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

2. Skilled Nursing Facilities
Hospitals
Perform an enhanced assessment  of post-hospital needs
Provide effective teaching and facilitate enhanced learning
Ensure post-hospital care follow-up
Provide real-time handover communications
Office Practices
Provide timely access to care following a hospitalization
Prior to the visit: prepare patient and clinical team
During the visit: assess patient and initiate new care plan or revise existing plan
At the conclusion of the visit: communicate and coordinate ongoing care plan
Home Care
Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan
Assess the patient, initiate plan of care, and reinforce patient self-management at first post-discharge home care visit
Engage, coordinate, and communicate with the entire clinical team
Skilled Nursing Facilities
Ensure that SNF staff are ready and capable to care for the resident patient’s needs
Reconcile the Treatment Plan and Medication List
Engage the resident and their family or caregiver in a partnership to create an overall place of care
Obtain a timely consultation when the resident’s condition changes

3. Transition from Hospital to Home
Enhanced Assessment
Teaching and Learning
Real-time Handover Communications
Follow-up Care Arranged
Post-Acute Care Activated
MD Follow-up Visit
Home Health Care (as needed)
Social Services (as needed)
Skilled Nursing Facility Services
Hospice/Palliative Care
Supplemental Care for High-Risk Patients *
Transitional Care Models
Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)
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 Engagement Tips 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. Model for Improvement Setting Aims Establishing Measures
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?
Setting Aims
Establishing Measures
Selecting Changes
Study Do
Plan
Act
The Model for Improvement is the most basic tool we can use to first understand the problem we are facing and then to begin testing changes.
The model begins with three fundamental questions:
-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?
The model combines those questions with an action-based, iterative learning process known as PDSA – applied in small tests of change in rapid cycles. [we will talk more about PDSA in a later session; this session is about the 3 iterative questions]
*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 Providing Real-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?