MA STAAR Fall Learning Session Engaging Front-Line S taff and Your Cross Continuum Team

1. MA STAAR Fall Learning SessionEngaging Front-Line Staff and Your Cross Continuum Team 1:15-2:30PM Breakout Peg Bradke and Rebecca Steinfield

3. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

4. Vision for Cross-Continuum Teams Understanding mutual interdependencies, the hospital-based teams co-design care processes with their cross-continuum care partners and collaborate to solve problems to improve the transition out of the hospital and reception into community settings of care. 29

5. Cross-Continuum Improvement Teams • One of the most transformational changes in the STAAR Collaborative • Reinforces that readmissions are not solely a hospital problem • Need for involvement at two levels: 1) at the executive level to remove barriers and develop overall strategies for ensuring care coordination 2) at the front-lines -- power of “senders” and “receivers” co-redesigning processes to improve transitions of care • New competencies in partnering across care settings will be a great foundation integrated care delivery models (e.g. bundled payment models, ACOs) 30

6. Starting your Cross-Continuum Team IHI How-to Guide, Page 6

7. Starting your Cross-Continuum Team IHI How-to Guide, Page 8

8. CCT Membership Recommendation • Executive Sponsor • Day-to-day Leader • Patients and family members • Hospital clinicians and staff • Supporting staff (QI, IT, Finance, etc.) • Palliative Care • Payors • Clinical and administrative staff and/or leaders from the community • Skilled nursing facilities • Office practice settings • Home health • Community or Public Health Services • Area Agencies on Aging • Consider those that are part of your system but also • those outside of your organization/system

9. General Recommendations for CCTs • Meet regularly to facilitate bi-directional communications and collaboration, assess progress, remove barriers to progress and support the improvement of the front-line teams in all clinical settings. • Have members from the cross-continuum team visit each other’s sites (including accompanying a nurse on a home visit) to observe patient care processes during transitions. • Complete periodic diagnostic reviews of patients that have been readmitted. • Complete a gap analysis of your settings --Where to you have work going with the key changes currently? • Add patients and family members to the cross-continuum team to enhance the focus on the patient’s experience and to harvest their suggestions for improving care processes.

10. Frontline EngagementTips from Steve Spear • Allow the frontline team interests to determine where to start. What have you found? How have you used observation to move test of change? • Solve a problem that really matters … When you start to score gains, your staff to take notice. • Don’t think too much but do a lot. That’s where the real learning takes place.

11. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Act Plan Study Do Setting Aims Establishing Measures Selecting Changes Model for Improvement *2001 Associates in Process Improvement

12. Discussion Questions for Frontline Engagement • What stories have you used to enhance the work and move you process? • In what way are you using data or measure results to engage your staff? • What are your barriers to engaging your frontline? • What are your successes in engaging frontline staff and spreading your successful practices?

13. CCT’s Role in Performing an Enhanced Assessment of Post-Hospital Needs • On admission, how can hospital clinicians and staff get timely and relevant information from community providers (e.g. medication lists, comprehensive care plans, insights about the patient’s ability to provide self-care, advanced directives). • Other emerging best practices?

14. CCT’s Role in Providing Effective Teaching and Facilitating Learning • Develop and utilize universal patient-friendly education materials for common clinical conditions in all health care settings in a community. • Ensure that all health care providers in the community are competent in effectively teaching and facilitating learning for patients and family caregivers utilizing health literacy principles. • Other emerging best practices?

15. CCT’s Role in ProvidingReal-Time Handover Communications • Hospital team members and community providers co-design real-time handover communications (including preferred format, mode of communication and specific information about the patient’s status). • Consider adopting a universal format for patient care plans (with information about medications, diet, treatments, signs and symptoms that require medical attention and plans for follow-up). • Other emerging best practices?

16. CCT’s Role in Ensuring Post-Hospital Care Follow-Up • Determine who is the best clinical provider (from the patient’s perspective) to complete follow-up phone calls. • Collaborate with payers and post-acute care providers to determine eligibility for intensive care management and best clinical provider for various patient populations (Care Transitions Intervention, APN Transitional Care, HF Clinic, Patient-Centered Medical Home, Evercare, etc.). • Other emerging best practices?

17. CCT’s Role: Review Data • Patient experience data • Communication with patients (Q 3,7) • Discharge preparation (Q 19,20) • 30-day all-cause readmission rates for: • All conditions • Conditions of interest • Rehospitalization rates if available • Days between discharge and readmission • Readmission into Observation status • Patients readmitted within 30 days who had an office visit before return to hospital

18. What is one new thing you learned today that you would like to test?