Creating a Successful Care Coalition Judy Conner M

Creating a Successful Care Coalition Judy Conner, M. S. , C. P. G. Texoma AAA Program Manager Randy Mc. Broom, Ph. D Texoma AAA Director

Texoma Council of Governments (TCOG) ü The Texoma Council of Governments (TCOG) is a voluntary association of local governments in Cooke, Fannin, and Grayson Counties that works directly with citizens and local jurisdictions to improve and advance economic vitality and quality of life in Texoma.

Texoma Council of Governments (TCOG) ü TCOG Serves Through Three Departments ü Client Services (211, Energy Services, Section 8 Housing, Public Housing) ü Regional Services (Public Safety/911, GIS, Economic Development, Municipal Solid Waste, Planning) ü Aging Services (ADRC, Benefits Counselling, Care Coordination, Caregiver Services, Long-term Care Ombudsman, Medication Services, Money Management, Nutrition Services, and Senior Corp – RSVP, Foster Grandparents)

Texoma Area Agency on Aging (Texoma AAA) ü Responsible for the development and coordination of a comprehensiv system of services for citizens over the age of 60 and for citizens wit a disability residing in Cooke, Fannin and Grayson counties in North ü AAA provides necessary services to remain living independently as long as possible • • • Home-delivered meals Ramps Health maintenance Respite care Prescription medication assistance Connecting needed local resources ü AAAs in perfect position to identify unmet needs/lack of available ser

What is a Care Coalition? ü Purpose • To formally organize players with a community-level focus to reduce hospital readmissions of Medicare beneficiaries in local hospitals by enabling safe and effective transitions of patients between all settings of care, and empowering patients and their families to manage their health. • National Health Care Improvement Initiative The Centers for Medicare & Medicaid Services (CMS) reports that Quality Improvement Organizations (QIOs) have helped to save nearl $1 billion by improving care transitions across the country.

What is a Successful Care Coalition? What are the elements for a Successful Care Coalition? ü Goals • Organize a forum for key health care providers of the community to meet • • • Conduct analysis to identify the root cause of need (RCA) Engage in social determinants such as education in self-management of health Establish evidenced based interventions to assist in improving processes or systems (per RCA) Monitor and track interventions Work in collaboration with local agencies and area stakeholders towards a common goal ü Assessment (RCA) • • • Conduct needs assessment of healthcare process Out of 22, 678 discharges in Texas, 34. 1% were readmitted within 7 days WHY? Factors: Do patients have in-home support? Needed medications? Follow up visits with physician? WHY NOT?

What is a Successful Care Coalition? What are the elements for a Successful Care Coalition? ü Engagement • Engaging key health care providers and stakeholders • Effective communication of the problem (hospital readmissions adversely affects the whole community) • Effective structuring of process ü Commitment • Recognize it is a long-term process • Provide necessary tools, documents and reports for success • Provide ongoing mentoring

The Texoma Care Coalition ü Purpose • To improve the health of our community, thereby reducing hospital readmission rates in our community • To be a voice for the patient and family • Assist the patient’s ability to self-manage their own health through patient-centered and patient directed models of care • To foster wise stewardship of limited community resources, reducing redundancy, waste, and build and sustain a community coalition with a focus on improving transitions of care for Medicare beneficiaries • To improve patient safety during transitions between health care settings • To enhance the satisfaction of providers and staff through increased collaboration • To collaborate and encourage efforts of organizations with shared visions and public policies that furthers the vision

The Texoma Care Coalition, cont. Texoma Care Coalition ü Engaged the services of a Quality Improvement Organization We were told at a national conference on aging that we needed a Quality Improvement Organization to get the Coalition off the ground. • Assisted in identifying key players • Infrastructure of short-term and long-term goals (process) • Formed Community Coalition Charter ü Evidence Based Intervention • • Trained staff coaches in care transition process Assessment findings provided to Coalition ü Community Organizational Input (Affinity Groups critical component) • • Home Health; Hospice; SNF’s/ALF’s; Physicians; Hospitals; Pharmacies Nursing facilities had a 21. 5% re-hospitalization rate and Hospices were being under utilized --- WHY? ü Hold the vision/trust the process Comparison of Hospital Readmissions Progress Report (Handout)

Why it works Texoma Care Coalition ü Needs Analysis • To discover: - What happened? - Why did it happen? - What to do to prevent it from happening again? - Why? ü Successful Website • Mission Statement • Participation • Meetings • Policies & Outcomes • Useful Documents available to all members of Coalition (Audit tools, sample assessments, interview guide for root cause analysis, etc. )

Why it works, cont. Texoma Care Coalition ü Charter Agreement (Handout) • Is it important to have one? - YES ü Continuing Engagement and Commitment • When commitment is made to a common goal or process, there will be engagement. Both are needed for success. • Community Organization Input from Affinity Groups • Charter Member Commitments: - Share best practices and knowledge - Mentor partners and providers - Share data and support analyses - Promote implementation of evidence-based interventions

Challenges to Success What are the Challenges to a Successful Care Coalition ü Organizational and Community Silos • Culture • Independent processes • Lack of communication between health care industries ü Lack of an Efficient Needs Analysis • Identify the lack of poor standard processes in community • Identifying the missing links between health care services to patients ü Lack of Community Organizational Input on Healthcare Transition

Conclusion and Summary ü Identified problem • Sherman has over a 22% senior population per capita in the state • With a Hospital readmission rate over 18% ü Engaged Quality Improvement Organization • • • Organized Kickoff Meeting – Invited 300 decision-making healthcare administrators (hospitals, physicians, home health, hospice, SNF’s/ALF’s, BHC’s) Ensured key stakeholders were members only with common goal Charter commitment to a 5 -year process with short-term and long-term goals ü Community Organizational Input on Healthcare Transition (Affinity Gro • Provide a venue to express and be active toward reaching our collective goals to help patients, and give us a voice • Groups met between quarterly meetings, bringing findings to the Coalition quarterly meetings

Conclusion and Summary, cont. ü Set Goals/Anticipated Outcomes • • Improvements in Practice Reduction of Readmission Rates Promotion of Best Practices Improved Communication Communities working together to provide better leaders building better lives.

Questions – Contact Informaiton Question Time Judy Conner, M. S. , C. P. G. , Texoma AAA Program Manager Texoma Council of Governments 1117 Gallagher Drive Sherman, TX 75090 jconner@tcog. com (903)813 -3575 Dr. Randy Mc. Broom, AAA Director Texoma Council of Governments 1117 Gallagher Drive Sherman, TX 75090 rmcbroom@tcog. cog (903)487 -6580