Coordination of Care Modules 1-4

What populations does Medicaid provide coverage for?

Low income individuals, pregnant women, children under 19, people 65+, blind, disabled or need nursing home care

What is the Children's Health Insurance Program (CHIP)?

Part of Medicaid specifically designed for low income children

T or F. Low income, elderly patients qualify for Medicare and Medicaid.

TRUE. Will cover premiums, deductibles, copays and medications not covered by part D

What population does Medicare provide coverage for?

those age 65 or older, any age with kidney failure or long-term kidney disease and currently disabled and cannot work

What does Part A of Medicare cover?

hospital admissions

T or F. The premium for medicare part A is deducted from social security checks.

FALSE. Part B deducted from social security checks, part A is free if qualified

What does Part B of Medicare cover?

doctor visits

Medicare Part C is also known as ___.

Medicare Advantage Plan

What is Medicare Part C?

private insurance in addition to medicare, additional premium required, more restrictions on providers and services (covers vision, dental, hearing etc)

What does Medicare Part D cover?

medication expenses

T or F. Medicare part D does not require an additional premium.

FALSE

How does the medicare part D coverage cycle work?

Starting January first patient is responsible for all costs until deductible is met

When deductible met, bulk of cost is covered minus a small copay and small percentage

Once cap on coverage is exceeded patient is responsible for all costs

Coverage resumes if costs become exceedingly high (usually because catastrophe)

Cycle restarts every January 1st

People on medicare usually meet their deductible around ____ and reach their gap on coverage around ___ or ____.

March

November or December

Medigap is aka ____ ___ ____.

Medicare supplemental insurance

What is medigap?

covers expenses not included in other parts of medicare (co-pays and out-of-pocket expenses)

deferes cost for services (private insurance)

Private insurance can be ___ sponsored or ____ pay.

employer, self

T or F. Self pay private insurance can be very expensive.

TRUE

What is the ultimate goal of effective care coordination and transitions of care?

improved patient outcomes

If the patient is readmitted within __ days with the same diagnosis, the second hospital stay may not be ____.

30, reimbursed

T or F. Medicare and medicaid can impose fines on hospitals based on readmissions.

TRUE

What are some diseases with highly preventable readmission rates?

MI, CHF, pneumonia

What does the Hospital Readmission Reduction Program (HRRP) do?

sets goals for healthcare institutes to lower 30 day readmission for MI, CHF and pneumonia or they face penalties

gives them programs and strategies

What are some ways to prevent readmission for a patient with CHF?

lifestyle education

follow up on medication adherence

What are some ways to prevent readmission in a patient with unaffordable medication?

unaffordable=untakble

verify cost and coverage upfront or follow up

In fee-for-service based care more ___ --> more ____ --> more ____.

more services, more patients, more money

How do facilities compete with fee-for-service based care?

on sheer volume of patients seen and treated

What is the problem with fee-for-service based care?

no incentive to limit cost or keep people healthy

more hospitalizations and procedures (leads to more revenue)

How do we see healthcare providers and facilities compete for patient services now?

value based care

What is value based care?

everyone invested in promoting positive patient outcomes

What is emphasized in value based care?

health outcomes of each individual treated

T or F. With the value based care system, facilities compete to provide better care at a lower cost.

TRUE

What are initiatives used to promote value based care?

tying reimbursement and/or financial penalties to a facility's 30 day reimbursement rate

T or F. In value based care, it is the best financial interest of the provider and facility to promote events that result in increased procedures or hospitalization.

FALSE.

Value based care = prevent increased procedures and hospitalization

Fee-for-service care = promote increased procedures and hospitalization

What are the goals of "triple aim"?

improve patient experience

improve health

lower cost

T or F. Triple aim requires interprofessional team effort.

TRUE

What is the purpose of HCAHPS surveys?

gives standardized way to assess patient experience in the hospital

How did the Affordable Care Act in 2010 use the HCAHPS?

to calculate value based care incentive

Who is given an HCAHPS survey?

all adult patients that are discharged from an acute care facility after at least one night stay

How many HCAHPS surveys do participating hospitals need to submit each year? For what?

300 completed surveys each calendar year

to meet requirements for full reimbursement updates

What are some components of HCAHPS surveys?

communication with nurses and doctors

responsiveness of hospital staff

pain management

communication about meds

discharge info

overall experience

Who is responsible for compiling results of HCAHPS and sharing findings?

AHRQ

What is hospital compare?

Website designed for consumers to compare hospitals and their services based on HCAHPS to allow patients or consumers the ability to make informed decisions about where they get their healthcare and encourage hospitals continually improve the care they provide

What is nursing home compare?

reports on quality measures in long term care facilities including percentages of complications such as major injuries, UTIs and pressure ulcers

What is teamSTEPPS?

an evidence-based framework to optimize team performance across the health care delivery system

model for effective communication focused on positive patient outcomes

What are team competency outcomes for teamSTEPPS?

Knowledge- shared mental model

Attitudes- mutual trust, team orientation

Performance- adaptability, accuracy, productivity, efficiency, safety

What are the five key principles of teamSTEPPS?

Team structure

Communication

Leadership

Situation monitoring

Mutual support

How is team structure promoted using teamSTEPPS?

identify components of multi-system team that must work together efficiently to ensure patient safety

What is SBAR?

communication technique in teamSTEPPS

Situation, Background, Assessment, Recommendation

used to communicate critical information that requires immediate attention and action concerning the patients condition

What is call-out?

communication technique in teamSTEPPS

used to communicate important or critical information

informs all team members simultaneously during emergent situations

helps team members anticipate next steps

important to direct responsibility to a specific individual responsible for carrying out the task

What is an example of call-out?

Airway clear? airway clear

Blood pressure? Blood pressure is 100/62

What is check-back?

communication technique in teamSTEPPS

use close loop communication to ensure the information conveyed by the sender is understood by the receiver

How does check-back work?

sender initiates message

receiver accepts message and provides feedback

sender double checks to ensure message was received

What is a handoff?

communication technique in teamSTEPPS

transfer of information and responsibility during transition in care

opportunity to ask questions, clarify and confirm

What is an example of a handoff technique?

I (introduction)

P (patient)

A (assessment)

S (situation)

S (safety)

the

B (background)

A (actions)

T (timing)

O (ownership)

N (next)

What is leadership according to teamSTEPPS?

ability to maximize the activities of team members by ensuring the team actions are understood, changes in information are shared, and team members have necessary resources

What do effective team leaders do according to teamSTEPPS?

organize the team

identify and articulate clear goals

assign tasks and responsibilities

monitor and modify plan

communicate changes

review team performance and provide feedback

manage resources

facilitate information sharing

encourage team members to help one another

facilitate conflict resolution in learning environment

model effective teamwork

What are three critical events leaders should initiate during team events according to teamSTEPPS?

Brief- sharing the plan

Huddle- monitoring and modifying the plan

Debrief- reviewing the team's performance

What is situation monitoring according to teamSTEPPS?

process of actively scanning and assessing situational elements to gain information or understanding or to maintain awareness to support team function

What is STEP?

situation monitoring tool in teamSTEPPS

Status of the patient

Team members

Environment

Progress toward goal

What is cross-monitoring?

situation monitoring tool in teamSTEPPS

monitor actions of other team members, provide safety net within team, ensure mistakes are caught easily and quickly

"watching each other's back"

What is I'M SAFE?

situation monitoring tool in teamSTEPPS

assess own safety status

I (illness)

M (medication)

S (stress)

A (alcohol and drugs)

F (fatigue)

E (eating and elimination)

What is mutual support according to teamSTEPPS?

ability to anticipate and support team members needs through accurate knowledge about their responsibilities and workload

What is task assistance?

mutual support tool used in teamSTEPPS

protect eachother from work overload

all offers and requests for assistance in context of patient safety

foster environment that is expected that assistance is actively sought and offered

What is feedback?

mutual support tool used in teamSTEPPS

information provided to team members to improve performance

What are the 5 characteristics of feedback?

Timely- soon after target behavior

Respectful- focus on behaviors, not personal attributes

Specific- specific task or behavior that requires correction or improvement

Directed- toward improvement

Considerate- of feelings and delivers negative information with fairness and respect

What is the two-challenge rule?

mutual support tool used in teamSTEPPS

empowers all team members to "stop the line" if they sense or discover an essential safety breech

assertively voice concern at least two times to ensure it has been heard

What is CUS?

mutual support tool used in teamSTEPPS

C- i am Concerned

U- i am Uncomfortable

S- this is a Safety issue

What is DESC?

mutual support tool used in teamSTEPPS

used to resolve conflict

Describe specific situation or behavior

Express concerns or how it makes you feel

Suggest alternatives and seek agreement

Consequences stated in terms of impact on teams established goals

How should a nurse go about patient centered discharge planning?

Nursing process- ADPIE

Assessment

Diagnosis

Planning

Intervention

Evaluation

What should be included in the assessment part of discharge planning?

identify possible need barriers (depends on what plan for transition is)

identify gaps in care (r/t coverage or supplies needed to be delivered to the home prior to discharge)

ensure patient understands healthcare status (starting at admission)

What should be included in the diagnosis part of discharge planning?

specific parts of transition planning should be based off diagnosis

complicated with comorbidities

What are some high risk diagnoses for hospital readmission?

Pneumonia

Myocardial infarction

Congestive heart failure

What joint commission standard core measure is used to prevent readmission in a patient diagnosed with pneumonia?

oxygen assessment

What joint commission standard core measure is used to prevent readmission in a patient diagnosed with MI?

aspirin prescription

What joint commission standard core measure is used to prevent readmission in a patient diagnosed with CHF?

smoking cessation counseling

What should planning outcomes for discharge be based on?

patient's individual goals, preferences, cultures and values as well as family preferences

Why is it important to understand the patient's goals for transition?

allows them to actively participate in care

Effective _____ is necessary for transition.

communication (with receiving facility, provider for follow up care, home health care etc)

What is included in the intervention part of discharge planning?

transition with effective communication

ensure patient has adequate coverage to implement plan

What might happen if the transition is not covered?

the out of pocket cost may not be feasible and may need to be revised

What is included in the evaluation part of discharge planning?

follow up phone call, written survey or in person visit after transition

may need reevaluation if initial plan did not meet goals

T or F. Discharge planning/transitioning is concluded when the patient leaves the acute facility.

FALSE

What is Project RED?

evidence based program used to improve the process of discharge planning and prevent hospital readmissions

sets expectations for discharge to avoid missing key elements

What is included in project RED?

clear system for educating patient, making discharge appointments, giving written discharge instructions and follow up phone call after discharge

nursing discharge advocates meet in person with patients before their discharge, make follow up appointments, and send discharge summaries to primary care

pharmacists call 2-4 days after discharge to review meds

What is project BOOST?

similar to project RED but focuses on transitional care for older adults

What is the Care Transitions Intervention?

advanced practice nurses meet with high risk elderly patients prior to discharge then conduct one home visit and 3 phone calls over 4 weeks after discharge

What is the Transitions Care Model?

advanced practice nurse provide a minimum of 8 home visits to high risk elderly patients over 3 months and are available by phone 7 days a week

What are some considerations to improve transitions?

comprehensive discharge planning

complete and timely communication of information

medication reconciliation

patient/caregiver communication using "teach back"

open communication between providers

prompt follow up visit with an outpatient provider after discharge

Comprehensive discharge planning should address ____ and ___ barriers, draw on ____ resources and include a ____ ___ ___ 1-3 days after.

financial and psychosocial

community

follow up call

T or F. Discharge summaries should be provided to outpatient providers within a week of discharge.

FALSE. 1-2 days

What should be included in medication reconciliation?

check accuracy of medication lists and dosages

look for contraindications

assess financial barriers

A follow up visit with an outpatient provider should be scheduled ___ ___ and be within ___ days.

before discharge

7 days