Patient Safety and Home Care Tina Hilmas RN BSN Project Manager July 10,

Who we are 2 CPS was founded in 2005 as an independent, not-for-profit organization dedicated to improving patient safety and quality of healthcare Founding members are Missouri Hospital Association, Missouri State Medical Association and Primaris Serve as a central and resource and facilitator to improve patient safety through a collaborative approach to education, information and resource sharing, and learning. We emphasize the importance of culture in promoting safe systems of care, and a culture that supports individualized care, teamwork and communication We are a federally listed PSO which allows us to provide the confidentiality and protection privileges listed under the Patient Safety Act

3 Health Care Continuum Safety and Culture is a common denominator to safe care and high quality care across the health care continuum Work with multiple different agencies: – EMS (throughout Missouri and the nation) – Hospitals (through Missouri and the nation) – Ambulatory Surgical Centers – Medical Offices – Long Term Care Organizations – Government Agencies (CMS, HRET and AHRQ) – Collaborate with other medical organizations across the nation (Johns Hopkins and University of Michigan) – Collaborate with other PSO’s across the nation ranging from California to North Carolina

4 An environment that supports and promotes open communication, teamwork and leadership is key to improving patient safety. Studies have shown that up to 80% of medical errors occur during transitions (Communication) Center provides tools and education to assist with improving teamwork and communication Services include: – SOPS (Survey on Patient Safety Culture) – Just Culture – CUSP (While hospital based, since it is geared to promote the front line staff as leaders in patient safety, can be utilized by home health nurses/staff) Culture Activities

5 Trend is starting to focus more outside hospital walls New Research looking at Ambulatory Care and Long Term Care Transitions Care Coordination Home Health Home and Community Based Services Population Health – Obesity – Health Literacy Future of Patient Safety/Hot Topics

6 NQF and AHRQ both looking at HCBS and dual eligible population in regards to patient safety and quality of care – NQF is doing a call for Measures and Measure Concept for Patient Safety in the HCBS population – Research into increased Unnecessary Re-hospitalization in the HCBS Population – AHRQ comparing HCBS to Institutional care (quality, outcome and cost) Since 2012 when OIG performed a study and found CMS lacking in oversight on OASIS data closer scrutiny on quality of care provided by home health Home Care Under Scrutiny

7 Star Ratings IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation ) – the reporting of standardized patient assessment data with regard to quality measures, resource use, and other measures to allow for exchange and comparison – Promotes the National Quality Strategy (Better Care, Healthy People/Communities, Affordable Care – CMS Quality Strategy Goals: Making care safer by reducing harm caused in the delivery of care. Ensuring that each person and family is engaged as partners in their care. Promoting effective communication and coordination of care. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease. Working with communities to promote wide use of best practices to enable healthy living. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models. 2 new NQF quality measures beginning July 2015 – Re-hospitalization during first 30 days of Home Health – Emergency Department Use without hospital Readmission during the first 30 days of Home Health Home Care Changes

Other Areas of Federal Focus CMS released 2016 CY HH PPS – $350 million decrease – Penalizes those who do not submit required quality data Value Based Purchasing Model – Reimbursement based on quality outcome rather than volume Increase in unannounced inspections – Connecticut, this had the effect of fining an agency and mandated to hire a nurse patient safety officer – Increase in immediate jeopardy “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.” Only ONE INDIVIDUAL needs to be at risk. Identification of Immediate Jeopardy for one individual will prevent risk to other individuals in similar situation 8

9 Identify Patients Correctly Use Medicines Safely – Major issue across entire health care continuum Prevent Infection – HAI’s many times identified after discharge to home Prevent Patients from Falling – Elderly and disabled high risk population – Missouri has higher than national rate Identify Patient Safety Risks – Emphasis on utilization of home oxygen therapy – Potentially Avoidable Events (PAE’s) 2015 Home Care National Patient Safety Goals

How CPS can help Administer SOPS (Survey On Patient Safety) – Culture within an organization is strong indicator of quality of care provided – Provides baseline as to where organization is from a patient safety systems point of view PSO Services – Learn from errors/event reporting system. – Active participation can provide federal protection Provide Education – On science of safety – Toolkits, such as medication reconciliation, falls prevention Provide Training – Just Culture classes – CUSP Collaborate – Work with MAHC on Identification and prevention of PAE’s – Provide workshops/conference breakout sessions 10

QUESTIONS? 11

Center for Patient Safety Staff Becky Miller, MHA, CPHQ, FACHE, CPPS – Executive Director Alex Christgen, BS – Project/Operations Manager and Analyst Tina Hilmas, RN BSN – Project Manager Kathy Wire, JD, MBA, CPHRM – Project Manager Lee Varner, BS, EMS, EMT-P – Project Manager, EMS Services Eunice Halverson, MA – Patient Safety Specialist 12