Cultural Diversity in Home Health Care The Role

Cultural Diversity in Home Health Care – The Role of a National Campaign Cindy Sun, MSN, RN HHQI RN Project Coordinator

First, a little background… • What is a Quality Improvement Organization? • What is Home Health Care? • What is the Home Health Quality Improvement Campaign (HHQI)? • What is the Acute Care Hospitalization (ACH) rate? • What is the Improvement in Oral Medication Management rate?

The HHQI Campaign • Cross setting initiative • Focusing on quality of home health care measured by • ACH reduction • Improvement in oral medication management • Special Project funded by Centers for Medicare & Medicaid Services • Patient-centered focus • Interdisciplinary • Free tools, resources, networking

Best Practice Intervention Packages (BPIPs) • Primary Resource • Focus on – ACH – Medication Management – Cross Settings • • Patient Centered Interdisciplinary Standardized Steps Flexible for implementation

BPIP Contents Quick Start Guide • • Introduction • Leadership Track • BPIP timeline • Resources/Tools • Leadership guidance • Checklist for Agency Leadership • Success Stories • Organizational Culture • Physician Perspective INSIGHTS • Discipline Tracks • Application throughout! • Links to Podcasts, Webinars, Discussion Boards

BPIP Contents • Individual discipline sections (1 -2 pages) • SN, Therapy, MSW, HHA • Interdisciplinary • Discipline Checklist • Coordination with OASIS-C INSIGHTS

Success Stories • 1 page stories • Links to agency tools

Social Networking Opportunities • • • Twitter Facebook Message Boards Live Chats You. Tube Blog

HHQI Data Reports • Individualized HHQI Data Reports can be obtained through a separate secure login on the HHQI Web site • Need secure ID to obtain login (from CASPER Reports)

Quality, not Quantity HHQI National Campaign Goals: – Align with existing efforts – Reasonably paced – Sustainable – Cross-setting

The HHQI Diversity Focus • In baseline data, we have found racial/ethnic variations for both the ACH rate and the Oral Medication Improvement rate • We are also seeing some evidence of geographic disparities in both rates

What do these data mean? • If the data are indicative of true racial and/or geographic disparities, we will design interventions to address these issues • One of the first areas we will focus on will be care transitions, because this is where breakdowns in the continuity of care often take place

Care Transitions • Cross-Setting Care • Care Transitions • Transitional Care “…the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness” Care Transitions Intervention SM

Cross-Setting Focus OR

What is the Care Transition Project? • 14 communities selected by CMS • Lead by each state’s QIO to assist health care providers, consumers and stakeholder groups to refine care delivery systems • Develop and Implement: – a) hospital and community system-wide interventions – b) interventions that target specific diseases or conditions – c) interventions that target specific reasons for admission.

What is the expected outcome? “The goal of the Care Transitions Project is to improve health care processes so that patients, their caregivers, and their entire team of providers have what they need to keep patients from returning to the hospital for ongoing care needs” CMS

Readmissions OR

Why do we care? § America has a $2. 2 trillion medical bill. § Hospital inpatient care is the most expensive type of health care. § Nearly $31 billion - 10 % of the total patient care budget – was spent on more than 4 million patient stays that could possibly have been prevented with timely and effective ambulatory care. (Agency for Healthcare Research and Quality)

Care Transitions Theme "Care transitions is a team sport, and yet all too often we don't know who our teammates are, or how they can help. " ~ Eric A. Coleman, MD, MPH

What can you do to help? • • • Become a supporter Join the disparities workgroup Join a Technical Expert Panel (TEP) Help us to be even more inclusive Give us your ideas!

Questions / Suggestions / Comments Cindy Sun, HHQI RN Project Coordinator csun@wvmi. org 304. 346. 9864 ext. 4279