1. Value-based Purchasing Update and Best Practice Process
April 25, 2019
August 27, 2019

2. Genesis HealthCare
The Direction of Healthcare & Value-based Purchasing
Hospitalization Avoidance
Evidence-based Medicine
Hardwiring Effective Clinical Systems
August 27, 2019

3. Direction of Healthcare

4. The Direction of Healthcare
Value-based Care Delivery
Alternative Payment Models
MSSP
CJR
BPCI Advanced
Payment Reform
Patient-Driven Payment Model
Value-based Purchasing
SNFRM
Home Health
August 27, 2019

5. Payment Quality expectations
Outcomes Reducing hospitalizations & adverse events

6. Hospitalization Avoidance

7. Integrated Practice Drives Better Outcomes
Interprofessional Practice Standards
Integrated Practice Drives Better Outcomes
Established and functioning IDT
Risk for Readmission Assessment
Post Admission Patient/Family Conference (72 hour meeting, Wellness meeting etc.) the IDT will:
Review the risk areas with the patient/family to determine accuracy and identify additional risk areas.
Ensure that the Risk for Readmission Care Plan has been completed for patients with a score of 10 or >.
Engage the patient in discussion related to:
Potential discharge date and plan
Patent expectations and goals of care
Documentation of the Patient/Family conference serves as the baseline care plan review and care plan meeting note.

8. THINKING RIGHT|ACTING RIGHT ABOUT PATIENT CARE
A consistently used, guided clinical reasoning and problem-solving model that generates a sustainable process for collaborating on clinical care (teaching others, holding staff accountable to the process, new hire mentoring to the process, expansion of the process to other operational endeavors) and that can be implemented easily within existing center processes:
Conduct meaningful Clinical Case Review meetings that result in pertinent, efficient, effective, reasonable, and actionable recommendations that are implemented and evaluated in a timely manner
Incorporate correct clinical reasoning and problem-solving (Thinking Right) in every situation and interaction related to patient care

9. An Approach to Collaborative Clinical Reasoning
Idaho Centers started implementing the clinical reasoning and problem solving methodology in April This chart shows 3 years, from April 2013 through May 2016, of 30-day reshospitalizaton data for all Idaho Centers. Note improved, sustained performance.
An Approach to Collaborative Clinical Reasoning
Findings from a Demonstration of “Thinking Right”
All GHC Centers in one state began implementation of the clinical reasoning and problem solving methodology in April This chart shows 3 years, from April 2013 through May 2016, of 30-day aggregated reshospitalizaton data.

10. “Change at the Scale of the Whole”
Changing the messaging
Care transitions from hospital to Center; Center to Community
Clinical Capabilities
Clinical Reasoning
Communication

11. Evidence-based Medicine

12. Example: Evidence-based Clinical Specialty Programs

13. Standardizing Care Delivery
Example: HF Pathway

14. Hardwiring Effective Clinical Systems

15. Hardwire Effective Clinical Systems/Strategies
August 27, 2019

16. Manor Care Managing Re hospitalization inside the SNF
Transition Planning
Managing Community Transition with Down Stream Providers

17. Process From Admission to Discharge
Tracking and Trending of Re Hospitalization Data: Focus is on Monthly, Quarterly, and Annual Trends, Admission Diagnosis, Reason for Discharge by System, Decision Maker, Time from Admit to Discharge and Shift, also can trend process steps to identifying opportunity.
Upon admission, protocol and care paths initiated by diagnosis ( sepsis , CHF, Stroke, COPD (non bundle) )
Nurse to Nurse transition report with the hospital
Point Click Care: POC alerts for change in condition with emphasis on nursing and rehab
Utilize the interact flow chart/ flow 02 tool with all change in condition. Completion of SBAR tool before calling physician.
In PCC all POC alerts reviewed two times a day, in the morning meeting and at wrap up ( STOP & WATCH, early warning signs )

18. Process From Admission to Discharge
7. Focused daily rounds held at lunch and or after rehab. Focus is on new admits,
targeted diagnosis and anyone with a change
Vital signs daily and monitor for change in baseline
Utilize respiratory therapy for any patient with a respiratory diagnosis to evaluate and develop plan of care
Emergency Department called prior to all patients being sent to the ED. Utilization of either hospital or interact tool for clinical capabilities.
Weekly call to review all re hospitalizations, to review process steps, what could we have done differently and facility follow up plan ( interact quality improvement tool )

19. Target Diagnosis Stroke F A S T assessment
Assess stroke deficits upon admission / continue assessment for acute neurological changes
Asses Vital Signs and Pulse Oximetry
Assess for dehydration
Check Blood Glucose
Assess Mobility / Pulmonary Status
Implement blood thinners, statins
Rehab (assess eating, swallowing, communication, muscle tone and provide daily rehab)
Nursing ( assess bowel and bladder, fall risk, psychosocial impact)

20. Target Diagnosis Sepsis / Infection CHF
Implementation of Antibiotic Stewardship Program
Patients admitted with history of infection / sepsis are recommended for ADM consult
Patient who exhibit any 2 symptoms (3 100’s - temp >100, BP <100, heart rate >100) temp 99, chills, altered mental status, decrease in appetite, hypotension, decreased urine output or concentrated dark urine, cool extremities or mottling of skin ) should signal a change in condition with potential infection
Review advance directives with change in condition, ADM can assist
Facilities Capabilities completed and reviewed with medical director to determine facilities ability to treat sepsis in the center.
CHF
Medication Management ( IV Lasix )
Daily weights
Diet education
Functional performance in rehab, areas to monitor

21. Target Diagnosis COPD Gold Criteria for COPD
Assessment completed by respiratory therapy
Respiratory protocol and equipment utilized based on their rank from mild to severe, based on their performance in rehab.
Assess breathing daily in the AM prior to rehab

22. Palliative Care (ADM) / Hospice
Discussion of POLST form on all admission and is part of the assessment process
Initiated consult with chronic disease
Cancer
Heart Disease
Pulmonary Disease
Kidney Disease
Alzheimer’s Disease
Parkinson’s Disease
Combination of diseases resulting in a disabling or debilitating status

23. Palliative Care (ADM) / Hospice
Advanced Disease Management ( ADM ) Screening Tool used to discuss either palliative care or hospice
Team members involved in palliative process
Patient
Family
Collaborative Physician
Nurse Practitioner
Helps avoid re hospitalization when someone advances to the chronic disease management
ADM / NP evaluate pts for advance care planning.

24. Transition Planning Transition Program Transition Assessment
Pre admission
hrs
Week 1 to discharge week
Discharge week
Week after discharge
Transition Assessment
Plan A and B
Evaluate community environment
Chronic Disease – assess for training needs and home support
Evaluate ADL function to home ( develop plan for transition )

25. Transition Planning 3. . 24 to 48 hours
Utilization of DVACO Preferred Home Health Providers whenever possible
Identify home care prior to discharge
Transition Assessment and facility diagnosis protocols
Week 1 to Discharge - education to patient and family
Focus on medication management
Utilize zone programs for chronic disease education program ( education to patient / family / staff )
CHF/ COPD / Sepsis / Stroke zone programs ( poster Identifying how a patient feels and helps to educate the family and patient to help improve change in condition communication, so that we have consistent care for the patient) Track every patient on the program using a tracker. We participate in this program with MLH

26. Transition –Planning 5. Discharge Week 6. After Discharge
Risk Assessment – nurse to nurse report hand off
Involve the assigned Ambulatory care coordinator from DVACO / Abington Jefferson Hospital with discharge process
My transition home packet sent to PCP and home care
After Discharge
Home Care and facility communication calls through out their stay with home care
Follow up calls 48hrs post transition home / PCP appointment made prior to discharge

27. Managing the Community Transition with down stream providers
Home Health Community Transition - Transition Planning Worksheet is completed on all new admissions - Home Health is notified of referral - Home Health attends weekly Medicare skilled meeting - Weekly rounds are completed of patients referred with facility and home health liaisons - Hand off to home care before transition to community and a risk assessment is completed. High risks are communicated to nursing at home health following the guidelines for nurse to nurse report

28. Managing the Community Transition with down stream providers
- Facility does follow up at 48-72hrs after community transfer and around PCP appointment - Weekly call is established reviewing 100% of all patients referred following tracking form - Patients at risk for hospitalization are evaluated to return to the skilled facility - All patients admitted to the hospital are reviewed and tracked - All patients receive a follow up call from the home health, 48 hrs after service ends for health check

29. Managing the Community Transition with down stream providers
Non skilled home care
- Liaison meets with patient and family
- Interact with home health
- Work in conjunction with home health
- Follow up 60 to 90 days post home health
- Provide non skilled home services

30. Open Discussion
August 27, 2019