Health Plans and Hospitals:
Working Together to Prevent
Readmissions - A Collaborative
Approach to Transition
Management
July 30, 2013
Hosted by the RARE Operating Partners:
Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health
Our host today will be…
Kim McCoy, Project Manager – Stratis Health
Ms. McCoy provides leadership on health care quality
initiatives throughout Minnesota. She supports development
and implementation of Minnesota’s participation in the Patient
Safety and Clinical Pharmacy Services Collaborative, a
national initiative to reduce adverse drug events.
Kim provides technical assistance to participating pharmacists
and health care teams to successfully integrate medication
therapy management and clinical pharmacy services into their
organizations. She also provides leadership for the RARE
Campaign to reduce hospital readmissions and communitybased efforts to improve care transitions as part of the
Centers for Medicare & Medicaid Services (CMS) Quality
Improvement Organization contract.
Why RARE Conversations?
Share
Networking
opportunities
Engage
Learn
Conversation
July’s Conversation…
A Collaborative
Approach to Transition
Management
Sharing their work:
Ucare
More about the presenters…
Caroline Dietz-Carlson, RN
•
Caroline Dietz-Carlson is a Quality
Improvement Specialist at UCare. Caroline
is a Registered Nurse (RN) with extensive
clinical, program development, project
management, and performance
improvement background.
• She is a team member with the 2012
Collaborative Performance Improvement
Project (PIP) for the Readmission topic:
“Improving Transitions Post-hospitalization”,
a partnership among four Minnesota health
plans – Blue Plus, Medica, Metropolitan
Health Plan, and UCare.
More about the presenters…
Lorraine Cummings, LPN
•
Lorraine Cummings is a Quality Improvement
Specialist at UCare. Lorraine is a Licensed Practical
Nurse (LPN) with a background in health plan,
managed care, clinic, and hospital settings and has
project management experience in quality
improvement, disease management, and health
education.
•
She is the project lead with the 2012 Collaborative
Performance Improvement Project (PIP) for the
Readmission topic: “Improving Transitions Posthospitalization”, a partnership among four Minnesota
health plans - Blue Plus, Medica, Metropolitan
Health Plan, and UCare.
A Collaborative Approach to
Transition Management
7
Care Transition Management
Session Objectives:
•
Understand the health plan care
coordinator’s role and responsibility with
transition support.
• Explore improved communication and
collaboration between hospitals and health
plans to provide effective transitions and
reduce avoidable readmissions.
8
2012 CMS QIP / 2013 DHS PIP:
Improving Transitions
Post-hospitalization
Goal:
• To reduce hospital readmissions by improving
member support for the transition from hospital
to home or a care setting for:
 Minnesota Senior Health Options (MSHO)
 Minnesota Senior Care Plus (MSC+)
 Special Needs BasicCare (SNBC) members
9
Care Coordinators
Who are they?
• Registered Nurse or Licensed Social Worker
• Health plans have “delegate” care coordinators
(contracts with care systems, counties, agencies)
What do they do?
• Communicate, support, educate, arrange
services
• Communicate with members and their health
care providers
10
Care Coordinator’s Role
• Coordinate services
• Provide effective transition support
• Communicate with individuals involved in the
discharge process
• Assess issues known to impact readmissions
• Identify and note current services and needed
changes
• Update care plan
11
Communication and Efficiencies
•
On admission, ask member if they have a care
coordinator and connect with care coordinator
•
They want to help you with your job
•
Good resource - they can assist and provide info
•
They can help get services / authorize services
•
They know benefit sets
12
Key Interventions:
• Improve Transition of Care (TOC) Log
• Train care coordinators in use of TOC Log
• Annual audits of TOC Logs
13
Additions to TOC Log
Four Pillars for Optimal Transition:
•
•
•
•
Timely follow-up visit
Medication self-management
Knowledge of red flags
Use of personal health record
As a result of this transition discussion:
• Have you updated the member’s care plan?
• Services Started, Stopped, Changed and/or Refused?
14
Reality:
•
Hospital: 24/7
•
Health Plan: M-F (9-5)
•
Weekend coverage and processes
•
RN / SW discharge planners, health coaches
and health plan RN / SW care coordinators
15
Care Coordinator Challenges:
•
Care coordinator often does not know when a
member is admitted or discharged
•
Difficult to connect with hospital discharge planners
•
They call hospital and can’t obtain info - HIPAA
•
Member may not know reason for admission
(e.g. Non-English speaking)
16
What Health Plans Hope to Achieve:
•
Timely notification of admission and discharge info
•
Reduce duplication
•
Decrease confusion
•
Optimize coordination of care and communication
•
Reduce readmissions
•
Request that hospital discharge planner give
patient the health plan care coordinator’s contact
info and let them know they will connect with them
post-discharge
17
Questions & Answers
Discussion
18
Questions or Feedback
Kim McCoy, MPH, MS
Program Manager, Stratis Health
KMCCOY@stratishealth.org
952-853-8563
Caroline Dietz-Carlson, RN, BS
Quality Improvement Specialist, UCare
cdietz-carlson@ucare.org
612-676-3341
Lorraine Cummings
Quality Improvement Specialist, UCare
lcummings@ucare.org
612-676-3246
19
20
Upcoming RARE Events….
• RARE Action Learning Day,
November 11, 2013, (8:30 a.m. – 3:30 p.m.)
• Next RARE Webinar, August 23, 2013 at
noon. Stay tuned for more details.
Future webinars…
• To suggest future webinar topics,
contact Kathy Cummings at
kcummings@icsi.org.