1. Winona Health: Community Care Network Program Robin Hoeg, RN, MS, Service Line Leader of Inpatient Services Paula Philipps, RN, BSN Cassie Boddy, LSW April 30, 2014 Participants:1-866-639-0744, no code needed

2. Webinar Objectives: Describe the overall goals of the Community Care Network program Identify ways the program helps overcome care gaps in the community Discuss the role of the health coach within the multidisciplinary team Discuss the significance of early results on overall sustainability of the program

3. Community Care Network Robin Hoeg, RN, MS, Service Line Leader of Inpatient Services Paula Philipps RN, BSN Cassie Boddy, LSW

4. Outline of Presentation  Background of Community Care Network  Recognizing and linking needs in the community  Developing the community program  Review of outcomes and results

5. Community Care Network  Idea, concept and innovation  Meadville Medical Center & Allegheny College Meadville, PA  Intention o Reduce hospital and emergency department readmissions o Increase primary care clinic visits o Maintain patients in their home environment o Offer health coach philosophy

6. What is our BIG picture?  Improving community health  Patient engagement  Cost avoidance

7. Recognizing the Need  Increasing population with staggering health care needs  Hospitals are being charged with finding ways to treat patients more efficiently and thereby decreasing length of stays and decreasing overall cost of care  Patients are leaving hospitals earlier and bearing the burden of managing their health care needs at home  No reimbursement for readmissions within 30 days.

8. What’s Missing?  Care Gaps  Meeting criteria  Working in silos  What do patient’s want?  Poor communication  Lack of coordination

9. Care Transitions  Medication errors  Non compliance due to social constraints  Exacerbations of chronic illness  Inability of patient/families to recognize and react to signs of acute illness  Handoffs

10. Who are our high risk patients?  Readmissions  Low health literacy  High users of emergency department  Frequent hospital admissions  Frequent clinic visits for social needs  Multiple chronic diseases

11. Impact of Health Literacy  Limited health literacy skills are associated with an increase in preventable emergency room visits and hospital admissions  33-69% of medication related hospitalizations were due to poor adherence  Though shared decision-making is associated with improved outcomes, only 9% of patients actually participate in decisions.  50% of patients leave visits not understanding what their provider has told them.

12. Program Development  Utilized model from Meadville  Started by admitting a patient who was frequently hospitalized  Adapted model to meet Winona’s needs  No rules = greater creativity  Told our story  Recognized benefits of trained health coaches

13. Program Development/ Health Coach Curriculum  Partnered with Winona State University  Students get credits for class and practicum(s)  Purposefully recruit non-nursing students  Class content focus  building relationships  therapeutic communication  strategies to cope with chronic conditions  Students are required to do at least one semester practicum with a CCN client

14. What are health coaches?  A new team member who helps connect patients with providers and community resources.  Health Coaches act as a liaison between the patient, family, community and primary care provider.  Health coaches:  Have a positive impact on adherence  Help make links to community resources  Contribute to better outcomes  Control costs  Improve Health  Accountability partner

15. Benefits of health coaches  Health Coaches can develop relationships with the patients that healthcare personnel can not.  See patients in their own environment where the patient is most comfortable and in control  Become confidants and “Cheerleaders”  Celebrate success no matter how small  Provide self-management support  Bridge the gap between clinicians and client  Help client navigate the health care system  Offer emotional support  Serve as a continuity figure

16. CCN Team Members  RN  Social Worker  Health coaches  Interdisciplinary panel  Dietician  Mid-level Provider  Administration  PT/OT  Chaplain  Counselor

17. Purpose of Program  Reduce an individual’s healthcare costs  Reduce hospital admissions  Reduce Emergency Department visits  Provide support to individuals by bridging gaps in care at the appropriate setting  Improve healthcare outcomes  Improve an individual’s overall health  Improve an individual’s quality of life  Reduce overall health care costs in our community

18. Who Qualifies?  No age limit  Anyone with a chronic disease  Target the high risk patients  Frequent hospitalizations  Frequent ED visits  Frequent clinic visits for non-medical reasons  It’s not home health care  No homebound or skilled criteria

19. Results/Outcome  10/1/13 - 12/31/13  ED Visits: 91% reduction  Rehospitalization: 94% reduction  1/1/14 - 3/31/14  ED Visits: 88% reduction  Rehospitalization: 85% reduction

20. Client Story  Prior to program  34 Emergency Department visits in one year  27 Clinic visits in one year  2 Hospitalizations  Since admission to CCN (10/4/14)  2 Emergency Department visits  3 Clinic visits  0 Hospitalization  The Success:  Health coach involvement  Cognitive skills and activities  Increased social engagement

21. Reflections  Age of clients  Visit is driven by client, not staff  Vulnerability of the clients after a hospitalization or clinic visit  The impact of listening and how we can improve  Seeing how the system fails our clients (multiple providers)  Impact of health coaches  Barriers to admission

22. Questions?

23. Upcoming RARE Events…. Stay tuned for the next …. Webinar: May 20, 2014 A Perfect Partnership: Ensuring a Safe Patient Transition With a Post discharge Firefighter Visit Park Nicollet and St. Louis Park Fire Department Action Learning Day: June 17, 2014 Action Learning Day and Reception Celebration Crown Plaza Hotel, Plymouth, MN Registration now open!

24. Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact: Kathy Cummings, kcummings@icsi.orgkcummings@icsi.org