP Team and align with
existing internal/external team outcomes Evaluate additional patient populations
requiring special consideration, ie Homeless/Shelter, etc.
Continue increasing knowledge of health care providers in transitional care thus addressing risk assessments, high risk patients, and reduction of 30 day all cause readmission
Focus Groups Home Health LTACH/Rehab Nursing Homes/SNF Hospice Mental Health ALF’s PCP’s/Onc’s/CNT/CHC/Incompass/ Ambulatory Physicians
Focus Groups (cont’d) 2014 Meetings revamped for attendees’
convenience at the Wellington 11am-12am Home Health and Hospice Focus
Groups 12n-1pm Community Partners Main Group 1pm-2pm LTACH/Rehab/NH/SNF/ALF Focus
Groups Mental Health, Physicians meetings held as
needed 2015 meetings moved back to URHCS
2014 Accomplishments
BOOST Processes Readmission Processes: Policy & Procedure GAP analysis Teachback Methodology
Community Partner Website developed and launched OOHDNR “Luby’s for the Community” ELNEC Developed “Hand-Off” processes for patient transitions to community
facilities Transition of Care Document electronically to community providers
including HealthSouth, Monterey Care Center, River Oaks, Electra Memorial Hospital, CNT physicians, The North Texas Community Health Care Clinic, The Wichita Falls Family Health Center, Hamilton Hospital, Haskell Memorial Hospital, Ridgewood Rehab, Senior Care, and Texhoma Christian Care.
2014 Accomplishments (cont’d) Membership & Involvement in
Diabetes Management Teams: HealthSouth Advisory Diabetes Team Diabetes Summit Diabetes Communications – Survival
Skills and Nursing Essentials.
2015 Next Steps
Continue work on Medication Reconciliation Continue collaborative work on Discharge
processes Continue increasing knowledge of health
care providers in transitional care thus addressing risk assessments, high risk patients, and reduction of 30 day all cause readmission
Community Education
Questions?
