Home Health Reimagined: Thriving in a Value

Home Health Reimagined:
Thriving in a Value-Based World
Beth Hennessey, BSN, MSN
and
Paula Suter, BSN, MA
Sutter Center for Integrated Care
Sutter Health
Disclosure Statement
Beth Hennessey DOES NOT have a financial
interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or
apparent conflict of interest in the context of the subject
of this presentation.
Disclosure Statement
Paula Suter DOES NOT have a financial
interest/arrangement or affiliation with one or more
organizations that could be perceived as a real or
apparent conflict of interest in the context of the subject
of this presentation.
Learning Objectives
• Discuss the urgency to reimagine Home Care
• Review an ALWAYS event to humanize care delivery for
patients and populations
• Identify leadership best practices to transform care
delivery to be person-centered
• Connect transforming care to be person-centered to
organizational strategic priorities.
Learning Objectives
• Define what it means to be a competent clinician in order
to provide person-centered care
• Explore communication methods that promote
relationship-based care
• Communication methods to identify what matters most
• Sustaining the culture of humanistic care
• Tools to hardwiring communication best practices
• Technology example for hardwiring what matters most
Reimagined Homecare/Healthcare:
Healthcare Promise
• Person-centered/evidenced based care
is the standard of care
• Patients/staff/leadership engaged in
achieving vision
• Positive clinical, satisfaction/experience, &
financial outcomes continuously improved
• Collaborative relationship with providers
across healthcare system; integrated
healthcare provider
• Demonstrated homecare’s value to
stakeholders
• Employer of choice: magnet homecare
Integrated Care Management (ICM):
A Care Delivery Model for Transforming Healthcare
Person-Centered
Evidence-Based
Coordinated Care
- Care with dignity and
respect
- Clinical best practices
- Seamless transitions
across providers,
settings and time
- Values, needs and
preferences guide care
- Patient as partner
- Patient Engagement:
Self-management support
Health literate care
- Meaningful and timely
information exchange
Improved outcomes leading to better health, better care and lower cost
The Evolving Ecosystem
- Payment models are shifting
from volume to value
- Experience is landing front
and center on strategic plans
- Organizations are
consolidating
- Patients are demanding care
that is increasingly
convenient, high-tech, and
still high-touch
Office of Patient Experience
Sutter Center for Integrated Care
Sutter Heath
Reach Beyond Sutter Health
• 5,000+ physicians
• 55,000+ employees
• 24 acute care
hospitals
• Homecare, Hospice,
Infusion, & DME
• 7,000+ providers
• 49 States
• 3 Countries: US, Canada, &
Singapore
Seeking to transform healthcare delivery nationwide to be:
Person-Centered, Evidence-Based, & Coordinated
Humanizing Population Health
“More than ever, hospitals are seeing a growing need to
improve population health by putting a face to data,
incorporating measures to engage and support team
members in humanizing their work.”
-Healthcare IT News
November 5, 2015
Finding the Individual
Independent.co.uk
Illustration: Martin Hanford
Source: www.saturdaymorningsforever.com
A True Partnership
“These findings suggest that patient experience scores,
such as those on the CAHPS survey, may be a reflection of
a transaction that is shaped by both the clinician and
the patient and is not just a measure of provider
performance.”
-Health Affairs
February 2013
Source: What The Evidence Shows About Patient Activation:
Better Health Outcomes And Care Experiences; Fewer Data On Costs
Judith H. Hibbard and Jessica Greene, Health Affairs: February 2013
ALWAYS Event
Always event refers to aspects of the patient
experience that are so important to patients and
families that healthcare providers should always
get them right.
-Picker Institute, 2011
Summary - our “Always Event”
Always Event: Identify “what matters most” to patients and ensure
patients’ values, needs, and preferences guide all care delivery
• Initial target population: All patients referred to Sutter Care at
Home (SCAH) Home Health and Hospice
• Future: expand practice across providers, settings, and care
continuum
• Work informed by:
• IOM definition of patient-centered care
• Evidence on patient engagement
• John P. Kotter’s works on leading transformational change
“The Right Thing to Do”:
Person-Centered Care
ALL health care providers should pursue six major aims:
1. Safe
2. Effective
3. Patient Centered
4. Timely
5. Efficient
6. Equitable
“Providing care that is
respectful of and responsive to
individual patient preferences,
needs and values and
ensuring patient values guide
all clinical decisions.”
“A New Health System for the 21st Century”
(IOM, 2001)
Patient Engagement is
“The Right Thing to Do”
Evidence reveals that patients who are
actively involved in their health and healthcare:
 Achieve better clinical
outcomes
 Have lower healthcare costs
 Are more satisfied with their
care experience
“The Right Thing To Do” :
Leading Transformational Change
8 Steps of Successful Change
1. Create a sense of urgency
2. Select a guiding team
3. Develop change vision & strategy
4. Communicate for understanding
5. Empower others
6. Produce short term wins
7. Don’t let up
8. Create a new culture
Our Iceberg is Melting: Changing and Succeeding
under Any Conditions
by Kotter and Rathgeber
Key Drivers for Adoption and Spread
• Create a culture that values person-centered care and
patient engagement
• Execute best practices in leading transformational
change and engaging all staff:
• Urgency for change
• Change vision
• Communicate for understanding and buy-in
• “Make the right thing to do the easy thing to do”
See the Need for our ALWAYS Event
“We think our job is to ensure health and survival. But really it is
larger than that.
It is to enable well-being.
And well-being is about the reasons one wishes to be alive […]
those reasons matter all along the way.”
-Atul Gawande, MD, MPH,
Author of Being Mortal: Medicine
and What Matters in the End
Meet Mr. Smith
From Clinician Directed to
Patient Guided
BEFORE
Manage signs and
symptoms of HF
exacerbation, low
sodium diet, and fluid
restrictions adhered
to by end of episode
NOW
Be able to join my
ROMEO group
(Retired Old Men
Eating Out)
for lunch once a week
Extending Across the Continuum
Communicate for Understanding
and Buy-in
Tie to organizational
strategic initiatives:
Patient Experience
Patient and provider
experience measures
Communicate at every
level of organization
Create a Culture That Values Person
Centered Care
Lead by Example
• Incorporate into
standard work flows
• Role model
• Round for outcomes to
remove barriers
A
I
D
E
T
Explain
In addition to doing the wound care,
I’d like to review your medications with
you to make sure ...
Before we get started, what questions
or concerns do you have? I want to
make sure we take time for what is
most important to you.”
Make the
Right Thing
to Do
the Easy Thing
to Do
Success Measure
January 2016
CMS STAR Ratings
Based on HHCAHPS
Surveys
1-5 Scale with 5 being
The BEST patient
experience
5.0
• Marin
• Roseville
4.0
• Concord/ San Leandro
• Lakeside
• Modesto
• North (Yuba City)
• Sacramento
• Santa Cruz
• Salinas
3.0
• San Francisco
• San Mateo
10 Rules for Healthcare Re-design
Rule
Care is based on a continuous healing relationship
Care is customized according to patient needs and values
The patient is the source of control
Knowledge is shared and information flows freely
Decision making is evidence based
Needs are anticipated
Cooperation among clinicians is a priority
Waste is decreased
Transparency is necessary
Safety is a priority
Source: Healthcare Professionals Education - A Bridge to Quality, IOM 2003
Institute of Medicine Committee
Recommendations (2003)
All health professionals should be educated to deliver
patient-centered care as members of an interdisciplinary
team, emphasizing evidence-based practice, quality
improvement approaches, and informatics.
How to Get There
Evidence-based
person-centered
practices
People/
Practices
Tools/
Technology
Processes
Continuous
improvement
Educate the team
Strengthen the culture
PersonCentered
Care
Use to hardwire
humanistic care
Specific Competencies for
Person-Centered Care
•
•
•
•
Patient Competencies
Define the patient/provider
relationship
Convey health problems,
concerns, beliefs, expectations
Access and evaluate relevant
information
Negotiate decisions and agree
on plan
Talk
Choices
Evidence
Improved outcomes
Provider Competencies
• Develop relationship/partnership
• Identify the patient’s values,
needs and preferences
• Present info, evidence, review
options, in plain language
• Elicits, values questions
• Help the patient reflect on and
assess decisions
• Action planning that promotes
empowerment
Core Competency
“Questions are at the very core of how we listen,
behave, think and relate, both as individuals and as
organizations; virtually everything we think and do is
determined by the questions we ask.”
Marilee Adams (as cited in Aubry, 2009)
A Good Place to Start…
What concerns you the most right now?
What would you like to have happen as a result of our
care?
How would you like to feel? What would you like to be
able to do again?
What is it that you hope for?
If in hospice, we might ask what would a good day look
like to you?
Continuous ImprovementStarting with a Small Test of Change
3 patients
1 clinician
Do
Plan
Check
Act
Lessons learned:
-Choose early adopter
-Anticipate and prepare
staff for common barriers
Demonstrate Empathy
Strengthening Culture
Strengthening Teams
• Multi-disciplinary care
conferences start with
positive story
• “What matters most”
projected to anchor care
planning discussion
• Learning enviroment
facilitates culture change
Tools for Consistent Care Delivery
Feeling lonely as I live alone.
Specific Competencies for
Person-Centered Care
Patient Competencies
• Define the patient/provider
relationship
• Convey health problems ,
concerns, beliefs, expectations
• Access and evaluate relevant
information
• Negotiate decisions and agree
on plan
Talk
Choices
Evidence
Improved outcomes
Provider Competencies
• Develop relationship/
partnership
• Identify the patient’s values,
needs and preferences
• Present info, evidence, review
options, in plain language
• Elicits, values questions
• Help the patient reflect on and
assess decisions
• Action planning that promotes
empowerment
Patient Tools
“We must design
processes and identify
technologies that
hardwire humanity at
every point of care.”
Bridget Duffy, MD
My homecare clinicians explain
things in a way I could understand.
Get out front of
HHCAHPS scores
Strongly agree, agree, neutral, strongly
disagree, disagree
My homecare clinicians really listen
to what is important to me.
Strongly agree, agree, neutral, strongly
disagree, disagree
My homecare clinicians treat me
with dignity and respect.
Strongly agree, agree, neutral, strongly
disagree, disagree
Julie’s Story
Restoring Joy in Healthcare
Contact information
Beth Hennessey
[email protected]
Paula Suter
[email protected]
References
• Institute of Medicine (IOM). 2001. Crossing the Quality Chasm.
Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, D.C: National Academy Press.
• Our Iceberg Is Melting: Changing and Succeeding under Any
Conditions, Kotter, John & Rathgeber, Holger, St Martin Press. 2006
• Kotter, J. P. 1995. Leading change: Why transformation efforts
fail. Harvard Business Review (March-April): 59-67
• Bernabeo, Elizabeth, and Eric S. Holmboe. Patients, providers, and
systems need to acquire a specific set of competencies to achieve
truly person-centered care. Health Affairs 32, no. 2 (2013): 250-8.
References
• Boehm, L & Petty, K. Humanizing efficiency in healthcare. 2015
Research Report. Experience Innovation Network.
• Kimberly Petty, MBA, MBB, Liz Boehm, M. Bridget Duffy, MD. The
journey to the ideal human experience. Experience Innovation
Network White Paper.
• Sinsky, C. et. al. A search of joy in practice. Ann Fam Med May/June
2013 vol. 11 no. 3 272-278
• Greiner, AC and Knebel E. Health Professions Education: A Bride to
Quality. Institute of Medicine Committee on Health Professionals
Education Summit, National Academies Press. 2003.