Collaboration Key to Making Outcome Based Pathways

Collaboration Key to
Making Outcome Based Pathways
and Reimbursement a Reality
Yvonne Ashford (Central CCAC)
Valerie Armstrong (North Simcoe Muskoka CCAC)
Tina Hamilton(Saint Elizabeth Health Care)
OACCAC Knowledge and Inspiration Conference
June 20th, 2013
Supporting Structural
and Cultural Change
Kotter’s 8-Stage Process
1. Establish a sense of urgency
2. Create the guiding coalition
3. Develop a vision and strategy
4. Communicate the change vision
5. Empower employees for broad based action
6. Generate short term wins
7. Consolidate gains and producing more change
8. Anchor new approaches in the culture
2
Improving Care
Experiences
• Patient outcomes drive care
delivery
• Care decisions made by
patient and care
professional closest to
patient
• Care based on evidenceinformed best practice
• Payment for quality
(outcomes)
Establishing a Sense of Urgency
3
Planning
Service Provider and
CCAC Joint Team
Cross-functional teams
NSM and Central CCAC
Consolidated project plans
developed with SPOs & CCACs
Local Service Provider
Internal Project Team
Cross-functional team from
CCAC including frontline staff
Local CCAC Internal
Project Team
Cross-functional team from
CCAC including frontline staff
Joint CCAC Project Team
Central CCAC
Champlain CCAC
North Simcoe Muskoka CCAC
Creating a guiding coalition
4
Planned Activity
Central CCAC
NSM CCAC
Pathways
Wound
Wound / Orthopaedic
Description
All new wounds
All populations
All new wounds/joint replacements
Short Stay population
Wound:
1. Bayshore
2. Closing the Gap
3. Saint Elizabeth
Provider Partners
1.
2.
3.
4.
5.
6.
7.
8.
9.
Start Date
CHRIS changes – Oct. 25
Business change – Nov. 26
Bayshore
Closing the Gap
Paramed
Revera
Saint Elizabeth
Spectrum
SRT Med-Staff
VHA Home
Calea
Orthopaedic:
1. Revera
2. Closing the Gap
CHRIS changes - Oct. 25
Business change - Nov. 26
5
Developing a vision and strategy
6
Planning
WORK
BREAKDOWN
STRUCURE
OA &CCAC
Project
Planning
CCAC
Business Process
Program Design
CCAC
Client Service
Governance
CCAC
Engagement and
Communication
CCAC
Education and
Training
CCAC
Deployment and
Testing (IT/IS)
CCAC
Contracts
SPO
Communication
CCAC
Evaluation
Measurement
Reporting
SPO
Evaluation &
reporting
SPO
Training
SPO
Billing
Process
SPO
Business
Process
CCAC
Finance
Detailed schedule
outlining activities
for all parties involved
Communicating the change vision
7
CCAC/SPOs Joint
Planning
VSM/Process Mapping Session
• Reviewed current state
• Identified “What will change” and “What
remains the same”
• Mapped future state
• Completed gap analysis
• Demonstrated CHRIS and HPG interaction
Outcome:
• Joint action plan
• Business rules
• Revised process maps
8
Educational
Tool Kit
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Business process scenarios
Business rules document
Process maps
Q&As
Presentations
Change management material
User Guides – HPG / CHP
Guidelines for completing reports
Pathways
Video for HPG / CHP use
9
Educational
Tool Kit
Change Management Resources
• Model for change analysis
• Change management exercises
• Train the trainer
10
Educational
Tool Kit
Business process
scenarios
• All known scenarios
• Communication
• SPO & CCAC actions
Scenario and technology
testing
• Testing scenarios with
CHP & CHRIS
• SPO & CCAC
11
Educational
Tool Kit
Video for
HPG / CHP use
 Recorded instruction
video
 Accessible to all
stakeholders
 Easy to understand
 Standardized
instruction
12
Lessons Learned
Planning
• Define Scope Early
•
Risk analysis key
• Set the Stage
Consolidated contracts, IT readiness, aligning caseloads
•
• Scenario Development and Testing
Define workarounds, identify improvement opportunities
•
• Collaborative Approach
Involve frontline early and often, involve cross-functional
•
• Resource Intensive
•
Identify consistent lead, local and SPO steering committees
• Process Redesign
•
•
Core standard processes, decisions impact local and SPOs
Communication
•
Internally and often, key messages across stakeholders
13
Implementation
Strategies & Challenges
Empowering employees for broad based action
14
Implementation
Strategies
CCAC
 Management support for initial OBPs – confirmation
of processes prior to sending out initial offers
 Regular team huddles to review and provide real-time
information
 All managers were knowledgeable of model and
available to support staff
 Manager most involved to be on call initially
 Ensure staff on all shifts are knowledgeable of
processes
Empowering employees for broad based action
15
Implementation
Strategies
Service Providers
 Initial interval reports reviewed and submitted with
support
 Ensure IT and support staff knowledgeable and be
available
 Resource experts available to support a Coordination
staff – real time
 Internal steering committee to guide decision making
 Ensure all staff on all shifts are knowledgeable of
processes
Empowering employees for broad based action
16
Implementation Strategies
CCAC and SPOs
1. Regular check-ins with CCAC and SPOs (first two weeks)
• Real-time problem-solving and decision-making
2. Identification of one contact person at CCAC and SPO
• For communication and escalation
3. Continue with internal committees – the “new norm”
• CCAC and SPO internal committee
• Joint CCAC/SPO committee
• CCAC and OACCAC
• Weekly provincial meetings
17
Post-Implementation
Lessons Learned and Impacts
Consolidating gains & producing more change
Anchoring new approaches in the culture
18
Impact on Clinical
Processes
Focus on Outcomes
• Communication more focused on outcomes and less about visits
• Focus on “Clinical Management” by SPOs well received
• Shift from teach, reduce and discharge to ensuring wound is
healed prior to discharge
• SPOs have more autonomy with clinical judgement – with some
controls internally
SPOs monitoring patients/frequencies and best practice
• Consistency being seen
19
Impact on Clinical
Processes
Shift in SPO thinking
• Holistic and consideration of other services to meet gaps
• e.g. ET Nurse consults - earlier escalation to prevent delays
Some SPOs – additional work
•
•
Lack of system integration and duplicate effort
Increased time for orientation
Physician Practices
 Challenges with physician practices
20
Impact on Internal
Operations
Scalability
• Model and business rules must be scalable to other populations
(i.e.. Palliative, etc.) = sustainable
• Consideration of multi-disciplinary pathways
Works well with Short Stay population
• More complex, more challenging
• FFS and OBP processes complex
Shift in care coordinator thinking
• Focus on patient and patient outcomes versus frequencies
OBP reporting
• More succinct and clinically based
• Method of reporting remains a challenge - Paper
21
Impact on
Technology
Lack of integration between SPO systems & CHRIS
• Duplicate entry and effort for CCAC and SPO
Workarounds until enhancements made
• Increased time and effort for staff
Tracking of enhancements and bugs
• Ongoing tracking informs improvements
Early scenario testing using CHP / HPG
• Completed early to confirm processes and limitations
• Reduces re-work
• Ensure billing codes are accurate
22
Impact on Financial
Processes
Revenue Reconciliation Challenges
• Not well understood or possible
• Organizational risks for CCACs and SPOs
• More intensive financial auditing processes - CCAC and
SPO – new auditing processes defined
Financial risk during POC
• Best practices reports shared with SPO
Reimbursement Model
• Impact not fully understood
• Organizational risks for CCACs and SPOs
23
Impact on Financial
Processes
Central CCAC
24
Impact on Patients
Standard approach to wound care and hips/knees
• Promotes best practice
• Focus on outcomes
Simplified referrals
• Less patient time required for completion
Reduced variation among care coordinators and SPOs
• Consistency in provider / agency
• Consistency in care coordinator
25
Active Short Stay Clients
with an Authorized OBP
(as of May 28, 2013)
On May 28, 2013:
• 1674 active Short Stay clients
• 19.77% (n=331) had an OB
pathway currently authorized
Of the 331 clients:
• 74.3% (n=246) OB-W pathway
• 25.7% (n=85) OB-O pathway
NSM CCAC
25.68%
74.32%
OB-O
OB-W
Wound Pathway Types
Authorized
(November 26, 2012 – May 28, 2013)
1130 Wound pathways authorized
during this 6 month period:
• 325 assessment pathways
Remaining 805 wound pathways:
• 43.9 % Surgical Wound
• 17.9% Traumatic Wound
• 32.7% All Other - Healing
• 5.6 % Non Healing
NSM CCAC
Data Note: “Non Healing” accounts for: Maintenance Wound Initial,
Maintenance Wound Recurring, Non-Healing Wound Initial and Non-Healing
Wound Recurring authorized pathway types.
“All Other – Healing” accounts for: Arterial Leg Ulcer, Diabetic Foot
Ulcer, Malignant Wound Initial, Pilonidal Sinus, Pressure Ulcer and
Venous Leg Ulcer authorized pathway types.
Healable Wound Pathways
Discharged – Goal Met vs.
Goal Not Met
(November 26, 2012 – May 28, 2013)
478 healable wound pathways
have been discharged during
this six month period
100%
25%
32%
75%
68%
20%
25%
80%
75%
80%
• 75% (n=359) discharged:
pathway completed - goal
met (all outcomes have been
met)
• 25% (119) discharged:
pathway completed - goal
not met
•NSM CCAC
60%
40%
20%
0%
All
Other
Surgical
Traumatic
Wound
Wound
Discharge: Pathway completed - goal not met
Discharge: Pathway completed - goal met
Data Note: Excludes all discharged assessment and non-healing/
maintenance pathways.
Healable Wound Pathways
Discharged - Goal not Met
• 119 Wound pathways were discharged:
pathway completed – goal not met.
19.3%
• 19.3% (n=23) were due to
supervening events (death,
hospitalization, transfer)
56.3%
24.4%
• 56.3% (n=67) were classified as
“other”
Supervening Events
• 24.4% (n=29) service is still active
• 7 transferred to maintenance/
non- healing pathway
•NSM CCAC
Service is still Active
Other
Average LOS (in days) per
Wound Pathway
Discharged: Goal Met
(November 26, 2012 – May 28, 2013)
Expected
Length of
Pathway = 60
days
Expected
Length of
Pathway = 60
days
45.0
40.0
35.0
38.6
30.0
25.0
20.0
Expected
Length of
Pathway = 7
days
41.0
15.0
10.0
7.8
5.0
0.0
CCAC (n= 182)
CCAC (n= 171)
CCAC (n=78)
Surgical
Assessment
Traumatic Wound
NSM CCAC
Wound (OB-W) Clients
with Fee for Service
(November 26, 2012 – May 28, 2013)
• 670 clients have been authorized or previously authorized for a
Wound Pathway during this six month period
• 89% (595) have a outcome based wound service authorized
only
• 11% (n=75) had fee for service assigned at the same time
(defined as service unrelated to wound – nursing, therapy,
personal support)
NSM CCAC
Top 5
Lessons Learned
1. Collaborate early and often – between and among
CCACs, providers and the OACCAC
2. Investment in resources for planning will result in
effective implementation
3. Adapt your business processes to new CHRIS and
HPG-CHP functionalities including some workarounds.
4. Don’t underestimate change management required –
fundamental shift!
5. OBP is the “right concept” – focusing on the outcomes
and shared accountability
32
Outstanding care – every person, every day
Outstanding care – every person, every day