The Dream Team: A New Twist on Care

The Dream Team: A New Twist on Care
The Dream Team: A New Twist on Care
Management Design (Title/Presentation #359)
• Paula Spears, DNSc, RN, NEA-BC, VP Professional Practice, Research and
• Darla Banks, MS, BSN, RN, CCRN, CNL, Director CNL Program
• Sherry Petrillo, MS, RN, CCM, Senior Director Care Transition Management

                           AONE Annual Meeting
                               April 2015
The Dream Team: A New Twist on Care
Today’s presenters do not have any relevant financial interests presenting a conflict of interest to disclose.

Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be
earned by completing the online session evaluation.

      The American Organization of Nurse Executives is accredited as a provider of continuing nursing
          education by the American Nurses Credentialing Center’s Commission on Accreditation.

AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non-ACHE) for this program toward
advancement, or recertification in the American College of Healthcare Executives.
The Dream Team: A New Twist on Care
1. Participants will describe the role of nurse leaders to
   effectively develop a new delivery model for the acute care

2. Participants will critically analyze a care delivery model that
   creates a nurse led team to optimize the functions of care
   coordination within redesigned and integrated care
   management processes.
The Dream Team: A New Twist on Care
Our Story: Background Information
The Dream Team: A New Twist on Care
• Total of 25 acute-care and short-stay hospitals that are owned, operated, joint-ventured or
  affiliated with the System.
• 14 Hospitals are wholly owned
• 18 Outpatient Facilities
• 250 Community access points
• 3,800 Licensed hospital beds
• 22,500 Employees
• 6700 Registered Nurses
• 5500 Physicians
The Dream Team: A New Twist on Care
“There is no more powerful engine
driving an organization toward
excellence and long-range success than
an attractive, worthwhile, achievable
vision for the future, widely shared.”

— Burt Nanus, Visionary Leadership
The Dream Team: A New Twist on Care
Alignment with AONE

AONE’s Future Care Delivery Models                        AONE’s Nurse Executive Competencies.
Managing the Journey                                      Competency: Knowledge of the Health Care
• Nurses integrate all contributions to patient care      Environment
  and serve as managers of the patient’s journey –        Delivery Models/Work Design
  not only their piece but also the interdisciplinary     • Maintain current knowledge of patient care
  hand-offs throughout the patient care process.             delivery systems and innovations.
• Integrated teams achieve patient outcomes. As           • Articulate various delivery systems and patient care
  managers of the patient’s journey, nurses are              models and the advantages/disadvantages of each.
  responsible for clarifying, integrating and             • Serve as change agent when patient care
  coordinating the roles of the interdisciplinary team.      work/workflow is redesigned.
• The role of manager ensures that what the patient       • Determine when new delivery models are
  has negotiated with his/her caregivers is carried out      appropriate, and then envision and develop them.
  appropriately and that the nurse-patient team stands
  above all as the model for care delivery.
The Dream Team: A New Twist on Care
Alignment with THR Objectives

    •   Quality Measures                           •   Nursing and Physician Engagement
         – Nursing Core Measures                   •   Nursing Retention
    •   Pay for Performance Documentation               – First Year Retention
         – Present on Admission Indicators (POA)        – Nurse Vacancy
    •   Value Based Purchasing Indicators          •   Improved Patient Throughput
         – HCAHPS                                       – Average Discharge Time
         – Hospital Acquired Conditions                 – 11AM and 2PM Discharge
    •   Prevention of Complications/               •   Cost savings
        Risk Avoidance                                  – Variable Cost Opportunities
         – DVT                                          – LOS
         – Nosocomial Infections
                                                        – Decreased Overtime
         – Readmissions
The Dream Team: A New Twist on Care
Triple Aim

                  Goals                             Tools                    Outcomes

               Population                     Disease Registry
                Health                                                   Clinical Outcomes
                                Disease       Quality Measure            •   Disease specific
                               Management     Disease Managers               (Diabetes, Cardio,
                                                                         •   Preventive care
                                 Access                                  •   Care coordination
                                                                             (all cause
                                              Care Providers                 admission for
                Member            Care                                       ambulatory sensitive
Triple Aim                                    Care Transition Mgmt
               Experience      Coordination                                  conditions)
                                                                         •   Member experience


               Total Cost of                  Robust reporting
                   Care                       Dashboards             Financial Outcomes
                               High Value     Clinical Review        •       Total medical PMPM
The Dream Team: A New Twist on Care
Business Model
             Expense reduction                          Revenue

Decrease unit cost         Decrease utilization          Growth

 Delivery Efficiency
                              Utilization               Revenue
• All care team          • Population health      • Total population
  members                  risk management          risk and global
  practicing at the        strategies               budget
  top of their license   • Care coordination        arrangements
• Streamlined work         and navigation         • Bundle services
  flow                   • Decrease                 and payment for
• Process                  variation in             episodes of care
  automation               diagnosis and            or chronic health
• Decrease care            treatment                conditions
  process variation

            … while increasing quality and member experience
Care Management Redesign Initiative
The Case for Change

 The need for change:
    Over the next few years, we expect health care costs to rise, reimbursements to
     decrease and a large growth in the number of patients we will serve. To succeed in this
     new environment, THR has to deliver care differently. One of the ways THR will do this is
     in care management.
    There is a great variety in how THR cares for patients from hospital to hospital, making it
     difficult to consistently deliver evidence-based care system wide and across the
 The vision:
    Over the next few years, we will create a new care management model, adopt new
     technologies, workflows and processes.
The New Definition of Care Management
                                               Acute Care Coordination
                                       •   Nurse Manager
Improve outcomes by reliably           •   Charge Nurse
applying medical science to each       •   Advanced Practice Nurses
patient.                               •   CNL/PCF
                                       •   Direct Care Nurse

 Denials & Appeals Management                                                          Care Transition
• Clinical Review Denials &                                                              Management
  Appeals RNs                                                                   •   CTM RN
• Clinical Review Specialists
                                             Care Management                    •   CTM SW
                                                                                •   Post-acute Care Managers

                                             Utilization Management
                                   •   Clinical Review Utilization Management
                                   •   Clinical Review Specialists
Care Management Redesign Initiative
Corporate Level Organization Structure
                                                                 EVP, President of Population Management                                     SVP, Chief Nursing Executive
                                                                                                                                                   (Dr. Joan Clark)

                                                                         Chief Accountable Care               Care Management                 VP of Professional Practice
                                        Physician Advisors                       Officer                      Program Ownership                      and Research
                                                                                                                                                  (Dr. Paula Spears)

    CBO Leader                                                                                                    Entity CMOs

                                                                                                              Blue Care Transition                 CNL/PCF Director
                                      Clinical Review Director             Green Care Transition
                                                                         Management Senior Director        Management Senior Director               (Darla Banks)
                                                                              (Sherry Petrillo)

                                                                       • Texas Health Presbyterian         • Texas Health Harris Methodist       All Entity CNLs/PCFs
                                                                         Hospital Dallas                     Hospital Fort Worth
                                                                       • Texas Health Presbyterian         • Texas Health Harris Methodist
                                                                         Hospital Plano                      Hospital H-E-B
                                                                       • Texas Health Arlington Memorial   • Texas Health Harris Methodist
                                                                         Hospital                            Hospital Southwest FW
                                                                       • Texas Health Presbyterian         • Texas Health Harris Methodist
                                                                         Hospital Denton                     Alliance
                                                                       • Texas Health Presbyterian         • Texas Health Harris Methodist
                            Direct Reporting Relationship                Hospital Allen                      Hospital Stephenville
                                                                       • Texas Health Presbyterian         • Texas Health Harris Methodist
         . . . . . . . . . . . . . Collaborative Relationship            Hospital Kaufman                    Hospital Cleburne
                                                                                                           • Texas Health Harris Methodist
                                                                                                             Hospital Azle
What were the GAPs in accountability and what roles would
we need in a new redesigned care delivery model.
Accountability at “POC”

  • Needed a standard role to assume accountability for patient-care outcomes
  • Someone to OWN the patient’s experience
  • Needed a provider and coordinator of care at the point of care (not a manager)
  • Available, consistent, reliable, and across the patient’s stay
  • Needed POC application of EBP and PI to design, implement, evaluate, and improve
    patient-care processes
  • Additional issues:
     – Not meeting the desired mark
     – Lack of innovation for new roles / CDMs
     – Move to 12 hour shift
     – Hospitalists
Clinical Nurse Leader

                    • Master’s prepared advance clinician who functions as a
                      clinical leader for RNs and other staff, not as manager.
                    • Advances professional practice, accountability and reduces
                    • Major partner to nursing supervisors/managers.
                    • Knows about each patient in their microsystem.
                    • Acts as consistent figure for patient in the hospital to offset
                    • Acts in the role of ‘traffic control’ or “quarterback” or
                      “attending nurse” in coordinating rollout of the plan for care.
                    • Acts as the primary liaison for physicians, other disciplines,
                      and families.
                    • Monitors competency and mentors team members.
                    • “Advanced Generalist” is role needed.
                    • Responsible 24/7.
Twelve Bed Hospital©

• Model for coordinating patient care
• Breaks a patient care unit into small,               12 Bed   12 Bed    12 Bed

  manageable segments of 12 or more beds,
  depending on physical layout of the patient
  care unit
• Places a nurse facilitator in the “lead” role for   12 Bed             12 Bed
  all the patients in the hospital

Twelve Bed Hospital©

               Clinical Nurse Leader
                 per 12-16 patients
  Operational Standards
The CNL PAVES the way to great patient outcomes©

 Patient   ADIET    Assessing their understanding of   Assess understanding of    Validate Understanding   Evaluate Discharge Planning.   Safety Surveillance    Address Pain, Potty,   Anything      Explain
                    their plan of Care                 their illness              of education             Home situation                                        Position, Possession   else we can   continuity of
                                                                                                                                                                 Management             do for        Care/Give Card

                    P                                  A                          V                        E                              S   ©

                    What is the plan of care?          Health Decision            Health Literacy          What type of care will you     Fall Risk
                                                       Planning.                  Screening                need when you go home?         Central Line
                    Discuss Diagnosis, procedure,                                                                                         Foley
                    health care team, meds and         What happened during       Management plan          When are you going home?       Chest Tube
                    labs.                              this admission?            CHF                                                     Dressings
                                                                                  Coumadin                 Where are you going when       VTE
                    Begin discharge planning?          How long has it been       Diabetic                 discharged?                    Med Reconciliation
                                                       since your last            Inhalers                                                Restraints
                    Use leading questions?             admission?                 Diet                     Who is their support person?   Isolation
                                                                                  Stroke                                                  Seizure Precautions
                    Pt. journal                        Do you have primary        Core Measures            How will you get your          Suicide Precautions
                                                       physician – when was the   Pain                     meds?                          Depression Screening
                                                       last time you’ve seen
Facilitates Daily Care Briefings
CNL Dashboard: > 30 Indicators

                                                                                             Action Plan
 Transformational Theme: Improve Quality                             Max   Par   Threshold                   FY10        FY11        FY12     YTD 13   Q1 FY13   Q2 FY13
 Unit Acquired Pressure Ulcer - Premier per Clinical Advisor          0     1       2             3        Goal: Reduce Pressure Ulcers Occurrence
 By Cost Center                           CC#                  CNL                                             0          0             0        0       0         0
 Patient Falls - NDNQI                                                                                     Goal: Reduce Patient Falls
 Total Falls/1000 Patient Days                                                                                2.4         2.9        1.8        3.3      4.1       2.5
 By Cost Center                           CC#                  CNL                                            3.0         3.4        2.9        2.4      3.4       1.4
 DVT Frequency - Premier per Clinical Advisor                                                              Goal: Reduce DVT Frequency
 By Cost Center                           CC#                  CNL                                             7          3             1        1       0         1
 Failure to Rescue - Premier per Clinical Advisor                                                          Goal: Reduce Failure to Rescue Frequency
 By Cost Center                           CC#                  CNL                                             1          0             0        1       0         0
 Catheter Associated UTI - NDNQI                                                                           Goal: Reduce CAUTI Rate
 Total CAUTI/1000 Patient Days                                                                                N/A        N/A            0        0       0         0
 By Cost Center                           CC#                  CNL                                            N/A        N/A         1.33        0       0         0
 Core Measure: Pneumonia Vaccine                                                                           Goal: Decrease Missed Pneumonia Vaccine
 By Cost Center                           CC#                  CNL                                           0.00%      0.00%      0.00%      0.00%    0.00%     0.00%
 Core Measure: Influenza Vaccine
 By Cost Center                           CC#                  CNL                                           0.00%      0.00%      0.00%      0.00%    0.00%     0.00%
 Core Measure: HF 30 day Readmission Rate
 By Cost Center                           CC#                  CNL                                          33.33%      0.00%      0.00%      0.00%    0.00%
PCFs and CNLs - THR

•   14 wholly owned entities

•   124 budgeted positions

•   105 filled positions (March 2015)

•   CNL Director is operational leader

•   Resources are centralized and
    deployed to entity.
Academic-Practice Model

• Partnered locally with Texas Christian University.
   – First cohort of CNL students began in fall of 2009.
   – Two tracks:
       • Advanced Practice nurses post masters’ certificate course.
       • Generic CNL degree.
• TCU provides:
   – CNL certification preparation and host testing.
   – TCU provides philanthropic financial assistance to discount
• THR covers costs for THR nurses through tuition reimbursement
  and additional funding through THR’s Nursing Excellence Fund.
Redesign of Case Management to Care
Transitions Management
Care Transitions Management

    • Take patient through the continuum, not just to the front door at

    • Significant process variation through 13 hospitals

    • Abolishment of monthly CTM lead meetings
CTM Department/Processes


   • Refocus CTM Functions
    - Moving patient through system, including post-acute

  • Change Documentation Processes
     – Ease of use
     – Ease of real-time information finding
     – Ease of metric retrieval

  • Separate out UR-Denials/Appeals
Care Management
Ownership Matrix

                          Function                                CTMs                         CNLs             CR                        Facility
  Nursing Admission Assessment                                                                  o                                           X
  “Low-Risk” & No Transition Need Patients                                                         X
  “Low-Risk” & Transition Need Patients                               X

  “High-Risk” & Transition or No Transition Need Patients             X

  Readmission Assessment                                              o                            X                                            0

  Application of Readmission Risk Indicator (“RRI”) tool                                                                                        X

  Initial Estimated Transition Date (“ETD”)                                                                      X
  Updated ETD, if necessary                                           o                            X
  Discharge Instructions and Summary of Care                                                                                                    X
  Concurrent Reviews                                                  o                                          X
  Registration                                                                                                                                  X
  Identification of PCP                                               X                            o                                            o
  Post-Transition Planning                                            X                            o
  Health Decision Planning                                            o                            X                                            o
  Daily Patient Care Briefings Facilitation                           o                            X                                            o
                                                            X – Indicates primary responsibility       o – Indicates a role in facilitating the process/function

       Importance of the Role of the Unit Nursing Leaders
                                                                  • Share information and set performance
                                                                    expectations regarding the new
                                                Communicator        process for your Nursing staff

                                     Nursing                   Initiative
                                     Advocate                  Champion

   • Act as “voice” for acute care
     Nursing staff                                                          • Facilitate adoption of new processes
                                                                              and inter-disciplinary collaboration for
                                                                              your area
Care Transition Management
Implementation Timeline

                                               HIGH-LEVEL IMPLEMENTATION PLAN FOR CARE TRANSITION MANAGEMENT
    I M P L E M E N TAT I O N   March 2014             April 2014                 May 2014                        June 2014                            July 2014
          Care Transition Management
       M ILESTONES              3/24   3/31   4/7     4/14   4/21   4/28   5/5   5/12   5/19   5/26   6/2   6/9     6/16      6/23   6/30    7/7      7/14      7/21    7/28

          Implementation Timeline
  System Wide IT
  THP – 2 units
  THSW – 4 units
  THFW – 3 units
  THK – 2 units
  THD – 1 unit
  THAL – 1 unit
  THAZ – 1 unit
  THHEB – 2 units
  THC – 1 unit
  THA
                                                    Dates to be determined – dependent on recruitment/hiring of CNLs in upcoming 2 months
  THS

                                                                                                                                            Implementation Activities

 • CTM Documentation change before any roll out the units
   CTM Navigator
   CNL Navigator
   Superusers for each group

 • Physicians, Hospital Leaders, Nurse Directors/Managers informed of the
   overall initiative, education approach, and implementation approach

 • Charge Nurses and Direct Care Nurses educated through WBT; modules
   released (2-4 weeks prior to their unit go-live date)
   -- Supplemental Q&A sessions as needed using the CNLs/PCFs as Super Users to answer questions
Major Changes in Historical

              CTMs are both RNs and SWs

            - No longer react to referrals, instead proactive stance.

             - Each have a definite, discrete set of patients for which they are accountable.
Required New Model

          •   DCB (daily care briefing)
          •   Risk for admission
          •   ETD
          •   Transition Evaluation
          •   Completion of DC Plan
          •   PCP appointment
          •   Readmission evaluation, if applicable
          •   Post DC follow-up
          •   Regulatory compliance
Critical Success Factor

      The success of the daily care briefings process relies on recognition of the
        interdependencies between all members of the Interdisciplinary Team.
           Communication must be timely to improve the overall process.
Daily Care Briefings

    Daily Care Briefings Are…
    • Brief (average of one minute per patient)
    • Focused on patient progress and movement to transition, identifying any barriers and offering solutions
    • A high-level review of each patient’s needs for the next 24 hours
    • Led by a facilitator (i.e. Clinical Nurse Leader/Patient Care Facilitator/Charge Nurse/House Supervisor)
    • Inclusive of various members of the interdisciplinary team who bring information pertinent to their role

    Daily Care Briefings Are Not …
    • Patient care rounds
    • Shift report
    • Teaching rounds
Daily Care Briefing Questionnaire
Care Transition Manager

                              Daily Care Briefing Questionnaire – Care Transition Manager (RN & SW)

What is the patient’s payor source?

What is the appropriate patient status (IP, Observation, OP) and level of care (CC, Step-down, Acute, etc.)?

Does the patient continue to meet medical necessity criteria for current patient status and level of care?

What is the transition plan and plan progression for referred patients? Contingency plan(s)?

What are the patient transition needs/barriers (Financial, Psycho/Social, etc.) for referred patients?

Is this a high or low risk for readmission patient (based on RRP)?

What is keeping this patient in the hospital (medical necessity)?

What are the patient’s post-acute handover and follow-up care needs?

Communication by exception
Readmit Risk Tool

  • Use LACE + tool that is part of CareConnect/EPIC

        • “Validated index to predict early death or urgent readmission after
          hospital discharge using administrative data”
                • Score (red/yellow/green) shows on census list and also in
                  patient banners

                      • GOAL: To reduce readmissions by collaborative team
                        action for high risk patients
PCP Appointment

   • Within 3-7 days post acute care DC

                   • PCP, Free Clinic, Transitions House Calls
Purpose of Assigning an
Estimated Transition Date (ETD)

  • Ensures the patient has a smooth transition to the next care setting

  • Provides a goal for the interdisciplinary team to work towards

  • Enables proactive coordination of acute care services

  • Provides clarity to the patient/caregivers about when the patient is going home so they
    can prepare transportation and home arrangements

  • Prevents clinical complications (i.e. nosocomial infections, pressure ulcers, general
    debilitation, etc.)

  • Prevents denials for unnecessary days
Transition Evaluation

  • Initial patient screening that will serve as the foundation for the Transition Plan

  • Unit Care Transition Manager (for referred patients)

  • Occurs within 24 hours of receiving the CTM referral
  • Transition planning begins upon admission and therefore the Transition Evaluation must be conducted early in the patient’s stay in order
    to maximize health outcomes

  • Using the standardized Transition Evaluation template in CareConnect
  • Review ED CTM notes or previous acute stay notes to gather any pertinent information on patient background if able

   • Readmissions
   • HCAPS scores/R/T Care Transitions
   • # of unique patients touched by CTM
   • # PCP appointments made
   • Completion of T.E./DC plan
   • Regulatory Compliance.
Average Length of Stay

                                                 Care Management Redesign Average LOS
                                                                      All In-Scope Units - 24 month Trend

    5.20                                                                                          5.19
                  4.90                 4.92                                4.90            4.92                    4.90
                                4.85                 4.83                           4.85
                         4.81                                      4.79                                                      4.81                                                4.79
    4.80                                                                                                                                                                4.76
                                              4.68          4.67                                                                              4.66     4.67                              4.67    4.67





                                                               ALOS          Mean          UCL           LCL              Linear (ALOS)

  Systemwide ALOS was calculated using all patients, all in-scope units, and all wholly owned entities (excluding THSH and THHVH). ALOS
  analysis excludes inpatient rehab, psych, mother/baby, and expired patients.
                                                                                                                          Confidential And Proprietary – All Rights Reserved – For Internal Use Only Texas
                                                                                                                                                    Health Resources
Readmission Rate

                                              Care Management Redesign Readmission Rate
                                                                   All In-Scope Units - 24 month Trend


    10.5%       10.3%

    10.0%               9.9%                                                9.9%                          9.9%
                                       9.7%                                                       9.8%
                                                                                    9.5%                         9.5%                      9.4%                        9.5%
     9.5%                                            9.4%
                                                                                                                                                  9.3%                        9.3%
                                                                     8.9%                                                          9.0%
     9.0%                                                   8.9%                                                                                                                     8.9%




                                                      Readmit Rate           Mean           UCL          LCL            Linear (Readmit Rate)

 All-cause readmission rates were calculated using total 1 – 30 day readmits as the numerator, and total all-cause, all-readmission cases as the denominator.
 Includes all wholly-owned entities, excluding THSH and THHVHA.
Clinical Review Data Trend

                                                         Systemwide Clinical Review Performance
                                                                                      24 month Trend


                                                                                     5.20%   5.19%
     5.00%                                                                                           4.89%           4.85%    4.85%
             4.44%                                                                                           4.47%
                     3.99%                                   4.02%           4.01%                                                                                                           4.06%
     4.00%                                                                                                                                                                                           3.70%
                                     3.47%   3.40%                   3.47%
                                                                                                                                                                   3.28%     3.26%   3.34%
                                                                                                                                                 3.18%    3.18%
     3.00%                                                                                                                                                                                                   2.69%



             0.06% 0.05% 0.07%       0.07% 0.07%     0.05%   0.05%   0.07% 0.09%     0.11%   0.14%
                                                                                                 0.12% 0.09% 0.10% 0.10% 0.12% 0.11% 0.10%                         0.05% 0.07% 0.07%
             Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13    Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
                                                                                                                                                                   Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
                                                   % or Total IP Registrations with an initial Denial     % or Total IP Registrations actually written-off
                                                     Mean                                                       UCL
                                                     LCL                                                       Linear (% or Total IP Registrations with an initial Denial)
Source: Executive Dashboard metrics; XNET PXPWC1 AND PXPWC2
Includes clinical and technical denials.
Includes all wholly-owned entities.
HCAHPS – Care Transitions

                                                Care Management Redesign HCAHPS Care Transitions
                                                               All In-Scope Units - 12 month Trend

                                        61                         61                                         60.9
                             90th %

                        58                                                                                    57.3              57.2
 Care Transitions Top

                                       56.7                       56.9
                              75th %                                                                          55.8
                        56                                                                                                      55.4
 Box Score

                                       53.7                       53.9
                        52                                                                                    52.9              52.9
                             50th %   52.2



                                      2014 Q1                   2014 Q2                                      2014 Q3           2014 Q4
                                                         THR     50th %ile       75th %ile       90th %ile      Linear (THR)
HCAHPS – Nurse Communication

                                                       Care Management Redesign HCAHPS Nurse Communication
                                                                            All In-Scope Units - 24 month Trend

                                                                                     85.6                                             85.7      85.6
                           86                 85.3             85.3                                        85.2              85.3

                                90th %                                               82.7                                             82.5      82.5
 Nurse Communication Box

                                              82.3             82.3                                                          82.4
                           82         81.4

                                75th %
                                                                                                                                      79.5      79.7
                           80                                  79.3                  79.4                                    79.4
                                              79.1                                                          79
                                      78.3                                                                                                      79.5
 Top Score

                           78                                                                                                78.7
                                50th %                         77.9
                                                                                     77.4                  77.4



                                   2013 Q1   2013 Q2          2013 Q3               2013 Q4             2014 Q1            2014 Q2   2014 Q3   2014 Q4
                                                              THR       50th %ile           75th %ile   90th %ile   Linear (THR)
HCAHPS – Discharge Information

                                                           Care Management Redesign HCAHPS Discharge Information
                                                                                All In-Scope Units - 24 month Trend

                            92                                                           91.4                                                       91.4
                                                                                                               91.2              91.2     91.1
                                                  90.5             90.5
Discharge Information Top

                            90                                                                                                                      89.4
                                 90th %                                                  88.8                  88.7              88.7     88.8
                                                  88.1             88.2                                                                               88.4
                            88          87.5                                                                                             88

                                                                                          86.7                 86.5              86.7
                                 75th %
Box Score

                                                                   85.7                                                                             86.9
                            86                    85.3                                    86.2                                   86.3
                                                                                                                86                        86.3
                                 50th %


                                     2013 Q1     2013 Q2          2013 Q3               2013 Q4             2014 Q1            2014 Q2   2014 Q3   2014 Q4
                                                                   THR      50th %ile           75th %ile   90th %ile   Linear (THR)
Implications for Future Care

  1. Accountable care
     – CNL playing direct role in improvement workstreams with third party
       payers for diabetes, CHF, pneumonia and AMI patients to improve
       outcomes and reduce readmission on the inpatient units
     – Continue to evaluate the use of the CNL role to coordinate care and
       collaborate across three zones of hospitals and health care providers in
       over 250 physician practice settings.
     – Determine balance between using case managers, navigators, social
       workers, coaches and other roles
     – Continued innovation in care delivery models at micro-level
2. Value based purchasing and Pay for Performance
  – Retention of masters prepared generalists at the point of care and actively
    engaged in patient management
  – Focus of the CNL role is on patient advocacy and continuity
  – CNLs lead and improve interprofessional team coordination and
  – CNLs directly intervene to prevent complications and assure appropriate
    documentation of care
  – CNLs can impact quality and performance outcomes
  – CNLs promote evidence based care at the point of care and directly with
3. Cost containment and reduction
  •   Coordination of care to enhance the flow and delivery of services, reduction
      in unnecessary work (or rework) and cost
  •   Partner with the nurse manager and leadership team to tackle operational
      improvements at the point of care
  •   Provide direct feedback on staff effectiveness, staffing and care delivery
      appropriateness and barriers to effective staff nurse performance
Future Plans

• Continued partnership
• Development of options for CNLs to matriculate to DNP
• Identification of new environments for CNL practice
• Continued collaborative professional activities
• Focus on disseminating value of CNL role through
  demonstration of enhanced patient outcomes
Questions & Discussion

                         "Vision without execution is hallucination.”
                                     — Thomas Edison

                              Dr. Paula Spears:

                                Darla Banks:
                              Sherry Petrillo:
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