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Health Care Home and Care Transitions March 15, 2013
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  1. Health Care Home and Care TransitionsMarch 15, 2013 Hosted by RARE Operations Partners: Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health

  2. Our host today will be… Kattie Bear-Pfaffendorf – Minnesota Hospital Association Kattie Bear-Pfaffendorf is a patient safety/quality specialist with Minnesota Hospital Association. She focuses or Transforming Care at the Bedside, Partnership for Patients, Readmissions, and Perinatal Safety. Kattie holds a MBA and Lean Six Sigma Green Belt. Kattie has over 7 years of experience in the clinical laboratory including; pathology, cytology, histology and microbiology. 

  3. Why RARE Conversations? Share Networking opportunities Learn Engage Conversation

  4. March’s Conversation… Health Care Home And Care Transitions Sharing their work: Fairview Medical Group

  5. More about the presenters… Leanne Roggemann, RN, MPH Leanne Roggemann, RN, MPH, is the Director of Nursing for the Fairview Medical Group (FMG).  She is the Health Care Home lead for FMG.  This work includes the implementation of care coordination and partnering across the system to establish a smooth process for care transitions from the hospitals and other care settings.  Leanne has worked for FMG for 26 years in many roles including the inpatient setting and the ambulatory clinic setting.

  6. More about the presenters… Vicki Weber, RN, MSN, CMC Vicki has spent the last 12 years in care management leadership, and is currently working as the system director of care transitions for Fairview Health Services.  During the past year Vicki led the implementation of a system-wide care transitions strategy focused on assuring the highest quality patient and family support experience. She has a 21 year history in case management and is recognized for program development, building cross-continuum care teams and administering patient-focused care models.  Vicki is a graduate of Loyola University, New Orleans, with a MSN in Health Care Systems Management.  She also holds a bachelors degree in nursing graduating from College of St Catherine, St Paul.

  7. Health Care HomeandCare Transitions Leanne Roggeman, RN, MPH Vicki Weber, RN, MSN, CMC Director of Nursing Director of Care Transitions Fairview Medical Group Fairview Health Services March 15, 2013

  8. Health Care Home Standards Access 2) Panel Management 3) Quality 4) Care Coordination 5) Care Planning

  9. Detailed components of the standards Access • 24/7 access • Alternative visits: telephonic, MyChart, RN MTM, behavioral health clinicians • Communication/handoffs between care teams Panel Management • Disease specific patient lists • Reporting workbench • Population management tool

  10. Detailed components of the standards Quality • Clinical outcome data • PDSA cycles at the local level to improve flow/clinical outcomes • Patient experience/satisfaction • Patient partners Care Coordination • High risk referral management • Care transition handoffs • Health maintenance reminders • Pre-visit planning

  11. Detailed components of the standards Care Planning • After visit summary • Disease specific action plans • Complex care plans • Emergency care plans

  12. Supportive Program Components Care Transitions • Transition/Hand-Off Communication • Summary of event • Physician Summary • After Visit Summary • Phone call/email/face-to-face discussion • Clearly telling the patient story, what occurred, and what suggested/required care interventions need to occur • Results in • Immediate information related to the patient’s hospitalization • Confirmation of post-discharge needs

  13. Why Focus on Care Transitions? • Personalized care management focused on patient-centered goals (use of HCH POC) • Enhanced alignment of continuum of care management • Outcomes driven • Seriousunmet needs resulting in poor satisfaction with care • High rates of preventable readmissions • 40% (4/10) in hospital beds do not need to be there(Improvement in Science Research Network)

  14. Care Transitions Process • 1)Risk Stratification – identify the patient’s risk level – this will determine what level of transition services a patient may need. • 2)Assessment/Triage – complete a clinical and/or psycho-social assessment to determine probable post-event needs. • 3)Patient Story – understand: • What led to this event, • What level of understanding the patient has about the event, • The patient’s clinical/psychosocial history that impacted the event, • The patient’s ability and willingness to work on changes to maintain care in his/her home setting, and • What support the patient may need to carry out the plan.

  15. Collaborative Partnerships • Clinics • Clinic Care Coordinator role • Partner with Care Transitions Specialist during the patient’s hospital stay • Communicate transition plan to physician and health care team members • Post-hospital, work with patient to make adjustments in Medical Home Care Plan • Act in the role of Patient Advocate to support care needs • Hospitals • Care Transition Specialist role • Partner with Clinic Care Coordinator on transition plan and patient’s continuum needs • Facilitate communication among all health care providers, proactively preparing for the transition • Partner with patient/family to review Medical Home Care Plan, identify new goals, prepare for transition back to primary care provider

  16. Successes/Challenges • Identified Successes • Assurance that follow-up needs will be met due to personalized hand-off with clinic/community partners • Greatly improved communication between hospital and clinic • Patients and families are more engaged in planning transitions • Easy identification of patients who are considered high risk, resulting in improved focus on those with the highest need • Identified Challenges • We want to share information with non-Fairview providers • More work to be done, particularly in our emergency departments • Skilled nursing facility transitions need a different type of hand-off (plan of care, why is the patient coming to them, medication reconciliation, orders confirmation)

  17. Questions?

  18. Upcoming RARE Events…. • RARE Rapid Action Learning Day, • April 23, 2013, (8:30 a.m. – 3:30 p.m.) • Mpls. Marriot Northwest, Brooklyn Park, • MN • RARE Webinar, ICSI will be hosting the May 2013 webinar. Stay tuned for more details.

  19. Future webinars… • To suggest future topics, contact Kathy Cummings at