The Playbook for Partnering with Hospitals in an Era of OutcomesBased Payment Reform Kenneth H. Cohn, M.D., MBA, Facilitator CEO, HealthcareCollaboration.com ken.cohn@healthcarecollaboration.com http://healthcarecollaboration.com 978-834-6089
Overview • • • •
What hospitals look for in long-term care partners Minimizing readmissions (an introduction) Optimizing ecosystem management A ten-step guide for partnering with hospitals
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I. What Hospitals Seek in Long-Term Care Providers • • • •
Aligned mission, vision, and values Commitment to quality and patient safety Customized, patient-focused experiences Risk-sharing that improves patient care
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Aligned Mission, Vision, and Values • Find ways to participate in joint conferences and strategic planning retreats • Use social media to build bridges • Use more traditional types of social networking to open up doors (Board member, spouse contacts)
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Customized, Patient-Focused Experiences • Demonstrate timely, seamless transitions • Deliver on promises • Target your services to hospitalists and engaged healthcare professionals who understand the value that you provide
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Risk-Sharing that Improves Patient Care • Move from risk-shifting to sharing via common vision and operational platform • Use similar vendors (e.g. group purchasing) • Demonstrate ways that your niche adds value (e.g. cognitive assessment to decrease readmissions)
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Commitment to Quality and Patient Safety • Demonstrate commitment with results and transparency • Use stories as well as numerical data • Measure and showcase improvement in Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) scores, (http:// hcahpsonline.org/home.aspx)
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HCAHPS: An Introduction • Standardized survey in use since 2006 to measure patients’ perspectives of hospital care to permit hospital comparisons • Increases transparency http://www.medicare.gov/hospitalcompare/search.aspx
• Creates incentives for hospitals to improve care
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The Three HCAHPS Categories • Composite: Nursing (1-3), Physician (5-7), Responsiveness (4,11), Pain Management (13,14), Medicines (16,17), Discharge (19,20) • Individual: Cleanliness (8), Noise (9) • Global: Overall Rating (21), Willingness to Recommend (22) http://hcahpsonline.org/surveyinstrument.aspx
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II. Dealing with Re-admissions Caveats: • What drives 30-day readmissions may be outside of providers’ control. Track day 3-7 readmission rate • There are better ways to improve discharge planning and care coordination than focusing on readmissions e.g. Geisinger warrantees following cardiac/ ortho surgery • Focus on decreasing readmissions can worsen outcomes if too narrowly focused Maintain quality and safety improvement programs, especially those that build a culture of quality & safety Joynt, KE, Jha AK. 30-day Readmissions: Truth and Consequences. [nejm.org, downloaded 4/1/12] Partnering with Hospitals
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Rationale for Improving Care Transitions • 17.6% of Medicare admissions are readmissions • Estimated cost $15 billion • 80% of readmission costs deemed potentially preventable Moral: The setting in which care occurs is largely irrelevant for patients and their families. The clinical outcomes matter to all of us. Patient Handoffs: Effectively Managing Care Transitions. 2009. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 6. Hackbarth GM et al. 2007. Report to the Congress: Medicare Payment Policy. Washington: Medicare Payment Advisory Commission. Partnering with Hospitals
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Context • Statewide 30-day hospital readmission rates vary from 13% (VT) to 24% (LA) • Nationwide analysis of Medicare claims found that half of patients readmitted to the hospital within 30 days following discharge had no intervening physician visit • 70% of surgical patients readmitted to the hospital within 30 days following discharge were readmitted with a medical diagnosis • Up to 70% of patients have problems with medications within the 1st week of discharge Naylor M et al. 2005. Opportunities for improving post-hospital home medical management among older adults. Home Healthcare Services Quarterly. 24(1):101-122. Partnering with Hospitals
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St. Lukes Hospital, Cedar Rapids: Case Report Used variety of techniques to decrease readmission rate for patients with congestive heart failure (CHF), including: – Involving family caregivers and community providers in predicting home-going needs – Reconciling medications for discharge – Scheduling a home-care or office visit within 48 hours of discharge – Using Teach-Back to assess the patient’s and family’s understanding of self-care expectations
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Teach-Back • Method to present information, requesting patients and caregivers to restate instructions in their own words as heard • Questions used for patients with CHF included – What is the name of your water pill? – What amount of weight gain should you report to your doctor? – What foods and condiments should you avoid? – What symptoms should you report to your doctor? Patient Handoffs: Effectively Managing Care Transitions. 2009. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 9.
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Lessons Learned • Interventions decreased readmission rate from 12% to 3-9% per month • Widespread variation resulted from patients near end of life but unwilling to discuss palliative care options • Has stimulated care team to discuss end-of-life options proactively • Palliative care practitioners included as ongoing members of care team • Need to address cognitive issues in caregivers as well as patients
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Stop and Watch If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift: • Seems different than usual • Talks or communicates less than usual • Overall needs more help than usual • Participated in activities less than usual • Ate less than usual (Not because of dislike of food) • N Drank less than usual
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Stop and Watch, II • • • • •
Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual http://interact2.net/docs/Communication%20Tools/ Early_Warning_Tool_(StopWatch)c.pdf
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Ten Steps to Decrease Re-admissions • Early assessment of discharge medications and ability to comprehend discharge instructions • Enhanced patient and caregiver instruction based on preferred learning style and understanding of condition(s) • Timely and complete communication among physicians, nurses, and allied healthcare professionals well before date of discharge • Telephone call from nurse within 24 hours of discharge to assess and confirm understanding of follow-up plan
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Ten Steps, II • Post-acute follow-up within 72 hours with a nurse and/or physician for all patients at risk for readmission Bisognano M, Boutwell A. 2009. Improving transitions to reduce readmissions. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 7.
• Referral for post-acute care services as soon as likely to be needed (www.Curaspan.com) • Sensitive, appropriate advanced care discussions and planning with patient and family • Remote monitoring • Streamlined, systematized transfer processes between facilities that work together frequently Partnering with Hospitals
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Ten Steps, III • Improved medication management, especially with regard to anticipation, avoidance, and management of drug interactions with prescription and non-prescription medications Bradley EH, et al. Contemporary Evidence about Hospital Strategies for Reducing 30-day Readmissions: A National Study. J Am Coll Cardiol. 2012;60(7):607-614. doi:10.1016/j.jacc. 2012.03.067.
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Readmission Summary • Unnecessary readmissions are now seen as defects to be eliminated, much like “Never Events” • The boundaries between physicians, hospitals, and post-acute care facilities are blurring • Transcending silos can improve the quality and safety of patient care • Start now and be proactive to differentiate your clinical outcomes
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III. Ecosystem Management • If your organization is innovative, but your partners do not share in your success, your organization's success will be short-lived • When partners in an ecosystem do well, innovation flourishes • Population health and wellness require viable ecosystems Adner R. The Wide Lens: A New Strategy for Innovation. NY: Penguin Books. 2012
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Ecosystem Value Blueprint I • Who needs to adopt the innovation for your organization to be successful? • What does your organization need to deliver? • What inputs do you need from suppliers? • Who stands between your organization and the end-consumer? Adner R. The Wide Lens: A New Strategy for Innovation. NY: Penguin Books. 2012, 85-87.
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Ecosystem Value Blueprint II • What needs to happen for your intermediaries to move your innovation to consumers? • Identify the risks in your ecosystem that your intermediaries, complementors, and suppliers must bear • For those partners whose status is not greenlighted, work to understand the reason and to identify a viable solution • Update your blueprint at least monthly or more rapidly depending on the pace of change
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IV. Ten-Step Approach to Partnering with Hospitals • Reach out to one (or two) hospital(s) where you have a relationship(s) • Connect at multiple levels: case mgr./ DC planner, utilization review, hospitalist, nurse mgr., C-suite, Board • Partner on pilot projects that produce wins for hospital, assisted living community, and residents (e.g. reducing readmissions within the first week after transfer, web-based discharge planning)
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Partnering with Hospitals III • Make it easy for your strategic partners to know you – Hotline or designated connection number – Informative, interactive website: about us, history, awards & recognition, comments from residents and patients (video) – Thought leadership: blog, newsletter, watercooler links to your facility that add value, repurposing content – Social media, esp. LinkedIn
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Partnering with Hospitals III • Demonstrate support at highest levels at kick-off of new pilot project – Set stretch goals – Use plan, do study, act (PDSA) framework – Limit planning to 30 days, execution to 120-day cycles – Make deadlines public – Use a dashboard to highlight barriers to progress (red-green light) – Summarize goals, actions, learning, and next steps on Intranet to aid others in your organization
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Partnering with Hospitals IV • Strengthen your network(s) by attending local, regional, and national conferences with hospital leaders (eg. ACHE Congress March 24-27, 2014 or ACHE cluster seminars approved for NAB credit, http://ache.org/NAB ) • Form an interdisciplinary group that meets quarterly to move from us vs. them to we
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Partnering with Hospitals V • Provide value: V= Quality/ Price – Focus on quality, as measured by people you serve – Use checklists to improve safety http://www.nejm.org/doi/pdf/10.1056/NEJMsa0810119 http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/ DesktopPDF/English/booklet_Eng_desktop.pdf
– Eliminate waste Quality = Appropriateness x (Outcome + Service)/ Waste chris.backous@vmmc.org, www.VirginiaMasonInstitute.org 206-341-1654
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Some Sources of Waste • Duplicate laboratory testing and imaging • Time searching for frequently used items • Rework from not doing something correctly the first time • Unnecessary patient transfers • Arbitrary individual caretaker variation • Fighting fires rather than preventing them National Priorities Partnership, http:// nationalprioritiespartnership.org/aboutnpp.aspx
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Partnering with Hospitals VI • Give the HCAHPS survey to your residents twice annually and publish results on your Intranet: (http://hcahpsonline.org/surveyinstrument.aspx)
– After a year, publish the results on your Internet and in your annual report
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Partnering with Hospitals VII • Celebrate all successes publicly in person and on Intranet and Internet – Present results at local, regional, and national meetings – Use abstract deadlines to sustain momentum – View speed bumps as learning
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Conclusion • We encounter different perspectives as a result of our training, care models, professional organizations, and the people we serve • The pace of change and the need to balance the interests of different stakeholders make conflict inevitable • Well-managed constructive conflict is a challenging but rewarding journey that can be a source of innovative, transformative ideas • Long-term relationships can become a core competency, with competitive advantage accruing to those who do it well Partnering with Hospitals
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Thanks • Maribeth Bersani, mbersani@alfa.org Senior Vice President Public Policy, ALFA 703-562-1180 • Dr. Jennifer Daley, jenniferdaleymd@gmail.comalfa.org • Neal Peyser, nealpeyser@att.net President Healthcare Continuum Advisors, 708-829-7054 • Ron Tamol, rtamol@comsllc.com VP Southern Region, COMS Interactive LLC 704-661-150004-661-1500 • Stephanie Handelson, Eric Bartkowiak, Kristie Kronk, Loriann Putzier
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