Webinar 4: Implement Whole-Person Transitional Care for All: Slide Presentation

Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions
Text version of Webinar slide presentation.

Slide 1: Designing & Delivering Whole-Person Transitional Care

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Designing & Delivering Whole-Person Transitional Care
The Hospital Guide to Reducing Medicaid Readmissions

Webinar 4: Implement Whole-Person Transitional Care for All

Slide 2: Agenda

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  • Describe the guidance and proposed changes to the CMS Discharge Planning Conditions of Participation.
  • Identify the ways in which the guidance and proposed changes to CMS Discharge Planning expectations promote "whole-person" transitional care and are relevant to Medicaid patients.
  • Share tools from the Guide to support improving "whole-person" transitional care.

Slide 3: Objectives

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  • Understand that hospitals should improve transitional care processes in ways that apply to all patients, regardless of risk.
  • Understand that all hospitalized patients should be assessed for readmission risks and transitional care needs.
  • Identify ways to implement improved care processes for all

Slide 4: Table of Contents

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  • Introduction.
  • Why focus on Medicaid Readmissions?
  • How to Use This Guide.
  • Analyze Your Data.
  • Survey Your Current Readmission Reduction Efforts.
  • Plan a Multi-Faceted Data-Informed Portfolio of Strategies.
  • Implement Whole-Person Transitional Care for All.
  • Reach Out to Collaborate With Cross-Continuum Providers.
  • Enhance Services for High-Risk Patients.

Image: Cover of the book, Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions.

Slide 5: List of Tools

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The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations.

  1. Data Analysis.
  2. Readmission Review.
  3. Hospital Inventory.
  4. Community Inventory.
  5. Portfolio Design.
  6. Operational Dashboard.
  7. Portfolio Presentation.
  8. Conditions of Participation Handout.
  9. Whole-Person Transitional Care Planning.
  10. Discharge Process Checklist.
  11. Community Resource Guide.
  12. Cross Continuum Collaboration.
  13. ED Care Plan Examples.

Image: Tool icon (crossed hammer and wrench).

Slide 6: The ASPIRE Framework

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Image: The Framework is a flowchart reading from left to right. On the left is a box captioned "Reduce Medicaid Readmissions"; two lines connect this box to two boxes to its right captioned "Analysis" and "Action". Three lines each extend from "Analysis" and "Action" to connect to the elements that make up the ASPIRE acronym:

  • Analyze Your Data.
  • Survey Your Current Readmission Reduction Efforts.
  • Plan a Multi-faceted, Data-Informed Portfolio of Strategies.
  • Implement Whole-Person Transitional Care for All.
  • Reach Out and Collaborate with Cross-Continuum Providers.
  • Enhance Services for High-Risk Patients.

Slide 7: Understand evolving guidance and requirements

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Use these as your blueprint to improve standard care.

Slide 8: Improving Standard Processes for All Patients

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  • Identify all patients at high-risk of readmission.
  • Assess all patients for clinical, behavioral and social needs.
  • Communicate with patients simply and effectively.
  • Link patients to follow-up and post-hospital services.
  • Provide real-time information to receiving providers.
  • Ensure timely post-discharge contact.

And

  • Have a process.
  • Track, trend and review readmissions.
  • Continuously improve the process to better meet needs.

Slide 9: Excerpts from Recent CMS Guidance and Proposal

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  • Have a written discharge process approved by governing body.
  • Analyze and track readmissions.
  • Review readmissions and look for patterns.
  • Regularly review and improve the discharge processes.
  • Every patient in inpatient or observation needs a discharge plan.
  • Actively solicit the preferences of the patient and family/friends/support person.
  • The plan must be able to be realistically implemented.
  • Address behavioral health follow up as part of the discharge plan.
  • Provide customized education.
  • Provide verbalized instructions, using the teach-back technique.
  • Know capabilities of community-based providers—including Medicaid home and community based services.
  • Know options for Medicaid long term services and supports or have a contact at Medicaid who can help.
  • Provide patients with data to inform their choice of post-acute providers.
  • Transmit discharge summaries within 48 hours of discharge.
  • Follow up with patients at high risk of readmission.

Slide 10: New York Medicaid Transition of Care Process

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Excerpts from the New York Medicaid "DSRIP Toolkit":

  • Have a transition of care process in place.
  • Partner with MCOs, community and social service agencies.
  • Notify patient and partners of discharge early.
  • Allow transitional care providers to visit patient while in the hospital.
  • Ensure timely communication with providers.
  • Establish and track patients during a 30-day transition of care period.

DSRIP = Delivery System Reform Incentive Program

Slide 11: Understand and Align Rules & Requirements

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CMS Medicare & Medicaid Requirements NY Delivery System Reform Incentive Program (DSRIP)
Medicaid Requirements
X Have a specified process X Have a specified process
___ All patients need discharge plan  
___ Address behavioral health needs  
X Work with partners X Work with partners, including MCOs
X Engage patients & caregivers X Notify patients & partners early
___ Use data to refer to post acute care  
X Effectively link to post hospital care X Allow partners to visit in-hospital
X Communicate with PCP <48h X Communicate with PCP
X Follow up with patient after d/c X Track patients for 30 day period
___ Review & improve process  

Slide 12: Reflect on Current Practice: Still Rare to Do it All

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Regional survey of hospitals found:

  • Variation across hospitals in practices targeting readmission reduction.
  • Most hospitals use some method to identify readmission risk.
  • Most hospitals working on patient education and medication.
  • Few hospitals working on efforts to ensure follow-up.
  • Few hospitals have processes to coordinate with community providers.
  • Few hospitals working on efforts requiring shared accountability.
  • Few hospitals track services delivered and outcomes after discharge.

Slide 13: Improving Transitional Care for All Patients

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CMS has recommended that hospitals do the following to improve discharge planning, now referred to as "traditional care." These expectations apply to Medicare and Medicaid patients:

  • Have a documented discharge planning process, approved by the hospital's governing board.
  • Provide discharge planning for all inpatients, observation patients, and certain ED patients.
  • Analyze and track readmission rates.
  • Review readmissions to look for patterns.
  • Conduct root cause analyses on readmissions to assess whether the discharge planning process meets patients' needs.
  • Craft a discharge plan that can be realistically implemented.
  • Actively solicit the input of the patient and family/friends/support persons.
  • Address behavioral health follup as part of the discharge plan.
  • Provide customized education to patients and their caregivers.
  • Provide oral instructions using the teach-back technique.
  • Arrange for (not just refer to) posthospital services.
  • Know the capabilities of postacute and community-based providers, including Medicaid home and community-based services.
  • Provide patients data to help inform their choice of high-quality postacute providers.
  • Know options for Medicaid long-term services and supports, or have a contact at the State Medicaid agency who can assist with these issues.
  • Follow up with high-risk patients after discharge.

[Our hospital] is working to meet these expectations—and we need your help. Please contact your manager or supervisor if you have feedback or ideas to improve how we deliver safe and high-quality transitional care to all our patients. For more information, contact [Readmission Champion].

Slide 14: Discharge Process Checklist

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Image: The Discharge Process Checklist Tool.

Slide 15: Screen for and address transitional care needs

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Identify and address needs for all; identify high-risk patients.

Slide 16: Whole-Person Transitional Care Planning

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Image: The Whole-Person Transitional Care Planning Tool.

Slide 17: Implementation Tips: Standard Care

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  • Use Whole-Person Transitional Care Planning Tool to review the assessments your staff already conduct.
  • It is likely a significant percentage of these questions are asked by various hospital providers at some point; ensure information is in one place.
  • Update your standard nursing, case management, discharge planning, and/or social work assessment to more consistently assess "whole-person needs" and Medicaid-relevant risks.
  • Leverage electronic workflow prompts to promote efficiency (check boxes, clicks, review & confirm from prior events) and consistency.

Slide 18: Remember to Ask "Why"

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In practice: Listening to the Patient

Insights from Asking "Why?"

A 53-year-old man with HIV/AIDS presented to the hospital with a chief complaint of "unable to walk" and was promptly admitted to the medicine service. The next morning once the medical team reviewed all his labs and vitals and noted he appeared to be clinically stable, the attending asked the patient to restate "why" he presented to the hospital. The patient very clearly explained why he ended up in the hospital: he had run out of his gout prevention medication and his inability to bear weight on his leg was simply a result of a gout flare. The patient was seeking local steroid treatment for the flare, which he had had in the past. Because he presented with the label of HIV/AIDS and had been recently hospitalized, he was admitted for an issue that could have been managed as an outpatient.

Slide 19: Implementation Tips: High-Risk

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  • Use flags to identify patients with high-risk features on admission, based on your data analysis and root cause analysis:
    • Personal history of repeated hospitalizations (based on a specific definition).
    • Personal history of a behavioral health diagnosis.
    • Adult Medicaid patient (not admitted to an obstetrics unit).
    • Current admission diagnosis known to be high-risk (heart failure, sickle cell, etc.).
  • Leverage "high risk flags" to send alerts to staff:
    • Push alerts to case managers, hospitalists, readmission team.
    • Develop enhanced steps to follow for high risk patients (pharmacist med review, bedside delivery of medications, 48 hour follow-up contact, etc.).
    • Use alerts to identify "high risk" discharges per month for tracking and quality efforts.
    • Analyze alerts: how many per day? Per month?
    • Analyze response to alerts: were the enhanced steps followed? How often?

Slide 20: In Practice: Automated Flag Creates Efficiencies

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Flag that Populates Work List Saves Hours a Day

A hospital in Massachusetts has a 10-person team dedicated to improving care for patients with behavioral health conditions who present to the hospital. The model rests on navigators in the ED and in the inpatient setting being able to identify patients with behavioral health conditions so that initial engagement, assessment and offer for post-hospital continuation of care and support can occur prior to discharge. For the first 6 months of the program, the nurse navigator assigned to engage with inpatients was spending 3 hours of her morning every morning reviewing each admission to med/surg to identify through the clinical record which  patients had behavioral health conditions. The purpose of her job was to engage and assess and facilitate continuation of care—no one ever intended a third of her day would be spent on case finding! The hospital prioritized the development of an automated flag to provide her with a list every morning at 7 am of the target population patients. This returned 3 hours a day, or 15 hours of her week back to clinical care.

Slide 21: In Practice: IT Notification Facilitates New Process

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IT Flag for Patients Discharged to Skilled Nursing Facilities

A hospital in Texas was focused on improving the transition for patients being discharged to skilled nursing facilities because their data demonstrated that one of the groups with the highest readmission rates at their hospital were all discharges to skilled nursing facilities. They intended to conduct a pharmacist-led medication reconciliation prior to discharge for this target population. Under normal workflow operations, this would be unreliably implemented, because discharges are usually hastened once a patient and a SNF agree to the discharge disposition, there is a perception of lack of time, and the notification of the pharmacist would rely on busy floor staff. The team developed an automated alert to the pharmacist once the case manager entered the discharge disposition of SNF into the record. The notification served several purposes: served as an alert for a transitional care service; saved the floor staff time in notifying the pharmacist, saved the pharmacist time in case finding, and generated a list of all patients who met "criteria" for the service thus allowing measurement and improvement of the process.

Slide 22: Reliably Implement Processes

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The work of improving transitional care and reducing readmissions is the work of delivery system transformation: working to make standard, day-to-day processes more effective, efficient, high-quality and person-centered.

Tools that can help include:

  • Enabling tools and technologies.
  • Written standard operating procedures.
  • Updated work flow, roles, and responsibilities.
  • Communication and training materials.
  • Implementation measurement and feedback.

Slide 23: Summary

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  • Improve hospital based transitional care processes for all patients, including but not limited to patients identified as "high risk" of readmission.
  • We emphasize the guidance and proposals from CMS because they represent Medicaid-relevant and whole-person enhancements to transitional care and apply to all.
  • Reference tools and content in this guide to help your teams apply the CMS guidance in practice.

Slide 24: Thank you

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Thank you for your commitment to reducing readmissions

Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
amy@collaborativehealthcarestrategies.com

Angel Bourgoin, PhD & Jim Maxwell, PhD
John Snow, Inc.
Angel_Burgoin@jsi.com; Jim_Maxwell@jsi.com

Page last reviewed October 2016
Page originally created October 2016
Internet Citation: Webinar 4: Implement Whole-Person Transitional Care for All: Slide Presentation. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar4.html