2014 Care Coordination Session Details
Tuesday, May 6- Wednesday 7, 2014
DAY 1: CARE COORDINATION SUMMIT, TUESDAY, MAY 6, 2014
8:00 - 8:30 a.m.
Continental Breakfast and Registration
8:30 - 8:40 a.m.
Welcome and Introduction: Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN, Editor in Chief, Dorland Health and Conference Chair
8:40 -9:30 a.m.
Opening Keynote: Healthcare Transformation: Quality Is Key
Driven by the aims and priorities of the National Quality Strategy, CMS has developed its own quality strategy and is focused on better health, better care and lower costs through improvement. To achieve these goals, CMS is using multiple levers to drive change, including quality improvement programs, innovative care delivery models and quality measurement and value-based purchasing programs that emphasize system-based and team-based care. This session will show how, through partnerships with private and state payers, patients, providers and other stakeholders, CMS has been able to demonstrate early success on several of its critical goals and objectives.
Define the need for transforming the current healthcare systems.
Describe the role of the healthcare team in the transformation process.
Explain how the utilization of data will assist organizations in harnessing quality, capturing value and driving outcomes.
Presenter: Kate Goodrich, MD, Acting Director of the Quality Measurement and Health Assessment Group in the Center for Clinical Standards and Quality (CCSQ), Centers for Medicare and Medicaid Services
9:30 - 10:30 a.m.You Wanted Me to do What with Data? Using Bits and Bytes of Data to Harness Quality, Capture Value and Drive Outcomes
Bits and bytes of data, including claims from Medicare and commercial insurers, physician's electronic health records, hospital ADT feeds, and lab systems results, are interfaced into an electronic decision support tool which supports the delivery of quality, value and outcome-driven accountable care at Dartmouth-Hitchcock. This tool was developed by and for nurses and social workers with physician leadership and direction. This session will review the tool's use, provide a hands-on demonstration of the tool in order to illustrate how it is used in day-to-day practice, and provide data related to outcomes.
Articulate how care coordination staff within a physician group practice utilizes data to identify patients in need of enhanced care coordination.
Describe how evidence-based quality standards are translated into gaps in care and how the data is used to close gaps in care.
Demonstrate how to use data sets to harness quality, capture value and drive outcomes.
Presenter: Sheila Johnson, RN, MBA, Director of Clinical Services, Dartmouth-Hitchcock
11:00 - 11:45 a.m.The Illinois Health Experience: A Transformational Journey Toward Organization Excellence
As healthcare continues to grapple with unprecedented change – marked by escalating costs, declining reimbursement, and increasing demands for high quality care and service – the ability to adapt to the ever-changing landscape by altering cultural and operational processes is critical. This session will detail the UI Health System journey that entailed an enterprise-wide transformation to create an exceptional world-class experience for patients, families, employees, and providers coined the "UI Health Experience."
Understand the UI Health experience transformation strategy.
Learn key best practices and leading interventions employed through a real-life case study at the UI Health System.
Hear lessons learned and obstacles overcome while embracing change in a unionized and civil service healthcare environment.
Presenter: Dr. Airica Steed, Ed.D, MBA, RN, CSSMBB, Enterprise Chief Experience Officer, University of Illinois Health System, Chicago, Ill.
11:45 a.m. - 12:30 p.m.Coordinated, Cohesive Transitions of Care: Handing Off Care to an Activated Patient
Dr. Hall will give a brief overview of the clinical and research evidence base for bringing holistic health and wellness practices into behavioral health services. He will discuss how he integrates mindful breathing, movement, sensory awareness, musical tones and rhythms, guided imagery, and meditation with unconditionally compassionate counseling in helping complex care patients, with varied diagnoses, toward fulfillment of their treatment goals. He will explain the physiological and neurobiological premises of his body-inclusive approach. He will guide attendees in a few, brief, gentle, holistic mindfulness practices so they can experience the potential benefits in an embodied way. He will present clinical anecdotes that illustrate how clients have been helped. He will emphasize the importance of the care providers' mindful balance and presence as communicated through their own prosodic qualities of voice, facial expressiveness, relaxation of body, posture, rhythms, congruence of words and affect, attentiveness, responsiveness, and presence.
Attendees will learn about relevant research supporting the importance of holistic health and wellness practices in behavioral health, despite current lack of widespread clinical use.
Attendees will become familiar with a few mindful breathing and movement practices they can use to help complex care members regulate their physiological arousal and emotions.
Attendees will learn practices for their own self-regulation to help them prevent and, as needed, resolve vicarious trauma in addition to helping their clients.
Presenter: Mitch Hall, Ph.D is the Holistic Health and Wellness Coordinator for PsycHealth, Ltd
What happens when a woman's son is diagnosed with a chronic and debilitating disease like Crohn's and she has to put the brakes on her life to deal with this health crisis? When that mom is an electrical engineer, holds an MBA and is obsessed with processes, Questioning Protocol happens.
Questioning Protocol is a process to help parents and healthcare workers understandthe healthcare system from an executive business mindset and Six Sigma perspective. It is a solutions methodology, from a patient's perspective. The audience will ride a real-time emotional roller coaster to learn how the speaker used her engineering and business skills, alongside her compassion as a mom, to empower herself to change the direction of her son's care. In 2010, President Obama signed the Affordable Care Act into law and medical institutions are scrambling to change their current processes. Medical buzz words in the news today include patient engagement and shared decision-making to help improve results. Reforms take time. What is a patient to do, now? The speaker will share specific examples of how she:
2:00 - 3:00 p.m.Using Quality Measures to Ensure a Supercharged Discharge Plan
Discharge planning involves the development of individualized discharge plans for patients prior to leaving the hospital. Achieving a timely hospital discharge when a patient is clinically ready requires multidisciplinary input. However, there is room for improvement in this process. In this session, the faculty will describe the application of the LEAN performance improvement technique to discharge planning processes; present results regarding the success of a four-month intervention targeting the timeliness of hospital discharge; and discuss the implications of the findings for improving discharge planning processes.
Recognize the application of LEAN performance improvement techniques in hospital discharge planning.
Identify successful strategies for improving discharge timeliness in a medical/surgical unit.
Discuss implications of earlier care coordination for achieving hospital discharge planning goals.
Presenter: Mangla Gulati, MD, MBBS, Assistant Professor of Medicine, University of Maryland School of Medicine; Medical Director for Clinical Effectiveness, University of Maryland Medical Center Ada Ibe Offrum, MD, Assistant Professor of Medicine, University of Maryland School of Medicine: Director of Hospitalist Programs, University of Maryland Medical Center Ebere Onukwugha, MSc, PhD, Assistant Professor in the Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy
3:30 - 4:15 p.m.Healthcare Darwinism: Innovation to Match the Behavioral Health Evolution
Behavioral healthcare is evolving at an incredible pace, and the truth is that only those agencies ready to adapt will survive. The "who," "where," "why," and "what" of behavioral health has changed, and so must the way in which behavioral health service are delivered. This presentation outlines the ways behavioral healthcare is evolving, describes initiatives which address the changes, and offers data that demonstrates how these changes meet a quadruple aim of better health outcomes, client experience, staff experience, and financial viability.
Gain a better understanding of the core ways behavioral healthcare is evolving.
See examples of innovations which enable success in the changing field.
Learn how rapid cycle quality improvement and the quadruple aim can be used to enact similar initiatives in program.
Presenter: Tyler V.R. Booth, LCSW, Chief Operating Officer and Clinical Director, InterCommunity, Inc.
4:15 - 5:00 p.m.The HCAHPS Prescriptioin: Engaging Doctors for Best In Class Patient Experience
Holy Family Memorial (HFM) recognized successful execution of its strategic plan, "Redesigning Care around an Exceptional Experience by Way of an Ideal Culture," required deeper physician integration and leadership, in addition to alignment of strategy, structure and culture. Like many healthcare organizations working on patient satisfaction, the organization applied "the HCAHPS prescription," including hourly rounding, discharge phone calls, white boards, AIDET, etc. Scores increased to "so-so." This session will show how by using a new approach to shift the focus from tasks to connections. The new approach was characterized by drive, optimism, creativity, energy and boldness. There was even a rock concert complete with a flash mob. This time, satisfaction scores climbed, patient and family stories changed, and internal pride and commitment became so strong that consultants, vendors and The Joint Commission couldn't help but notice and comment.
Leverage the impact of culture on strategy to forge meaningful organizational change and results required of a value-based, outcome driven, accountable care environment.
Lead the culture integration process across your multi-specialty physician group and entire organization through relationship building, communication enhancement and physician leadership.
Boldly take your approach to the patient and family experience back to the basics and beyond the mechanics.
Presenters: Sara Hockers, Administrative Director, Physician Services & Chair, Exceptional Experience Laura Fielding, Administrative Director, Organizational Development & Chair, Ideal Culture
8:40 - 9:30 a.m.
Opening Keynote: Diagnosis: Déjà Vu
Wherever you look, healthcare is in the spotlight. It is the topic of political debates, special reports, nightly news, magazine articles and water cooler talk. It is hotly contested in both the public and private sectors, and at the center of the debate is rising cost. This was the scene in 1959 when the average American spent a whopping $59 a year on medical care. Fast forward 54 years and health spending per capita in the U.S. has exceeded $7,500. The Patient Protection and Affordable Care Act contains provisions aimed at decreasing costs including the formation of accountable care organizations. The purpose of accountable care is to drive down the bottom line by addressing high-cost areas of healthcare. This begs the questions: Why does healthcare cost so much and will plans to drive down costs work? A comparison of current news and trends to a snapshot of healthcare in 1959 highlights some encouraging differences and sobering similarities. By providing an understanding of the current accountable care landscape in conjunction with political and clinical perspectives, this analysis offers a unique view of healthcare and how it is changing.
Look at a comparison of current news and trends to a snapshot of healthcare in the past to determine the path forward.
Describe the purpose of an accountable care healthcare system.
Examine the current strategies taking place to change the course of care for the next generation.
Presenter: John Nelson, MD, MPH, Senior Advisor and Member of Future Panel, Leavitt Partners; Past President of the American Medical Association
9:30 - 10:15 a.m.Payer Provider Collaboration: Are We Ready for Clinical and Financial Decision Making at the Point of Care?
Payers and providers are being pushed to collaborate more than ever before. Payment reform and care delivery reform require them to work together to efficiently ensure that the right care is delivered at the right cost. But what do "payer-provider collaboration" and "work together" really mean? And what do we need to do to make it a reality? This session will highlight the role of actionable content as a foundational starting point for payer-provider collaboration.
Explore how technology can streamline clinical and financial decisions between payers and providers, ultimately putting those decisions at the paint of care to enable an informed interaction with the patient.
Explain how these technologies give providers the ability to answer questions about whether the care is appropriate, whether it is covered, how much it will cost and even where it should be provided.
Describe how the traditional utilization management process between a payer and provider will serve as a tangible study for this transformation.
Presenter: Holly Toomey, Director of Product Management for Decision Management, McKesson Health Solutions
10:45 - 11:45 a.m.Community-Based Care Coordination Delivers Integrated Care with Substantial Reductions in Hospital Utilization and Cost Savings
Keystone First (KF), a Medicaid managed care plan, has implemented a community-based care management program to deliver integrated care to members where they live via community-based healthcare teams. Targeted members include those with unmet medical/behavioral/social needs, many of whom are not effectively receiving care through their primary care provider (PCP) and have high hospital utilization rates. Member care coordination is performed by community-based healthcare teams; the mobile, bilingual team consists of a registered nurse, community health worker, social worker, pharmacist, and a supervising physician. Consultants in behavioral health, endocrinology, and medication management are engaged as needed. Team workers collaborate with the member, KF's care management teams, the member's PCP and the extended medical and social neighborhood.
Team workers build a trusting relationship with members, assessing care gaps and barriers, preparing a care plan, and assisting to connect the member with community services. They also support the member through chronic disease management, medication adherence monitoring, transitions of care, and improved health care access by assistance with healthcare and social services system navigation. Preliminary results from the Philadelphia-based 2012 pilot have demonstrated favorable reductions in hospital admissions and cost. Program expansion to additional communities is underway.
Present implementation process and outcomes of a health plan-sponsored, community-based care coordination model.
Demonstrate how a community healthcare team program provides value to key stakeholders: individuals, community, health plans and medical and social providers.
Discuss how a community-based program aligns with the triple aim of achieving better care and improved health at lower costs.
Presenters: Glen Hamilton, MD, Medical Director, Keystone First Barbara Schneider, MD, CDE Medical Director of Care Coordination Services and Disease Management Grace Lefever, PT, MS, MPH PT, MS, MPH, Director of Strategic Medical Management Initiatives, Amerihealth Caritas
11: 45 - 12:30 p.m. Capturing the Benefits of a Quality Program in the Bundled Payment Environment
The Center for Medicare and Medicaid Innovation recently launched the Bundled Payments for Care Improvement initiativeto unite hospitals and physicians in a common goal of coordinating care to achieve better outcomes and lower costs.Through the initiative, the Centers for Medicare & Medicaid Services would link payments for multiple services patients receive during an episode of care under a single fee or agreed upon payment. To achieve success in a value-based healthcare environment, providers will need to effectively redesign the way they deliver care. In this session, we will discuss the key quality initiatives tomaximize the coordination, patient-centeredness, efficiency, and high quality health care needed to demonstrate accountability for an episode of care.
Review the changing landscape of quality.
Discuss how bundled payments will affect data analytics.
Outline the future implications for quality and bundled payment.
2:00 - 3:00 p.m.Coordinating Care Across a Safety Net Health System
Cambridge Health Alliance (CHA) in Massachusetts is a unique safety net health system serving 100,000 people in multi-ethnic communities north of Boston. Volume: 100,000 visits to 3 EDs; 13,000 discharges from 2 acute care hospitals (half of which are children and adults admitted for psychiatric crises); 700,000 visits to primary care medical homes. 85% of CHA's patient population is reimbursed by Medicaid or Medicare, with at least nine risk contracts requiring care coordination by nurses and social workers. These challenges require a constantly-evolving and responsive infrastructure between inpatient and outpatient professionals and community agencies. In this session you will learn the importance of collaboration between inpatient case management teams and the care managers in the community to ensure safe, effective transitions of care for complex medical patients in order to minimize costly complications and readmissions.
Trace the evolution of organizational structure, roles, tools, and processes within a safety-net health system. referral tools and strategies for identifying high risk patients
Describe direct benefits to patients that are derived from team-based complex care management.
Review clinical and financial outcomes of care integration
Presenters: Eleni A. Carr, MBA, LICSW, Senior Director of Care Integration, Cambridge Alliance Karen Zander, RN, MS, CMAC, FAAN, Principal and Co-owner of the Center for Case Management
3:00 - 3:45 p.m.Using Clinician-Group Consumer Assessment of Healthcare Providers and Systems (CG CAHPS) to Optimize Your Patient Engagement Strategy
CAHPS surveys provide the needed, and often missing, patient engagement tool in clinical integration strategies. Coordination of care, information sharing, and improved quality – key components of clinical integration – must include engaging the patient. Value-based payment and new models of care require providers to involve the patient in their care. Lehigh Valley Physician Hospital Organization, a provider owned PPO, successfully implemented CG CAHPS in employed and private physician practices. This presentation will describe the challenges and successes of implementation and demonstrate how the results provided actionable feedback to improve clinical integration at both the physician and system level.
Apply the concepts of patient engagement to value-based models of reimbursement.
Describe interventions developed from Clinical Group Consumer Assessment Healthcare Providers and Systems (CG CAHPS) results that will increase patient engagement in their self-care.
Evaluate results of patient feedback in care systems.
4:00 - 4:45 p.m.Why More Patients Are Choosing Health Advocates for Quality Healthcare
The field of health advocacy is exploding due to a confluence of factors changing in healthcare and in our country that include an increased awareness and information regarding quality, access, pricing transparency, more people having to pay for their own healthcare and a movement to engage people in their own healthcare decision making process. In this session, we will explore the emerging field of health advocates both within the health care system and the rise of independent health advocates. We will look at who is doing the work, understand the typical services that health advocates provide and why more patients are hiring advocates and/or utilizing their services and und. Case studies will be presented to illustrate how health advocates can help patients achieve better health outcomes and impact cost savings.
Identify why patients are using health advocates outside the health care system.
Understand the trends and new job roles of health advocates.
Learn the difference that health advocates play both within and outside hospitals and health systems.