Home Health Quality Improvement (HHQI) National Campaign Improving Communication To Foster Partnerships With Physicians

1. Home Health Quality Improvement (HHQI) National Campaign Improving Communication To Foster Partnerships With Physicians October 10, 2007

2. New York State Local Area Network of Excellence (LANE)

3. Objectives • Discuss physician-nurse communication patterns • Review key strategies to promote effective communication & partnerships with physicians • Provide an overview of the Situation-Background-Assessment-Recommendations (SBAR) technique for communication • Identify available tools and resources to support implementation of a plan to develop and/or improve collaborative relationships with physicians

4. Best Practice Intervention Package Available on the HHQI Web site http://www.homehealthquality.org

6. Physician-Nurse Communication • Multidisciplinary patient care • Coordination of services • Review & approval of the Plan of Care • Care management for a change in condition • Collaboration regarding medical regimen – both planned and unplanned

7. Physician-Nurse Communication • Challenges • Complex co-morbid patient population in home care • Multiple health care provider involvement • Perceptions regarding roles & teamwork approach • Lack of focus on the benefits of collaborative relationships

8. Physician-Nurse Communication Different Communication StylesBased on Training • Nurses are trained to be narrative and descriptive • Physicians are trained to be problem solvers - “ what do you want me to do” – “ give me the details” • Human factors: gender, national culture, hierarchy, power distance, prior relationship • Perceptions of roles in meeting patient needs

9. Physician-Nurse Communication • System Challenges • Physician knowledge of home care • Telephone issues • Incomplete information • Accuracy of information transfer • Ability to return telephone calls • Interruption to daily routine

10. Physician-Nurse Communication • What Do Physicians Want To Know? • Accurate concise information • All pertinent information available • The patient was accurately assessed • Possible solution or recommendation

11. Physician-Nurse Communication • Internal Agency Assessment • How does our agency communicate with physicians? • Do we have consistent communication processes that all staff understand and follow consistently? • Is our agency viewed as an asset to physicians and physician offices? • Do we improve the efficiency of physicians & their offices or do we add chaos & confusion? • What has our agency done to improve the physician’s understanding of home care & communicate the benefits or partnering for improved care management?

12. Key Strategies to Collaborative Physician Relationships • Determine physician preferences • Determine & strive to remove barriers for collaborative relationships • Utilize the SBAR Communication Technique • Empower physicians to utilize care plan oversight as designed for quality patient care • Ensure clinical staff possesses current clinical knowledge of disease specific symptom management that is applied when communicating patient assessment information to physicians

13. Key Strategies to Collaborative Physician Relationships • Key #1 - Determine Physician Preferences by Conducting a Physician Office Team Survey • How do you get physician input? • Is it detailed enough to make any needed improvements? • How do physicians perceive your care delivery? • Benefits: • Assists the agency in determining perceptions regarding delivery of patient care • Identifies areas of potential misunderstanding regarding agency services & special programs • Provides valuable feedback on potential new programs to explore & how to more effectively market current programs

14. Physician Satisfaction Survey (provided as handout) Available in Word format in Additional Resource section of HHQI Web site at http://www.homehealthquality.org

15. Key Strategies to Collaborative Physician Relationships • Key #2 – Unlock the Barriers • Know your Physicians • Meet your Physicians • Notify Physician of changes in care setting • Seek alternatives to ED visits • Meet with Hospitalists • Empower Physicians to use Care Plan oversight • Partner with Physicians • Use SBAR Communication Technique

16. Key Strategies to Collaborative Physician Relationships • Know Your Physicians • How does Physician want to be notified of patient admissions to home care? • How does the Physician prefer to be notified of non-urgent issues (email, phone, fax)? • When would Physician prefer to be contacted? • Who would the Physician prefer the Nurse to contact (Office Manager, PA, NP)?

17. Physician Profile Available in Word format in Additional Resource section of HHQI Web site at http://www.homehealthquality.org Important to keep Physician Preference Files and to share with staff interacting with those physicians

18. Key Strategies to Collaborative Physician Relationships • Include front line staff in physician meetings

19. Key Strategies to Collaborative Physician Relationships • Key # 3 - Utilize the SBAR Communication Technique • The SBAR method provides a framework for communication from clinician to physician, clinician to clinician and/or staff to manager • Promotes clear, effective and efficient communication

20. Key Strategies to Collaborative Physician Relationships • Situation • Background • Assessment • Recommendation

21. Key Strategies to Collaborative Physician Relationships SBAR Technique — The Details S = Situation What is going on with the patient. A concise statement of the problem: 5-10 seconds B = Background What is the clinical background information that is pertinent to the situation (context) A = Assessment What I think--conclusions R = Recommendation • What do I as the Nurse recommend and when?

22. Key Strategies to Collaborative Physician Relationships • Why SBAR? • SBAR is similar to the SOAP model • Provides answers to physicians’ three main questions • What is the problem? • What do you need me to do? • When do I have to respond? • Standardized approach that promotes efficient transfer of • key information between physicians, nurses and other • members of the team • SBAR helps create an environment that allows clinicians • to express their concerns

23. Key Strategies to Collaborative Physician Relationships • S: Situation • Identify yourself, home health agency • Whether you are in the home • Describe the patient situation • When the problem started • Severity

24. Key Strategies to Collaborative Physician Relationships • B: Background • Patient’s admission to the agency • Current list of medications, including allergies • Recent medication changes • Laboratory values • Recent ED visits or hospitalizations • Date of Birth

25. Key Strategies to Collaborative Physician Relationships • A: Assessment • Clinicians current assessment of the situation • My assessment of the problem is: ___________

26. Key Strategies to Collaborative Physician Relationships • R: Recommendation • Recommend what action the clinician wants from the physician • Describe what you are able to do • Let physician know you will call back with the patient’s response • Request an extra skilled visit

28. Key Strategies to Collaborative Physician Relationships • SBAR Implementation • Pilot with a small group of clinicians • Modify the SBAR tool as needed during pilot • Develop procedures for SBAR • Pilot with your physician champions • Spread use throughout the agency across all disciplines • Reinforce to achieve behavioral changes and increase staff comfort level with use

29. Sample SBAR Tool (provided as handout) Sample Letter-Physicians Available in Word format in Additional Resource section of HHQI Web site at http://www.homehealthquality.org

30. Key Strategies to Collaborative Physician Relationships • SBAR Made Easy • 60-minute Webex posted to the HHQI Campaign Website • Provides education on SBAR with practice sessions and examples of use in home health • Post-test & free continuing education for RNs, LPNs/LVNs, PT, PTA, OT, COTA & SLP SBAR for Clinicians Podcast • 15-minute overview • Includes Physician perspective • Examples of Excellence • Practical application depicted by home care agencies

31. Key Strategies to Collaborative Physician Relationships • Key # 4 - Care Plan Oversight (CPO) • Educate physicians and empower them to use appropriately • CMS Physician Care Plan Oversight definition • CPO billing guidance and codes for physicians, nurse practitioners, physician assistants • Link to American Academy of Family Physicians sample checklists and 2005 article related to CPO • http://www.aafp.org/fpm/FPMprinter/20050500/23howt.html?print=yes

32. Resource: Page 18 of Intervention Package

33. Key Strategies to Collaborative Physician Relationships • Offer to provide an educational session at hospital medical board meeting • Prepare a Physician Care Plan Oversight Primer for Physicians • Educate agency staff about Care Plan Oversight

34. Key Strategies to Collaborative Physician Relationships • Key # 5 -Improve Knowledge of Symptom Management • Increases physician confidence and trust • Better communication • Improved patient outcomes

35. Additional Resources • The Hospice & Palliative Nurses Association BASICS Program • Convened Physicians & APN in 2005 to discuss root causes of ineffective communication between nurse & physician

36. HPNA BASICS Program • Identified significant symptoms that generated most calls to MD • Performed literature reviews related to the symptoms • Developed Pathophysiology Education Modules for the top six symptoms • Program utilizes interactive self-paced CD ROM modules for nurses B = Background A = Assessment S = Situation/Symptom I = Intervention C = Communication S = Successful Outcome

37. HPNA BASICS Program http://www.hpna.org/Multimedia_Home.aspx

38. SBAR versus BASICS • Same Goal – support clear, concise, effective and efficient communication

39. Additional Intervention Package Resources • Patient & Family Connection • Hospice & Palliative Connection • SOAP & SBAR Connection • Examples of Excellence • Education Tracks

40. Additional Resources • IPRO Home Health Web site Past Events Section: • http://providers.ipro.org/index/homehealth • Clinical Strategies to Improve Patient Outcomes: Strategies to Improve Communication with Physicians - 09/27/06 • IPRO Home Health Web site Resource Section • http://providers.ipro.org/index/homehealth_downloads • Physician Communication Resources

41. Additional Resources • HHQI Campaign Web Site – Physician Section • American College of Physicians, May 2007: Home Health Link Helps Avoid Costly Hospitalizations • Family Practice Management, May 2005: How to Document and Bill Care Plan Oversight • American College of Physicians, May 2007:Home health link helps avoid costly hospitalizations • HHQI: The Physician Role in Reducing Avoidable Hospitalizations • HHQI: The Physician Role in Improving Home Health Care

42. Additional Resources • HHQI Campaign Web Site – Physician Section • Home Health Telemonitoring Tips for Physicians • Seven Key Points for Physicians Related to Reducing ACH • Audio Recording: Dr. David Nash • What is SBAR? • Universal Medication Form • Physician Heart Failure Toolkit

43. Website Resources • HHQI Campaign Web site– www.homehealthquality.org • MedQICWeb site – www.medqic.org • IPROWeb site – www.ipro.org

44. Next Steps • Review the Best Practice Intervention Package – Physician Relationships • Leadership and Care Provider Tracks • Identify tools and resources for implementation • Begin improving your physician relationships today!

45. Month Best Practice Topic March 2007 Hospitalization Risk Assessment April 2007 Patient Emergency Plan May 2007 Medication Management June 2007 Phone Monitoring and Front-Loading Visits July 2007 Teletriage August 2007 Telemonitoring September 2007 Immunization October 2007 Physician Relationships November 2007 Fall Prevention December 2007 Patient Self-Management January 2008 Disease Management February 2008 Traditional Care Coordination Schedule for Intervention Packages

46. Sara ButterfieldProject Leader IPRO20 Corporate Woods BoulevardAlbany, New York 12211Phone: 518-426-3300 ext. 104Fax: 518-426-3418sbutterfield@nyqio.sdps.org IPRO Contact Information • Christine StegelPerformance Improvement CoordinatorIPRO20 Corporate Woods BoulevardAlbany, New York 12211Phone: 518-426-3300 ext. 113Fax: 518-426-3418cstegel@nyqio.sdps.org • Victoria AgramontePerformance Improvement CoordinatorIPRO20 Corporate Woods BoulevardAlbany, New York 12211Phone: 518-426-3300 ext. 115Fax: 518-426-3418vagramonte@nyqio.sdps.org

47. Kelly DonohueCoordinator of CommunicationsContinuing Care Leadership Coalition555 West 57th - Suite1500 New York, New York 10019 Phone: 212-506-5424Fax: 212-258-5331donohue@cclcny.org State Association Contact Information • Alexis SilverDirector of Development and Special ProjectsHome Care Association of New York State, Inc.194 Washington Avenue, Suite 400Albany, NY 12210Phone: 518-810-0658Fax: 518-426-8788asilver@hcanys.org • Rose DuhanSenior AnalystHome and Community Based ServicesHealthcare Association of New York StateOne Empire DriveEastRensselaer, NY 12144Phone:  518-431-7620Fax: 518-431-7915rduhan@hanys.org • Margaret ClarkAssistant Director of Public Policy New York State Association of Healthcare Providers, Inc. 99 Troy Road, Suite 200East Greenbush, New York 12061Phone: 518-463-1118 ext. 811Fax: 518-463-1606clark@nyshcp.org

48. Congratulations on your commitment to the HHQI National Campaign!! For more information, contact Comments and Questions This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. Publication Number:8SOW-NY-TSK1B-07-09.