may 10, 2012 1 person-centered hospital discharge planning workgroup

May 10, 2012

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Person-Centered Hospital Discharge Planning Workgroup

Agenda

Welcome and Introductions

Short review of workgroup goals

Review evaluation of ADRC Care Transitions Project

Discuss ADRC Care Transitions pilot site lessons learned

Understand opportunities for collaboration with other NH care transitions projects

Brainstorm options for the ongoing role of ServiceLink’s in discharge planning throughout the state

Finalize “recommendations” document outline2

Person Centered Hospital Discharge Planning Model

2010: Establish workgroup, evaluate models, develop model for NH, develop tools and resources

2011: Develop implementation plan for two pilots, develop evaluation, training in model and tools. Implementation in two pilot areas late in year 2

2012: Engage hospitals in statewide roll out, evaluate and modify, develop sustainability plan, roll out statewide late in year 33

Timeline established in grant application

The focus of a person-centered system is on the individual, their strengths, and their network of family and community support in developing a flexible and cost effective plan to allow the individual maximum choice and control over the supports they need to live in the community.

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Person-Centered System

Source: Sue Fox “Person-Centered Services Hosp Disch Webinar_suefox

A person-centered system respects and responds to individual needs, goals and values. Within a person-centered system, individuals and providers work in full partnership to guarantee that each person’s values, experiences, and knowledge drive the creation of an individualized plan as well as the delivery of services.

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Person-Centered System


A clear structure for shifting the focus of planning and problem solving from program menus and human service solutions to the broader perspective of individual’s and family’s lives and informal and community resources.

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Process Design in PCP


Person-Centered Hospital Discharge Planning Project: Vision and Mission

Vision: A coordinated, person-centered long term care system that supports individuals as they transition back into the community.

Project Mission: Partner hospitals & community providers will identify persons 65+ who are at-risk of institutionalization or re-hospitalization and utilize person-centered transition planning to help maintain their ability to live & age in the community.

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GOAL 1: Persons who may trigger for use of the Emergency Department or re-admission to the hospital will be identified and appropriate interventions developed and implemented.

Activities: Select person-centered criteria for identifying the target population. Define and document the current and potential role(s) for an SLRC

in hospital care coordination activities.-Done Offer technical assistance for county-wide inventory of medical and

community care coordination & care transition activities.-Ongoing Develop person-centered discharge planning tool for the individual

and caregiver(s) to use when communicating with primary care and other community care providers.- Done

Use follow-up phone call after discharge to check on how person is doing, and refer if further support needed.-Done (part of each pilot)

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GOAL 2: A person-centered planning approach is incorporated into the hospitals' discharge planning (transition) processes and communicated with care providers, including SLRC's, caregivers, community providers and nursing facilities.

Activities: Not Done Develop a “readiness tool” to assess current

person-centered planning practices within an organization to use as a baseline before participating in the training.

Develop a person-centered planning training customized for discharge planners/transitions coaches and offer to all community partners.

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GOAL 3: Perform ongoing project evaluation, which will include (as a minimum)

Activities: Assessment of project accomplishments, gathering

input from communities and integrating as appropriate. On-going

Assessment of barriers to implementing person-centered planning from hospitals to community care. On-going

Data collection of Nursing Facility v. Home & Community-Based Care of participants. Not started

Define data elements needed for evaluation- Done10

GOAL 4: Develop a plan for state-wide roll out.

Activities: Offer technical assistance for county-wide inventory

of medical and community care coordination and care transition activities. On-going

Develop an ongoing mechanism for medical and community organizations to share transition models in order to facilitate coordination and learning of best practices. In process

Design a roll out plan. In process.

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Design a roll out plan= “Recommendations Document”

“Recommendations Document” will help guide BEAS and the SLRC Network as they formalize their hospital care transitions work and will serve as sustainability/funding tool.

What have we learned about SLRC’s and acute hospital stays?

What have we learned from other care transitions/coordination projects?

What are the key components of the document? 12

Evaluation

Evaluation metrics used for three purposes:

1. Reporting to AoA

2. Guide “recommendations” document for SLRC resource statewide

3. Used by local SLRC’s for sustainability conversations

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SLRC Care Transitions PilotRefer7 Preliminary Data- Year 1

March 1, 2011 - February 29, 2012

BelknapCarroll Monadnock Total

Unduplicated pilot participants166*

32 38 236Referrals to SLRC

15029 25 204

Referrals outside SLRC51

2 32 85

Hospital

# visits pilot only44

3 16 63 # people pilot only

433 16 62

# visits total166

41 62 269 # people total

75**30 58 163

Consults84

49 135 268

Follow-ups

home0

2 0 2

hospital3

5 3 11

call1

10 0 11

14 *Does not include 18 whose names were not recorded, one pharmacy dept., and one duplicate. **Does not include 32 whose names were not recorded, 4 case mgt dept., 2 nursing staff, 2 social work dept.

Outcome 2: Participants feeling prepared for discharge (CTM 3 questions by phone in Monadnock & Carroll, by written survey in Belknap)

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Evaluation Template Monadnock Carroll Belknap

Number of consumer surveys sent/received ( as of Jan 5, 2012)

n/a* n/a* 141/12

% of responses on satisfaction survey feeling prepared for discharge

n=11 n=4 n=12

CTM question 1: staff took my preferences into account

(% strongly agree and agree)82% 100% 74%

CTM question 2: Left hospital with good understanding (% strongly agree/agree)

91% 75% 74%

CTM quesiton3: Left hospital understood purpose of taking meds (% strongly

agree/agree)81% 75% 69%

*phone survey for these questions

Outcome 3: Medical and Social Providers report good communication and coordination of medical and social services

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Hospital provider survey:• Belknap- completed (see next slide)• Monadnock- in the field• Carroll- waiting till Aug/Sept

Care Transitions Survey - Lakes Region General Healthcare

What is your role?

Answer OptionsRespons

e Percent

Response Count

Hospital Administrator 20.0% 4Social Worker 15.0% 3Nurse 5.0% 1Nurse Care manager 30.0% 6Physician 10.0% 2Other 20.0% 4

answered question 20

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Are you familiar with the Care Transition Specialist from the ServiceLink Resource Center, Nancy Bacon, who works part time within your hospital?

Answer OptionsResponse Percent

Response Count

yes 100.0% 20no 0.0% 0

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Please choose the most appropriate response.

Answer Options Never RarelySometim

esOften Always

Response

CountHow frequently do you interact with the Care Transition Specialist?

0 4 6 10 0 20

I trust the Care Transition Specialist to make appropriate referrals with community based services for patients.


Response Count

yes 94.7% 18

no 5.3% 1

answered question 19skipped question 1


Please indicate if you Disagree or Agree with the following statement:

Answer Options DisagreeSomewh

at disagree

Somewhat agree

AgreeNot

Applicable

% respondents who agree or

somewhat agree

The on-site Care Transition Specialist has made a difference in the level of care received by patients.

0 2 2 15 0 89%

The Care Transition Specialist communicates with me or my organization, appropriately.

0 1 2 15 0 94%

The Care Transition Specialist calls me or my organization when appropriate.

0 2 4 11 2 80%

The Care Transition Specialist is an integral part of the discharge planning process at our hospital.

0 2 5 12 0 89%

The Care Transition Specialist is an integral part of coordinating social services for patients as they transition back to the community settings.

0 2 3 14 0 89%


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If there were a full-time Care Transition Specialist available, care transitions would be improved at my facility.


Response Count

yes 94.7% 18no 5.3% 1


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Please answer Disagree or Agree to the following statement:

Answer OptionsDisagre

e

Somewhat

disagree

Somewhat agree

AgreeNot

Applicable

% respond

ents who

agree or somewhat agree

Overall, as a result of the ServiceLink Resource Center Care Transition Specialist on site at the hospital, I feel there is improved communication between ServiceLink staff and hospital staff.

0 1 3 14 1 89%

Overall, the ServiceLink Resource Center Care Transition Specialist on site at the hospital improved the level of care received by patients.

0 1 5 13 0 95%



Outcome 4: The referral process to link patients to community resources is improved

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Metrics:1. referrals to community resources (recall

from slide 14 we are still working on cleaning data)

2. Consumer Survey Questions- have results from Belknap for year 1 (see next slide)

Outcome 5: participants report confidence in their ability to navigate the medical and social systems.

Metric:1. Survey questions- results from Belknap for year 1 (see next slide)

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Belknap SLRC n=12

Strongly Disagree

Disagree

Agree

Strongly Agree

DK / NA% of Respondents

who Agree and strongly agree

I know how to find the help I need. 3 0 9 0 0 75%

I know what services and supports are available in my community.

3 0 7 2 0 75%

I have the tools and skills I need to manage my care at home.

3 0 5 3 1 67%

I am well informed and capable of making choices about my care.

3 0 6 3 0 75%

I can find the correct service provider(s) for my needs.

2 0 6 2 2 67%

I am able to clearly describe my needs to service providers.

2 0 3 3 0 50%

I am able to follow through with recommendations about my care.

2 0 7 3 0 83%

I am able to get answers and solutions even if a service provider

staff is not helpful.3 0 4 3 2 58%

Consumer Satisfaction Survey- Care Transitions- Belknap SLRC

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Very

ConfidentSomewhat Confident

Not Very Confident

Not Confident At

All

Don’t Know / Not Applicable

% of respondents who are very or

somewhat confident

Overall, how confident do you feel that you have the skills and resources to

manage your recovery at home?8 2 0 2 0 83%

Consumer Satisfaction Survey- Care Transitions- Belknap SLRC

Belknap SLRCLessons learned, challenges, surprises

Lesson Learned: We needed a better understanding of the Human Resource practices at the hospital. As a result, this delayed 'start up' date.

Lesson Learned: Our success came when we utilized existing SL staff. The Counselor is a natural fit for this type of work.

Surprise: We didn't need to 'sell' the importance of this pilot to the hospital staff. We had almost immediate buy-in.

Surprise: Unintended benefit to our other core services, i.e. value added, increased referrals for Caregiver Support and Medicare Counseling.

Challenge: We continue to struggle with discharge to facilities outside of our catchment area.

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Carroll SLRCLessons learned, challenges, surprises

Not every person is going to be receptive to having a non-medical /non-hospital staff person visit them.

Need to look more broadly at the CTI Coleman model criteria for health conditions and age and not restrict our program from the beginning.

We learned not to rule out participation by the Skilled Nursing facility (SNF) in the project, but to have conversations with the SNF for relationship building and to develop the project to its fullest, especially for the rural areas.

We learned that we should have developed and used the client tracking sheet from the beginning of the project.

We learned that it was easy early on to have community meetings with hospital, VNS, nursing facility and SNF in order to educate about the project. One challenge we have had is keeping those participants interested in the project and adding additional community members.25

Monadnock SLRCLessons learned, challenges, surprises

Utilization of E-discharge made it easy to receive discharge information and connect with the hospital.

The Medical Home clinic care coordinators don’t use e-discharge and effective communication was not established with them during the first year.

Data collection was and continues to be (although much less so) confusing.

Care Transitions Specialist models are very helpful for training and shifting traditional ways of thinking about providing services but can limit opportunities.

There needs to be a constant focus on the original goals

In an ideal scenario we would work with project partners locally and potentially elsewhere to establish buy-in for the model, tools for documenting and evaluating early in the process.

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Things every SLRC should know/consider when working with acute care hospital discharges (1 of 3)

Know the HR practices at the hospital.

Consider forming an advisory team specific to Care Transitions; include hospital, VNA and NF staff.

Reach out to community providers to explain pilot goals in order to reduce feelings of threat and 'duplication' accusations.

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Things every SLRC should know/consider when working with acute care hospital discharges(2 of 3)

Create relationships across the hospital early on and work to maintain communications:

– Not only with the head of the social services department, but with the social workers themselves.

– Meet with the hospitalist, covering physicians and nursing staff of the hospital.

– Meet with or include the hospital CEO in the process.– Meet regularly with the social services department to

reiterate the program, re-evaluate the CTI criteria & review the referral process.

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Things every SLRC should know/consider when working with acute care hospital discharges(3 of 3)

For the first year, a lot of work is needed at the management level to establish a successful project (ServiceLink Director level).

It is important to work with the hospital’s HR department very early in the process to obtain ‘privileges’ for SLRC staff.

It is important to have a good, simple PR document that your SLRC staff and your Care Transitions staff can distribute and refer to when appropriate so that other providers in the community are all getting the same message about the role ServiceLink is “suddenly” playing in a new arena-- what many have considered to be VNA/Nursing Home territory.

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Barriers within the current SLRC Network model that need to be addressed for formal care transitions models or formal partnerships to be implemented/expanded (1 of 3)

Sustainable Funding- included (and viewed) as a core service of delivery.

Catchment (territorial) limitations.

Educate SLRC regarding medical systems. Shared respect for and understanding of work.

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Time to attend meetings and processes need to be developed for good communication among Care Transition Specialists.

Another barrier may be the larger catchment areas of the SLRC network- travel time/cost, more then one hospital with different models, FTE needs.

The resources (like meeting time) it takes to start a pilot is significant and not currently reimbursed.

Good database skills for Refer7, so data is captured correctly from the start of the project.

Funding for on-going training of the Care Transition Specialist.

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SLRC Network needs to continue on current path toward becoming an independent group with the capacity to represent itself, make decisions as group, speak with one voice.

Need agreement for a common approach to collecting data and pulling report information.

Network should identify care transitions as initiative it would like to pursue and then identify what care transitions would typically look like for the Network so that we can promote as a group.

Network should meet with the hospital association and others to discuss potential roles.

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Person-Centered (P-C) Hospital Discharge Planning:Flowchart of possible project options-DRAFT

Non-CFI waiver

Has multiple needs

No case manager

“Trigger” Tool utilized in hosp

Hosp discharge utilizes

modified P-C tools

Direct referral to SLRCOptions Counseling: utilizes P-C tools & visits in hospital

before discharge

P-C transition packet given


SLRC VNA, Home Care

Other supports

Referral to “Choices For Independence” case

manager

Non-Medicaid Has supportsNot “high need”

NF, AL, Rehab

Discharged to the community with P-C info shared with community providers for continued planning and follow-up

ED or Hosp Admit triggers …..Follow-up calls made every…..

Primary Care

Medical Home

Case Management

Has MedicaidOn CFI waiver

Has case manager


KEY to Abbreviations:

P-C means “person-centered” CFI stands for “Choices for Independence,” a

NH Medicaid waiver program SLRC is “ServiceLink Resource Center” NF is “nursing facility” AL is “assisted living” ED is “emergency department”

Some Possible Components of Specific “Boxes”:

“Trigger Tool” is a type of screening form that will be used to identify the target population

“Transition Packet” contains person-centered tools and resources, possibly including: Personal Resource Guide, Meds “Day Planner,” few weeks of planning calendars, other P-C tools

“Choices for Independence” (CFI) case manager is one example, there are other care coordinators that should also be includes as appropriate

A clear structure for shifting the focus of planning and problem solving from program menus and human service solutions to the broader perspective of individual’s and family’s lives and informal and community resources.

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Process Design in PCP


Outline for Recommendations Document

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Work group name

Remain statewide with representation from both medical and community system providers.

Goal - have a forum for programs occurring around Care Coordination and Care Transitions can share projects, learn from each other, collaborative when appropriate, etc. We spend a good hour of every meeting on project updates and people seem to get a lot out of this time.

Goal - enhance the level of involvement of community based organizations with CC and CT projects across the state. The forum would allow us to identify opportunities and strengthen the approach.

MA= Safe Passages Collaboration 38

Work group Name

Partnership to Promote Effective Care Transitions Community Care Transitions Partnership Partnership on Care Transitions and Coordination (PCTC) Partnership on Community Care Transitions Care Transitions/Coordination Partnership Partnership on Community Care Coordination Partnership to Improve Care Transitions Partnership to Improve Community Transitions Care Transitions Resource Group Care Transitions Collaborative NH’s Care Transitions Network Care Transitions Collaborative (the CTC) Transitional Care Collaborative (TCC) Pathways Collaborative Passageways Paths Navigating Transitions

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may 10, 2012 1 person-centered hospital discharge planning workgroup

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