Team-Based Care to Enhance Patient Engagement, Improve

Team-Based Care to Enhance Patient Engagement, Improve Outcomes,
and Advance Population Health
Marcelletta Miles, RN, MBA, ACC; Sheri McCall, RN-BC, MSN, CCM; Juanita Larkins, RN, MSN, CCM; Treiste Newton, RN, BSN, CCM; Vicky Epps, RN, BSN, CCM
2016 CCNC Innovation Forum: Transformative Strategies for 21st Century Healthcare
April 18, 2016
The Institute for Health Care Improvement (IHI) “Triple Aim” is a single
aim with three dimensions, pursued simultaneously: improvement of the
patient experience of care, improvement of the health of populations, and
reduction of the per capita cost of health care.
Patient engagement, a broad concept of patients more actively involved in
their health care, is a fundamental care management intervention that is
crucial to the success of targeted outreach for improving patient quality of
care, patient experiences and outcomes, and facilitating cost-effective
health care, substantial components significant to impacting Triple Aim
outcomes.
Far beyond the search for valid phone numbers, team-based approaches are
essential to the success of patient engagement outreach, from systems level
workflows and technology to a leadership culture of mindfulness of the
patient experience.
POSTER PRESENTATION OBJECTIVES
Participants will be able to:
 Describe initiative involving a primary care practice collaborative
targeting systematic approaches for patient engagement for postdischarge transitional care interventions following acute inpatient
hospitalization.
 Explain tools of engagement strategies to increase care management
team awareness and understanding of key concepts relational to teambased patient engagement.
 Define patient suffering, in terms of inherent (unavoidable) and
avoidable.
 Discuss the relevance of reducing or alleviating patient suffering to
improve the patient experience and facilitate patient engagement.
 Define mindfulness.
 Justify the importance of mindfulness in motivational interviewing
and/or other patient interactions, to facilitate the patient
experience/engagement.
 Identify strategies to promote a leadership culture of mindfulness.
 Discuss a benefit of cultivating conscious leadership.
TEAM-BASED PATIENT ENGAGEMENT PROJECT
A Primary Care Practice Collaborative:
Transitional Care Post-DC Patient Engagement
Beyond valid phone numbers… how to keep them when we
find them…. being fully aware of why we do what we do…
Goals:

Team:


Utilize strategic practice engagement to facilitate increased patient
engagement and timely post-discharge follow-up visits to reduce
less than 30-day readmissions, thereby improving patient
outcomes and reducing health care costs.
AccessCare Embedded Nurse Care Manager, Pharmacist, Social
Worker
Expanded team to include primary care practice team members for
patient engagement outreach
Actions:
 Collaborative included all payers
 Internal primary care practice policy created for transitional care
collaborative
 Patient outreach and engagement for return office visit postdischarge
 Patient education, and BP cuffs, for self-BP checks
Increase Care Managers’ and CM team members’ awareness and
understanding of why we do what we do…. applying care management
strategies and interventions to reduce or alleviate patient suffering…
priorities fundamental to facilitating patient engagement, and
movement along the Readiness to Change continuum.
Patient Suffering, to name just a few…
 Pain
 Fear
 Anxiety
 Confusion
 Uncertainty
Providing the optimal patient experience through the four domains of
Compassionate Connected Care, a model to reduce patient suffering.
Measures
A Primary Care Practice Patient Engagement
Collaborative: Acute Inpatient Post-Discharge Transitions
of Care Reports - Progression
14
12
NUMBER OF PATIENTS
INTRODUCTION
TOOLS OF ENGAGEMENT:
CONSIDER THE PATIENT EXPERIENCE
Press Ganey. Compassionate Connected Care: A Model to Reduce Patient Suffering. Performance
Insight 2014. http://healthcare.pressganey.com/2014-PI-Compassionate_Connected_Care.
10
8
6
4
2
0
*where no yellow is noted, there were no readmissions
RESULTS BY WEEK
Number of Patients
Appointments in 14 days
Med Recs
Readmission in < 30 days
A Primary Care Practice Patient Engagement
Collaborative: Acute Inpatient Post-Discharge Transitions
of Care Report - Grand Totals
200
 Concepts of Patient Suffering
 Inherent (“unavoidable”)
 Caused by the disease or event
 Pain, symptoms, limitations
 Fear, worry about the condition and impact to quality of life
for patient, family, friends
 Encompasses the impact of treatment
 Stress waiting for diagnosis/concrete plan
 Anxiety prior to tests/procedures
 Unavoidable discomfort of certain medical procedures
 Uncertainty in navigating complex systems of care, “foreign”
terminology, processes, etc.

150
214
100%
208
97%
199
93%
100
Community Care of North Carolina Networks
50
7
3%
0
# of pts
AccessCare
A Community Care of North Carolina Network
3000 Aerial Center Parkway, Suite 101
Morrisville, NC 27560
www.ncaccesscare.org
RESEARCH POSTER PRESENTATION DESIGN © 2015
www.PosterPresentations.com
Appt in 14 days
Med Rec
Readmission < 30 days
Outcomes included
 Increased primary care practice staff participation in transitional
care post-discharge processes
 Percentage of return appointments kept in the identified patient
group reached 95-100% in Medicaid payer source; 90-95% in
other payer sources
 No readmissions within 30 days in Medicaid payer source
 100% adherence with self-BP checks in identified patients
provided with equipment and CM education.

Addressing the Inherent (“unavoidable”)
 Unavoidable does not mean un-addressable…may not be able
to completely eliminate this suffering
 Goal is to mitigate, make less severe, to greatest extent
possible, including psychosocial
 Provide information, orient to unfamiliar environments,
show compassion, acknowledge anxiety/fears and assist
to reduce, establish trust
 Accept and acknowledge that alleviating a patient’s suffering
is part of the healing process
Avoidable
 Results from dysfunction in a healthcare delivery system or
organization
 Lack of courtesy
 Care poorly coordinated
 Excessive waits for appointments, diagnosis, answers
 In an ideal state, is completely avoidable in the health care
process
AccessCare has received NCQA case
management accreditation for our complex
case management program.
TOOLS OF ENGAGEMENT:
AN ORGANIZATIONAL CULTURE APPROACH
When using motivational interviewing, and other patient
interactions…. are we focused on improving the patient
experience, and are we fully present in the moment…?
Increase Care Managers’ and CM team members’ awareness of how to
fully focus on the patient, conveying genuine attentiveness and
“taking time for what matters” to improve the patient’s experience.
Care Management Mindfulness
 Care Managers (and team members) introduced to
Mindfulness….knowing what you are doing, feeling, or thinking
in the present moment.
 Recognizing the need to be fully present with our patients (or
team members)….
 Not planning our next question, rushing to get an Initial
Assessment, or other “tasks” completed, thinking about dotting
all the “i’s” or crossing the “t’s”, telling the patient what he/she
needs to do, giving advice, etc.
 Ongoing promotion of a leadership culture of mindfulness…
 Promotes a care management team culture of mindfulness
 Facilitates engagement across multidisciplinary care team
members
 Promotes a team-based approach
 Facilitates patient engagement in both care management services,
and in patient self-management
 Improves outcomes
 Advances population health
 Cultivating Conscious Leadership
 Exploring philosophies and opportunities to lead from above
the line
REFERENCES
 Dethmer, Jim; Chapman, Diana; Warner Klemp, Kaley. The 15 Commitments of Conscious Leadership.
Dethmer, Chapman, & Klemp, 2014 (pgs: Cover, Table of Contents, 15.)
 James, Julia. Patient Engagement. Health Affairs Policy Brief, February 23, 2014. Retrieved from
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=86, April 4, 2016.
 Mylod, Deirdre E.; Lee, MD, Thomas H. A Framework for Reducing Suffering in Healthcare. Harvard
Business Review, November 14, 2013. Retrieved from
https://hbr.org/2013/11/a-framework-for-reducing-suffering-in-health-care/ , April 7, 2015
 IHI Triple Aim: “The IHI Triple Aim framework was developed by the Institute for Healthcare
Improvement in Cambridge, Massachusetts (www.ihi.org).”
 Press Ganey. Compassionate Connected Care: A Model to Reduce Patient Suffering. Performance
Insight, 2014. Retrieved from
http://healthcare.pressganey.com/2014-PI-Compassionate_Connected_Care, April 7, 2015.