In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease Care at Home Model Ms. Ann Rodriguez-McConnell, R.N. Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013

2. The faculty have no conflict of interest with regard to
any information presented, and will not endorse any
specific products or specific service vendor.

3.  Discuss Current Healthcare System
 Describe Wagner’s Integrated Chronic Care Model
 Describe the Care Delivery Practice
 Define Self Management Support
 Discuss Principles of Adult Learning
 Discuss Health Literacy
 Discuss the Principles of Motivational Interviewing
 Discuss Goal Setting

4.  2/3 of the nations hospitals will be penalized in Medicare's
campaign to reduce the number of patients admitted in
one month. 1
 Medicare identified 2,225 hospitals that will have payments
reduced for one year starting October 1, 2013. 2
 Hospitals that treated large number of low income patients
were more likely to penalized than those treating the
fewest impoverished people. 3
 Averting 1 out of every 10 of those returns [Re-Admissions]
could save Medicare $1Billion dollars. 7
 Solutions involve a coalition of post-acute providers to
work collaboratively, breakdown silos, and get patients to
the right care setting. 4

5. Meet
Harold…

6.  Fragmented health system
 Increasing incidents of chronic disease
 Complexity of care
 Acute based system
 Poor transitions
 Language barriers
 Changing healthcare landscape
 Patient labeled “non-compliant”
 What a patient does at home is different than what the
doctor ordered
 Uncoordinated care

7.  Poorly controlled disease
 Increased avoidable Re-Hospitalizations and
ED visits
 Unnecessary changes in treatment
 Increase incidences of Chronic Disease
 Miscommunication and Confusion
 Medication mismanagement
 Non Adherence and non-compliance
 Lack of follow up/Missed MD Visits

9. 3%
16%
26%
23%
15%
6%
11%
No Physician
1 Physician
2 Physicians
3 Physicians
4 Physicians
5 Physicians
6+ Physicians
Source: Anderson, G: Chronic Conditions: Making the Case for Ongoing Care, Johns Hopkins University; November 2007
@2010 Penta Health (All Rights Reserved)

10. 50
40
30
20
10
0 1 2 3 4 5
3.7
10.4
17.9
24.1
33.3
49.2
Number of Chronic Conditions
Source: Anderson, G; Chronics Conditions: Making the Case for Ongoing Care; Johns Hopkins University ; November 2007

11.  Patients understanding and adherence to medication
instructions is a key factor in avoiding a return to the
hospital 8
 The Home Health Quality Improvement (HHQI) National
Campaign helps home health stakeholders and multiple
health care settings improve medication management and
reduce avoidable re-hospitalizations. 9
 www.homehealthquality.org
 The campaign offers free Best Practice intervention
packages (BPIPs)
 “Fundamentals of Reducing Acute Care Hospitalizations”
 “Improving Management of Oral Medications”

14. Person
Centered
 Goals Drive Care
Member of Team
Dignity & Respect
Evidence Based
Clinical
Engagement/Self
Managing Support
Transitions
Coordinated
Time
Settings
Providers
Better Care, Better Health, Lower Cost

16. John Charde, MD, VP Strategic Development, Enhanced Care Initiatives, Inc. (April 2006)

17. Source: “Improving Primary Care for Patients with Chronic
Illness”, Bodeheimer, Wagner, Grumbach, Jama, October 9, 2002, Vol. 288, No.14

19. Relationships/ Patient Centered:
•Holistic Assessments
•Trust Building
•Patient Engagement
•Face to Face Visits
Self-Management support:
•Patient specific SMART goals
•Motivational Interviewing
•Facilitation of behavior change
•Problem Solving

20. Expertise/Coordination:
•Patient is “expert” of self
•Evidence based care delivery
•Interdisciplinary team
•Learning Environment
•SBAR Communication
Technology/Decision Support:
•Early Identification of Exacerbation
•Positive reinforcement & SMS
•Meaningful data exchange
•Make “right thing to do the easy
thing to do”

37.  Provides an avenue for health care professionals from
various disciplines to meet and discuss issues and best
practices for reducing hospital readmissions. 5
 It breaks down barriers by giving health care providers a
look into what's involved in other providers’ roles and a
view of the complete information needed to achieve
well-coordinated, patient–centered care. 6
 Examples:
 University Medical Center RHP 15
 Sierra Providence Post Acute Coalition Committee (PACC)
 Mano y Corazon Conference 2013
 Southwest Association for Healthcare Quality (SWAHQ)
 Project Amistad (Community-based Care Transitions Health Coaches)

40. “Life is a pond.
We are all
pebbles. Never
underestimate
the difference one
pebble can make.”
Hardwiring Excellence
Quint Studer