Building Community Engagement in Indiana: The Conduit to Transforming Healthcare Empowerment

1. Building Community Engagement in Indiana: The Conduit to Transforming Healthcare Empowerment Indiana Continuity of Care Conference Nancy Meadows, RN, BS Manager, Care Management Union Hospital Terre Haute, IN September 2013

2. Program Objectives 1) Describe the growing importance of taking a community-team based approach to integrated care. 2) Explain why addressing the underlying of community-level health factors may provide a beneficial approach to reducing unnecessary hospitalizations and readmissions. 3) Share the experience and lessons learned from community’s team-based approaches.

3. Quality and Poor Care Coordination “Today, one in five older patients who leave the hospital, thinking they are well and ready to go home, will  be back in the hospital within 30days.  That’s frustrating, painful, costly and most of the time, avoidable…” Source: Improving Health Care Close to Home, Rebecca Hightower, eQHealth Solutions, January 2013 http://www.eqhssmarterhealthcare.org/improving-health-care-close-to-home/

4. National Agenda(August 2011-July 2014) Three key activities shape the current direction for the Department of Health and Human Services (HHS) • National Quality Strategy (NQS) • Partnership for Patients (P4P) • Affordable Care Act (ACA)

5. Driving Improvement • National Quality Strategy, an evolving health care guide for our nation. • Strategy accomplished through three critical aims to make care better for everyone: • Better patient care - Patient centered, reliable, accessible, and safe • Better population health-Healthy People/Healthy Communities - Behavioral, social and environmental determinants • Lower health care costs through improvement

6. National Quality Strategy Strategy is driven by six priorities • safer care • coordinated care • person- and family-centered care • preventive care • community health • making care more affordable Three Broad Aims CMS Sensitive

7. Partnership for Patients • 2013 goals for the new partnership • Keep patients from getting injured or sicker. • Decrease preventable hospital-acquired conditions by 40% • Help patients heal without complication. • Decrease preventable complications during transitions of care so all are reduced by 20% http://www.healthcare.gov/center/programs/partnership/index.html

8. Roadmap to Better Care Integration and Improved Outcomes of Care • CMS is working in partnership with states, consumers and advocates, providers, and other stakeholders to create sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control, and access to a full array of quality services that assure optimal outcomes, health, and quality of life.

9. Evolution of Health Service Delivery • Shift of accountability and financial risk (clinically and economically) across the continuum of care • Shift to episodes of care • Shift to outcomes of care

10. Structure of Health Care Incentives • Expansion of pay-for-performance (P4P) to value-based purchasing (VBP) • Bundled payment pilots • Potential avoidable admissions, readmissions, and sites of care • Fixed hospital payments • Increasing focus on “cost and comparative effectiveness” • Present on admission (POA) and healthcare-acquired conditions (HAC)

11. Improve Quality Decrease Cost Increase Healthcare Value ACO VBP Reducme HAC Reduce Episoctic Based Payments Reduce preventable Readmision Electronic Health Records CMS Sensitive Teamwork / Community Infrastructure

12. 9/2/2013 Preparing for the New Era of Healthcare • Economics of value-based healthcare and reimbursement reform are driving fully integrated models • Individual hospitals are moving to system affiliation • Health systems are partnering with other health systems • Healthcare leaders are now faced with joining capital considerations with strategic planning to ready their organizations for the new era of healthcare Source: Capital Finance: Changing Structures, Health Leaders, March 2013

13. Preparing for the New Era of Healthcare Understanding the seriousness of the issues • Reduction in potentially “Avoidable Adverse Events” if patients had access to care and community-base support • Emergency Room Visits • Observation and Inpatient Hospitalizations • Costs of uncompensated care

14. Preparing for the New Era of Healthcare Understanding the “seriousness of the issues” • Numbers of persons affected in targeted at-risk populations • Particularly affected persons living in poverty or reflected health disparities • Availability of community-based resources to address the need”

15. Preparing for the New Era of Healthcare • Developing high quality care transitions • Transmitting and communicating essential data elements to practitioners involved in a patient’s care across all settings • Structuring organizational and community delivery systems to promote seamless transitions across care settings • Reviewing coverage and limitations that affect access to care and services • Helping patients and caregivers understand what should expect at the next care setting(s)

16. Preparing for the New Era of Healthcare The new era of healthcare requires a “Continuum of Care Approach” focus built on understanding the population served that resides within YOUR community It’s about the move to becoming a “Patient Engagement and Activation Network”

17. Preparing for the New Era of Healthcare • Creating awareness and understanding the value • Making it “personal” and “urgent” at a local level • Create a need for change/establish the “value of working together” • Create strategic partnerships • Kickoff community discussion/“coalition building” • Create welcoming atmosphere, earn trust

18. Community Action University of Wisconsin Population Health Institute. County Health Rankings 2012. Accessible at www.countyhealthrankings.org

19. Addressing the Importance of Underlying Health Risk Factors The primary component of reducing readmissions in rural settings is the ability to coordinate care and ensure the patient has access to health care services and community support.

20. Addressing the Importance of Underlying Health Risk Factors • Underlying risk factors that contribute to health disparities are the result of where people live, learn, work, and play. • Commonly called "social determinants of health," health factors interact to impact health and contribute to health disparities. • Eliminating “health disparities” will necessitate behavioral, environmental, and social-level approaches to address issues. The National Partnership for Action to End Health Disparities (NPA) http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=11

21. Addressing the Importance of Underlying Health Risk Factors • Differences in regional readmission rates for heart failure are more closely connected with the availability of care and socioeconomics rather than with hospital performance or a patient’s degree of illness. • Communities with higher (readmission) rates were likely to have more physicians and hospital beds and their populations were likely to be poor, black, and relatively sicker. • People 65 and older are also readmitted more frequently. Hospital readmission rates linked to availability of care, socioeconomics American Heart Association Meeting Report - Abstract 12, May 11, 2012

22. Model of Population Health Improvement University of Wisconsin Population Health Institute. County Health Rankings 2012. Accessible at www.countyhealthrankings.org

23. Current Opportunities for Community-based Care • Hospitals and Public Health collaboration part of federal Affordable Care Act requirements • Community needs assessment • Community-based Care Transitions Programs • Centers for Medicare & Medicaid Services Innovation Programs • Accountable Care Organizations/Medical Homes • Moving towards “Meaningful Use”

24. Realms of Integrated Care • Community • Individuals with chronic and progressive diagnoses live within “YOUR communities”. • Requires integration of access to community-based resources reflective to the needs of individuals and their families”

25. Realms of Integrated Care Health System • It’s about eliminating “discharge” mentality • Integrated efforts of the clinical caregivers supported by hospital operations that deliver not only “door-to-door” care and provide seamless and smooth transitions across care settings (it’s not just acute)

26. Realms of Integrated Care Clinician • Transforming the care process from a transactional activity to a “relationship” among the clinical caregivers and those they care for. • The human dyad there are “two human persons in relationship to each other” • Clinician to clinician • Clinician to patient and/or caregiver

27. Realms of Integrated Care Use of evidence-based best practices- “Spread” • Knowing current literature • Serving as “local” and homegrown experts • Sharing and spreading what works • Being mentors within our community

28. Realms of Integrated Care Developing community support • Coalition leadership • Secure organizational and individual commitments/formalize goals • Identify and communicate the resources

29. Realms of Integrated Care Developing strategic direction • Research best practices • When possible, draft your own language • Understand your supporters (map out key players and roles) • Understand those who will work against your success (internally/externally)

30. Realms of Integrated Care Developing an action plan • Finding out what other community organizations are doing regarding the priority • Organizing a team which includes both field professionals and representative community members • Developing a work plan • Critical Factor: “Establishing metrics including measurable outcomes indicators” • Assuring work is coordinated with other care transitions and/or readmission implementation teams

31. Realms of Integrated Care: Action Plan • What have we got? • What do we need to • develop? • How do we begin? • How do we tell if it's • working? “Sphere of Influence” • What do we want? • Who can give it to us? • What do they need to hear? • Who do they need to hear it from? • How can we get them to hear it? Nine Questions (County Health Rankings-ROADMAPS TO HEALTH ACTION CENTER, www.countyhealthrankings.org)

32. How far are you ready to go? Trust and Time Turf Wars 15

33. Key Team-based Approaches During Hospitalization • Risk screen patients and tailor care • Establish communication with PCP, family, and community-based service lines • Use ―teach-back to educate patient about diagnosis and care • Use interdisciplinary/multidisciplinary clinical team • Rounding and daily team huddles • Coordinate patient care across multidisciplinary care teams; include community-based service lines as part of team • Discuss end-of-life treatment wishes

34. Key Approaches at Discharge • Implement comprehensive discharge planning and follow-up • Educate patient/caregiver using―teach-back • Schedule and prepare for follow-up appointment • Establish system to help patient manage medications • Facilitate discharge to nursing homes with detailed discharge instructions and partnerships with nursing home practitioners

35. Key Approaches Post Discharge • Promote patient activation, engagement, and self- management • Conduct patient home visits; develop or work with community partners to develop coaching programs • Follow up with patients via telephone or utilizing at home coaching programs • Use personal health records to help patients and caregivers manage vital care management information and goals • Establish and utilize community-based service networks and • Build and utilize Telehealth programs

36. Discussion & Questions • What current steps has your organization and community taken to organize? • What do you feel is the biggest value of a community-team based approach? • What is the biggest barrier to forming a local team-based approach? • What do you feel will help take it to the next level?