Learning Session
Welcome and Introductions
Aubrie Augustus, RN, BSN, MHA;
Senior VP Network Quality, JPS Health Network and
Administrative Director, Learning Collaborative
8:30-8:40
Welcome and Introductions
8:40-8:50
Learning Session Overview
8:50-9:00
The Case for Improvement in Care Transitions and
Patient Navigation in Region 10
9:00-9:10
Intersection Between the Learning
Collaborative and DSRIP
9:10-9:20
Introduce Story Board Gallery Walk
9:20-9:30
Break
9:30-10:15
Storyboard Gallery Walk: Meet the other Provider
Teams
10:15-10:40
Model for Improvement, Part 1 Aim Statements,
Monthly Measures, Run Charts
10:40-11:10
Team Meeting#1: Revise Aim Statement, Data
Collecting Planning
11:10-noon
The Model for Improvement, Part 2: The PlanDo-Study-Act Testing Cycle
Noon-1:00 pm
Lunch
1:00-1:20
Overview of Change Package for Care
Transitions: What do we know that works?
1:20-2:00
Panel Discussion: The Patient’s World:
Using the Patient’s Voice to Guide our Work
2:00-3:15
Introduction to Motivational Interviewing to
Behavior Change
3:15-3:25
Break
3:25-3:55
Team Meeting 2 Planning for High Impact Change
3:55-4:10
Teams Share Their Plans for Action Period 1
4:10
Evaluation
4:15
Adjourn
Learning Session
Overview
Gillian Franklin, M.D., MPH
Clinical Effectiveness & Integration Specialist
Project Manager & Performance Improvement Specialist,
Learning Collaborative
The Learning Session
Goal: Participants will learn about the Model
for Improvement .
Objective: Participants will understand the
various aspects of the Model for Improvement
and their functions.
Instructional Objective: Participants will work
on parts of the Model for Improvement (PlanDo-Study-Act Testing Cycle) to test change.
Model for Improvement
 Full engagement as early adopters
Strategies
 Process Improvement NOT Research
Elements
 “Best Practice” Changes
 Learning Collaborative Change Methodology
 Aim Statements; PDSA Testing Cycle; Monthly Measures; Run
Charts etc.
Action Period 1
Inquiry-driven
The Take Away
» Knowledge
» New skills
» Immediate changes
» Steal Shamelessly
» Share Relentlessly
What is a proven way to
test potential changes
without disrupting your
organization’s day-to-day
operations?
Model for Improvement
&
Plan-Do-Study-Act Cycle
Elizabeth Carter, MD
Senior Vice President for Population Health
Director, Care Transitions Learning Collaborative
Inadequate case coordination including care
transitions responsible for $25-45 Billion in wasteful
spending
– “layers of processes and handoffs that patients and families find
bewildering and clinicians view as wasteful”
IOM report
“Crossing the Quality Chasm”
Sickle cell anemia- 31.9%
Gangrene- 31.6%
Hepatitis- 30.9%
Disease of white blood
cells-30.6%
» Chronic renal failure27.4%
»
»
»
»
Root Causes per Robert Wood Johnson:
• Hospital computers don’t interface to community providersless reliable hand-off
• Current payment policies may create disincentives for
hospitals to invest in care transitions
• Medicaid low payment incentivizes NH to send patient back
to the hospital to qualify for a more generous Medicare
payment rate
• Half of Medicare patients admitted within 30 days have not
been seen by a physician in the interim
Texas in the 4th quartile
» Medicare 30 day readmission
» NH admissions and readmissions
» Home health admissions
Texas in 3rd quartile
» Admissions for Pedi asthma
» Asthmatics with ED visit
» Medicare admission for ACS
Carrot
Stick
» Oct 2012, increase in Medicare
payment if achieve or exceed
performance (help at home,
warning signs/symptoms, discharge
instructions)
» Medical Home- pay providers for
care transition services
» Demonstration projects- Monthly
payments or per beneficiary per
month for transitions
processes/coordination
» Oct, 2012 reduced payments 1%
readmission for CHF, AMI,
pneumonia exceed target
» Transparent Physician level quality
data
Regional plans should recognize the importance of learning
collaboratives in supporting continuous quality improvement, RHPs
will provide opportunities and requirements for shared learning
among the approved DSRIP projects in the region.
Learning collaboratives should strongly be associated with
Performing Provider’s projects and demonstrate a commitment to
collaborative learning that is designed to accelerate progress and
mid-course correction to achieve the goals of the projects and to
make significant improvement in the Category 3 outcome measures
and the Category 4 population health reporting measures.
The continuation of
the journey we
have all been on
together!
Over the last two
years we have all
experienced
together…
Shared Learning
& New
Experiences
Regional
commitment
to improve
care across
the
continuum
Newly
fostered
relationships
and
collaboration
• A networking opportunity to learn how other similar projects are
doing and best practices occurring in our community
• Focus on specific issues where multiple providers will collaborate
to see improvement for all
• An opportunity to bring performance improvement practices (CQI)
to your projects
• Recognition that it’s not just about the milestones, but the
broader impact of participation in the Waiver, willingness to
collaborate with peers, and show improvement at the individual,
regional, and state levels
Best practices
Collaboration
Performance
Improvement
Practices
Regional
Impact
Storyboard Gallery Walk
Hunter Gatewood, MSW, LCSW
Storyboard Gallery Walk: Meet
the Other Provider Teams
Model for Improvement: Part 1 Aim
Statements, Monthly Measures, Run Charts
Hunter Gatewood, MSW, LCSW
Team Meeting #1: Revise Aim
Statement, Data Collection Planning
The Model for Improvement, Part 2:
The Plan, Do-Study-Act Testing Cycle
Hunter Gatewood, MSW, LCSW
What do we know that works for Care
Transitions and Patient Navigation
Acute Care Episode
Population
At Risk
Acute
Phase
Post
Acute/
Rehab
Phase
Secondary
Prevention
Trajectory 1 (T1)
Relatively healthy
adult with onset of
new chronic illness
Trajectory 2 (T2)
Adult with multiple
chronic conditions
Trajectory 3 (T3)
Adults at end of life
Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating
Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed
measurement framework for assessing efficiency, and ultimately value, associated with the care over the
course of an episode of illness and sets forth a vision to guide ongoing and future efforts.
IHI’s Blueprint for Improving Transitions and
Reducing Avoidable Re-hospitalizations
Post-Acute Care
Activated
Transition from
Hospital to Home
• Enhanced
Assessment
• Teaching and
Learning
• Real-time Handover
Communications
• Follow-up Care
Arranged
• MD Follow-up Visit
• Home Health Care
(as needed)
• Social Services (as
needed)
or
• Skilled Nursing
Facility Services
Alternative or
Supplemental
Care for HighRisk Patients*
• Hospice/Palliativ
e Care
• Transitional Care
Models
• Intensive Care
Management
(e.g. PatientCentered Medical
Homes, HF
Clinics, Evercare)
• Additional Cost
for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
Improved
Transitions and
Coordination of
Care
Reduction in
Avoidable Rehospitalizations
Very helpful interventions
• Speaking with a pharmacist about their medications
especially true if patient had low literacy
• Receiving a phone call 1-4 days after discharge
– receiving these two interventions made them more
comfortable with talking to their outpatient provider
after discharge
.
Courtney Cawthon, Sheena Walia, et al (2012) Improving Care Transitions: The Patient
Perspective, Journal of Health Communication: International Perspectives, 17:sup3 312-324
• Optimum Hospital Discharge Planning and Process
• Deliver Timely Access to Care
• Prior to the First Post-Hospital PCP: Prepare Patient
and clinical team
• During the First Post-Hospital PCP visit: Assess
Patient and Initiate New Care Plan
• At the conclusion of the First PCP Visit:
Communicate and coordinate ongoing care plan
Navigation is often necessary because of the
fragmented and complex health care system
New accreditation standard for navigation process to
address health care disparities and barriers to care by
the American College of Surgeons’ commission on
Cancer
Multiple approaches to problem-solve, educate, define
next steps
36 randomized, controlled trials of Inpatient to
Outpatient Hand-offs
• Multiple components ( 94% of trials)
• Significant improvement in outcomes (69% of trials)
• Strategies before and after discharge (>50% of trials)
• Transition managers employed (72% of trials)
– Care coordination
– Patient education
– Assessment of social and functional needs
Hesselink G et al. Improving Patient handovers from hospital to primary care: A Systematic Review. Ann Intern Med
2012 Sept 18; 157-417
Panel Discussion: The Patient’s
World: Using the Patient’s Voice to
Guide Our Work
Introduction to Motivational
Interviewing to Behavior Change
Scott Walters, PhD
University of North Texas Health Science Center
School of Public Health
Team Meeting #2: Planning for HighImpact Change, Drafting a PDSA Test
Teams Share Their Plans for Action
Period 1
Evaluation
Adjourn