1. Health Care Home and Care Transitions March 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? Networking opportunities Share Learn Conversation Engage

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

5. More about the presenters… 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. Leanne Roggemann, RN, MPH

6. More about the presenters… 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. Vicki Weber, RN, MSN, CMC

7. TITLE Health Care Home and Care Transitions Leanne Roggeman, RN, MPHVicki Weber, RN, MSN, CMC Director of NursingDirector of Care Transitions Fairview Medical GroupFairview Health Services March 15, 2013

8. AGENDA Health Care Home Standards 1)Access 2)Panel Management 3)Quality 4)Care Coordination 5)Care Planning

9. TWO CONTENT 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 9

10. TWO CONTENT 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 10

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

12. TITLE ONLY Supportive Program Components 12 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 patients hospitalization Confirmation of post-discharge needs

13. TITLE ONLY Why Focus on Care Transitions? 13 Personalized care management focused on patient-centered goals (use of HCH POC) Enhanced alignment of continuum of care management Outcomes driven Serious unmet 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. TITLE ONLY Care Transitions Process 14 1)Risk Stratification – identify the patients 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 patients clinical/psychosocial history that impacted the event, The patients 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. TITLE ONLY Collaborative Partnerships 15 Clinics Clinic Care Coordinator role Partner with Care Transitions Specialist during the patients 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 patients 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. TITLE ONLY Successes/Challenges 16 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. BLANK 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 kcummings@icsi.org kcummings@icsi.org