In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease Care at Home Model
Ms. Ann Rodriguez-McConnell, R.N.
Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013
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In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease Care at Home Model
1.
2. The faculty have no conflict of interest with regard to
any information presented, and will not endorse any
specific products or specific service vendor.
3. Discuss Current Healthcare System
Describe Wagner’s Integrated Chronic Care Model
Describe the Care Delivery Practice
Define Self Management Support
Discuss Principles of Adult Learning
Discuss Health Literacy
Discuss the Principles of Motivational Interviewing
Discuss Goal Setting
4. 2/3 of the nations hospitals will be penalized in Medicare's
campaign to reduce the number of patients admitted in
one month. 1
Medicare identified 2,225 hospitals that will have payments
reduced for one year starting October 1, 2013. 2
Hospitals that treated large number of low income patients
were more likely to penalized than those treating the
fewest impoverished people. 3
Averting 1 out of every 10 of those returns [Re-Admissions]
could save Medicare $1Billion dollars. 7
Solutions involve a coalition of post-acute providers to
work collaboratively, breakdown silos, and get patients to
the right care setting. 4
6. Fragmented health system
Increasing incidents of chronic disease
Complexity of care
Acute based system
Poor transitions
Language barriers
Changing healthcare landscape
Patient labeled “non-compliant”
What a patient does at home is different than what the
doctor ordered
Uncoordinated care
7. Poorly controlled disease
Increased avoidable Re-Hospitalizations and
ED visits
Unnecessary changes in treatment
Increase incidences of Chronic Disease
Miscommunication and Confusion
Medication mismanagement
Non Adherence and non-compliance
Lack of follow up/Missed MD Visits
8.
9. 3%
16%
26%
23%
15%
6%
11%
No Physician
1 Physician
2 Physicians
3 Physicians
4 Physicians
5 Physicians
6+ Physicians
Source: Anderson, G: Chronic Conditions: Making the Case for Ongoing Care, Johns Hopkins University; November 2007
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10. 50
40
30
20
10
0 1 2 3 4 5
3.7
10.4
17.9
24.1
33.3
49.2
Number of Chronic Conditions
Source: Anderson, G; Chronics Conditions: Making the Case for Ongoing Care; Johns Hopkins University ; November 2007
11. Patients understanding and adherence to medication
instructions is a key factor in avoiding a return to the
hospital 8
The Home Health Quality Improvement (HHQI) National
Campaign helps home health stakeholders and multiple
health care settings improve medication management and
reduce avoidable re-hospitalizations. 9
www.homehealthquality.org
The campaign offers free Best Practice intervention
packages (BPIPs)
“Fundamentals of Reducing Acute Care Hospitalizations”
“Improving Management of Oral Medications”
12.
13.
14. Person
Centered
Goals Drive Care
Member of Team
Dignity & Respect
Evidence Based
Clinical
Engagement/Self
Managing Support
Transitions
Coordinated
Time
Settings
Providers
Better Care, Better Health, Lower Cost
15.
16. John Charde, MD, VP Strategic Development, Enhanced Care Initiatives, Inc. (April 2006)
17. Source: “Improving Primary Care for Patients with Chronic
Illness”, Bodeheimer, Wagner, Grumbach, Jama, October 9, 2002, Vol. 288, No.14
18.
19. Relationships/ Patient Centered:
•Holistic Assessments
•Trust Building
•Patient Engagement
•Face to Face Visits
Self-Management support:
•Patient specific SMART goals
•Motivational Interviewing
•Facilitation of behavior change
•Problem Solving
20. Expertise/Coordination:
•Patient is “expert” of self
•Evidence based care delivery
•Interdisciplinary team
•Learning Environment
•SBAR Communication
Technology/Decision Support:
•Early Identification of Exacerbation
•Positive reinforcement & SMS
•Meaningful data exchange
•Make “right thing to do the easy
thing to do”
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37. Provides an avenue for health care professionals from
various disciplines to meet and discuss issues and best
practices for reducing hospital readmissions. 5
It breaks down barriers by giving health care providers a
look into what's involved in other providers’ roles and a
view of the complete information needed to achieve
well-coordinated, patient–centered care. 6
Examples:
University Medical Center RHP 15
Sierra Providence Post Acute Coalition Committee (PACC)
Mano y Corazon Conference 2013
Southwest Association for Healthcare Quality (SWAHQ)
Project Amistad (Community-based Care Transitions Health Coaches)
38.
39.
40. “Life is a pond.
We are all
pebbles. Never
underestimate
the difference one
pebble can make.”
Hardwiring Excellence
Quint Studer