Chapters Transcript Transitions of Care thank you and thanks, uh, for all that you do before we get into the presentation, I want as to pause for a minute and take stock that it's been a really, really Hard two years, and many of us have suffer. I say. All of us have suffered in large and small, visible and invisible ways, and it's so critical that all of you take care of yourself. We all take care of ourselves during this time because if we don't, we can't keep giving to those who depend on us. And one of the ways I would encourage you to care for yourself is to get out into nature and see when you walk or run or get out our bike in nature, especially if you're looking at the beautiful lake or the sun shimmering on the rippling river or a mountain, you not only get the health benefits of exercise, you get this sense of awe. Uh, is that sense of oneness with something bigger, something greater, that we're all connected to a higher purpose. If you're religious, you may call that purpose God or grace. If you're spiritual, you may call it a universal being, but Let's just call it love that sense of connected You see that love is not only rejuvenating us, but if I think about what it takes to transform, Uh, and the flip side is the absence of when we're connected to that. Love is fundamentally what's driving all of our problems of society. Now, in all of our quality and value defects, you see in almost all of those there's this sense that some group or some person or some role is less worthy of being part of the team of being connected to their voice isn't worth being heard. And because of that, we suffer harm. But the flip side is to transform, and we'll share what our framework at U H has been. When you align around that purpose, where you bring people together to innovate and get ideas and then you deploy solutions, it's the way we move mountains. And it's what the work that you have all done in stroke. And Kathy, thanks to your brilliant leadership, I mean, it's just breathtaking what you're going to do, uh, and what you have done. But my role is to push you even further on that, because when I look at where you h and almost all of health care is. It's, though we've done miracles. We still have medical error as at least the third leading cause of death. Third, And if you add not controlling chronic diseases and diagnostic errors, it's number one, and this isn't we need to wait for a cure. This is We know the solutions. We've just not deployed them. Healthcare today squanders a third of every dollar we spend on therapies that don't get people. Well, that's 1.4 trillion $11,000 per person, more than the net worth of a family in Cleveland, and somewhere between three and 10 and four in 10 patients leave their interaction with healthcare, saying I wasn't listened to. I wasn't respected. And I'm afraid to go home because I don't know how to self care. And for all of those gaps that I just said, if you're poor, if you're colored, if you're a woman, Those numbers are somewhere between 2-2 and a half times worse for almost everything we do. So I agreed to join here today, not just because I'm a huge fan of Kathy, which I am. But to get you to hopefully accelerate the great work you're doing because we're the ones who are going to solve these problems. I won't bore you with the national policy. But suffice to say, changing payment policy is kind of needed, but it's had a trivial impact on quality. What changes quality is what you do every day. But we need to get a broader lens if you're interested or want to read some of the work we did at U H or how we're approaching this. This is a New England Journal piece that we published that summarizes those gaps that I just said. But fundamentally what they evolved to goes back to my lack of love. You see, our health care system has evolved to be reactive and transactional. When a stroke patient shows up in front of you, they get amazing care. But what happens is they're care goes on over time. They get care over the next couple years and we haven't built those systems that are more proactive and relational that we cover people and you know, in my responsibility for the a c o. One of the highest cost groups, we have and I say cost. I mean annual costs are stroke patients, and when we meet and coach are people who have high expenses, the stories often the same. And there's probably a dozen people I talked to is that God, I got great care of my wife or spouse got great care, but I went home and maybe for the few months I was in rehab. But then I was kind of on my own, and I was in this middle ground. Where does my primary care doctor treat me does My neurologist does my PM and our doctor and and I often felt I fell between the cracks and so many of these things, and and I wasn't sure who owned that relational part of the care. And I think that's perhaps another front chair that if we, um, we would like to engage with you. So let's taking that concept. We call it leading of Love, and I want to just briefly share with you what you h has been driving towards as all of you. I'm sure I've heard this framework of zero harm and each of us becoming a zealot for zero harm to get zero physical harms, your emotional suffering, zero gaps in care and zero, uh, inequities. I mentioned every employee in the organization needs to be engaged, and we have a ways to go. But I want to just share with you some of the team members that might not have viewed themselves as team members but are essential, All right. And you'll notice that almost all of these people that are engaged are people of color who their baseline statements was marginalized. And we worked with our transport people to say I'm going to stop believing that my voice is not heard. And I'm gonna start believing that I when I speak up change will happen E. V s workers. I'm gonna stop believing that I'm just a housekeeper. I'm gonna start believing that I play a critical role in the safety well being and health of all we serve. This is key because imagine if every one of the employees on our units and our teams starts believing that they're a caregiver, because I can't tell you the number of times we've seen an E. V s worker walk into a room and say I don't know what the diagnosis is But this patient looks sick. Something's not right and picks up a problem earlier. Or a transport patient you know, does the same thing. Or even if not, pick up something comforts a patient as they're transporting some. So bring everybody into the fold. Now I mentioned why it's key to bring everybody into the fold, because this isn't just to feel good. It's where innovation occurs, an innovation if we define it as this concept of ideas that have an impact. And if you look at the science of innovation, it's really simple. It's where we create a culture and a structure where doors ideas could meet in me literally. Think of it as this idea of idea sex that you bring in different roles different. You bring in engineering outside of health care because almost every problem that we're facing, somebody's figured out a solution or there's a close solution to it. But we just haven't brought the spaces to bring all the different parties together, to brainstorm, to take ideas to new sense. And so what? The idea for this is is we don't just have really smart people, and I wouldn't be at a neurology comments I didn't show a brain, but that think of this as a collective brain amongst you. H where that were part of this group of a collective source of wisdom that has all the different role types and just the number of roles represented at this conference is breathtaking, and I would encourage you to do that. The third part of this innovation, or this transformation of leading with love, is our management system. You see, there's overwhelming data that good management matters in health care, much likely to hit performance. And good management is almost entirely absent in health care and accountability, and particularly physician accountability is virtually non existent. We have huge variation in practices, but not a lot of making sure that we narrow those variations and the management system that you may have seen we lazily drive on is these really four components of making sure everybody knows goals, roles and expectations. We build an enabling infrastructure where the idea is we provide measures or we convert goals. Two measures and behaviors we provide tool kits and product management is what many of you do. Third is that we engage and connect that the real work is at the bedside, So we create forums for this connection for that innovation. And finally, we report and have shared accountability. And and I want to take one moment about how we define accountability because so often accountability is I blame and judge someone. But I wash my hands of responsibility. It's this punitive thing. Shared accountability is this beautiful concept that says we will only hold someone else or a lower level leader in the organization accountable if we first hold ourself accountable to set them up to be maximally successful, and that means they know their goals. They know the roles we support them to win. But if we continue to do that and people don't engage, there has to be accountability. The idea is, this concept of love is big enough to you to have a to shine your own bright light, but to also be under the spotlight for performance. And this is everywhere we look. We have nursing safety practices, huge variation amongst individual staff that we have include amongst physician practices. And if we're going to get to zero, it means we have to drive performance about that. Yeah, Now, how have we gone about doing this? And what might you think about drugged driving this? Well, what we've done is this idea of making visible defects in value, and we group them into staying well, getting well and getting better. So let's just think about stroke. Staying well is annual wellness visits, cancer screenings, immunizations, which hopefully we've all had getting well is managing chronic disease. I'll show you some of our data are stroke patients about how many of them had uncontrolled hypertension. How many of them had uncontrolled diabetes? Was the stroke preventable? If we had treated them? Don't know for sure, But we're sure not helping if we're not doing those things and then defects in helping people get better. So that is for any acute condition. Are we coordinating care with primary care? Is the therapy beneficial for the literature is quite clear for virtually any therapy we do. 30% of them aren't needed. If we have appropriateness criteria for spine surgery, you all may know it's a whopping 45 to even 50% aren't needed if you have criteria, but we are now with our centers of excellence, but previously we weren't applying. Those have we used evidence based checklist and best practices to reduce harm, like the mobility stuff you're just talking about, because the evidence is unclear. And are we measuring and minimizing harm? The way we've been organizing to create that culture for innovation is this concept of fractal. And let me just Give you two seconds on this because it's a beautiful concept. Fractal are ubiquitous in nature. There are villi are fractal, capillary or fractal, glamorous or fractal ferns. Broccoli's flowers and fractals are identical shape and varying sized structures. And they evolved because if any time a flower wanted to grow bigger or are really we were expanding, I had to write new genetic code. It would be very efficient. So nature evolved to say we will grow by just making a simple rule. You create a repeating but smaller size structure, and you scale it in. Fractal management is a take off of that and are simple rule is that any higher level of the organization needs to create a table where every lower level has the voice and what does that allow us to do What allows people to co create goals so they buy in it allows horizontal connections for pure learning, so one hospital or VOCs One stroke center learns for another, but it also provides vertical connections for that often missing accountability piece. And so we've been using this to connect emergency departments, hospital stroke centers, and I would encourage you in all of your work to make sure, Do we have the right structure that supports this innovative culture of bringing two people together? So how has you H done in the last couple years of driving value? And it's a pretty cool story. Mhm Annual wellness visits. Probably one of the most important things for keeping people healthy. I hope you all have them nationally, about 12% of having them. We were at 12% this year. We will hit 70%. Just three years later. It's off the charts for nationally. wasn that it was random? It was because we applied those principles of believing in zero harm connecting people in communities driving a management system. How are we doing in our blood pressure control and are chronic disease well with covid? When cancer screenings plummeted, ours went up because again, these principles just apply over and over, and our hypertension and diabetes control. How about helping people get well For diabetes? We know 18% of people are on the right medicines. Nationally. We started a clinic, uh, specifically focused on diabetes management. It's up to almost 75%, and they're losing weight. This is across 600,000 people, by the way. It's just like remarkable work. We know that many of our patients indeed half of your stroke patients have behavioral health issues Just two years ago or moving a year and a half ago. 2%. Let me repeat that 2% of our patients who had behavioral health needs Get those needs met because we had no access. You had to go to the Walker building. And so we designed care around patients needs, which is one of our concepts of transformation and found that 50% of the patients behavioral health needs could be met by a social worker. They don't need a psychiatrist, so we put those in primary care. Another 30% could be met by a behavioral health tele consultation recall a access clinic where they would be seen up to three visits to just do a diagnosis and a treatment plan, but then get back to primary care. And we've launched that across our whole, uh, euh systems. So now you can see we're up to being around 800 referrals per month at 173 in October is just for the first eight days when we, you know, literally quadrupled our access just by reorganizing how we provide care. And the number of the physicians who are refusing Referring to behavioral health has likewise going up. It's now what will be over 600 this month. How do we help people get better? The great work that you're all doing in largely in the hospitals? Well, a big part of that is getting them, you know, not having complications your mobility, getting them to the right post acute sight of care. In this case, we lazily trying to get people into our pack win because they have better length of stay. They have much lower readmission rates, but we summarize all this in our A C o data, and they give us an aggregate composite of quality Out of 100%. And you can see, a few years ago we were at 73%,, Where you're now at 100% amongst a handful of ceos in the country. Our cost. This is per member per year down by $2,000. And what that means is that's about $800 out of every patient's pocket per year, which is real. Real money is most of us. Many people are struggling to pay rent, and we look at overall quality in these graphs, where qualities on the X access and cost is on the vertical. And so we want to be in that lower right quadrant where were high quality and low cost, and I'll share with you. You can follow the U H symbol on this Euh 2017. Maybe the lowest 20% in the country started getting some religion 2018, moved a little bit, but really started belonging, believing we can get to 0 2019. Huge improvement in our performance. 2020. Now the top A CEO performing in the country, right? And I think about this and the one way it's so hopeful because we've made a lot of progress on the other day, we still swim with these defects. I think they estimate of a third of health care is waste is grossly underestimated because when we aim towards zero, there's so many things that we just labeled as inevitable that we now say are preventable. So I challenge you to say, How are you messaging to your teams that you're believing in zero harm and engaging everyone of your staff to do this? How are we creating structures and cultures where everybody belongs across the continuum of care and a cross cross disciplines where were brainstorming about how to further get zero harm across our continuum care? And how do we make sure that all the brilliant interventions you're doing that we're performing and there's a management and accountability system to drive 20 to serve our patients I mentioned briefly pulled some of your our data that we have, um, for R A C E O. And happy to explore this with you? Because for we have about 650,000 people in our a CO for roughly around 400,000, we have full claims data, which we have their you know, any care they get for a whole year. So just to share the last two years 2.5 years We had around 10,000 people who had strokes or 2.6%. Around 86%% of them had hypertension. Around 55% of those hypertension Zwart controlled I mentioned. Overall, it's probably 20% of our blood pressure aren't controlled. And likewise, if I mentioned earlier, about half of our stroke patients have a diagnosis of depression and anxiety. It looks like probably a third, maybe a little bit lower, have some codes, or that they're connected to behavioral health, uh, services. If we look at our readmission rates for stroke, the hospital care has has really had a dramatic shortening of our length of stay. But across all of our hospitals are readmission. Rates are going up a lot. And again, this is because I think we need more relational coordinating care between primary care rehab, neurology to say okay, Once people leave your great care, how do we make sure that there still are supported and they're not falling through these care coordination gaps? So my challenge to you, and maybe questions is how do we build upon that breathtaking and brilliant work that you've all done in the hospital managing stroke, creating world class church stroke centers and broaden it across our continue of care so that we continue to drive towards zero harm zero suffering zero defects and value and zero inequities for all that we serve. How do you further believe in zero harm and infect that and your teammates? How do we create the right structures to bring those diverse people together to solve these problems? And how do we then perform to make sure we're getting the results that all of you desire and our patients deserve? So we frame this broad framework leading with love, and all of us are essential in our own personal well being or is essential to do that. So I'd love to hear if we have a few minutes about what your eye will statements are or where you think we have gaps in our continue of care that we can drive further. So thank you for all you do. So Sarah passed. Erica is the, uh, the associate program director for the PM and our residency and instructor in medicine at the medical school. Hi. So I'll be presenting on acute inpatient rehabilitation. I have, uh, nothing to disclose, um, objectives of the presentation. So I couldn't talk about acute inpatient rehab without first describing what physical medicine rehab is or fizzy a tree. I feel like we're this specialty that nobody really knows what we do. So I'm gonna go into a little bit of PM and our, uh, stroke rehabilitation. Um, kind of what patients go into acute inpatient rehab and the criteria The benefits of acute inpatient rehab versus a skilled nursing facility, Um, functional measures to determine home versus post acute care and, uh, goals and homegoing post stroke. So what what is, uh, P m and R r Physical medicine and rehabilitation? Since residency, I've pretty much gotten the gambit of what P. M and R stands for pain medicine or they call, you know, we were called one's physical therapy doctors. Um, but really, we, uh our academy defines us as fizzy interests as, uh, nerve muscle and bone experts who treat injuries or illnesses that affect how you move. I always tell medical students were the function doctors. We take care of the whole person, diagnose and treat pain, and actually also a pain doctor as well. So that's a big part of what we do. Restore maximum function, lost through injury, helping with therapies, illness or disabling conditions. Treat the whole person not just the problem area. And then we lead a team of medical professionals in our in patient rehab. So physical medicine rehab started. Um, around 1938. Uh, that's when they turned physical therapy. Physician people started coming back for more and polio epidemic. Um, and it started to spread towards the civilian world with role of fizzy interest in the management of neuro muscular disease, especially limb and respiratory muscle weakness, contractors and, um, gait disorders. And then the concept of comprehensive rehabilitation. Um didn't come until a few years afterwards. Um, and they began after World War Two when people were coming back from war disabled and they survived. And it's like, Well, now what? There was no vocational rehab. There was no, uh, nothing in place for patients to go back. And then they were noticing the same thing with stroke patients, and he made a quote. I'm talking about two million people in this country who have suffered strokes and are now sitting around waiting to die because no one is helping them to live. So he went as far as to say that people didn't get therapy after, um, strokes and disabling conditions. It was a form of medical negligence to not give patients appropriate therapy, which was I thought it was very powerful. Um, so acute inpatient rehab nowadays, um, stroke encompasses one of the largest, uh, proponents through Medicare and CMS guidelines. The way we, uh, you get Facility to classify as an acute inpatient rehab, you have to meet 13 diagnostic conditions, and 60% of the patients in that facility have to meet one of those conditions. The other 40% can be, um, pretty much your disability cases are very, uh, medically complex cases that don't have a distinct kind of diagnosis but have been in the hospital for a super long time. Some of our post covid are coming in like that, but we call them critical illness. Myopathy can slot them into, like, one of those neuro categories and things like that. So we kind of try to work with patients to put them in the categories so that they fit criteria honestly, So they get the rehab, um, so stroke rehabilitation. It's it's so important because 88% of strokes end up with some degree of Hemi apheresis. And the timing also matters because some intentional movements start beginning within the first 6 to 33 days. So in the first, within the first week to a month after you're gonna start seeing some motion flexor synergy followed by development of extensive synergy happens. Arm is more involved, usually in the beginning, with eventual motor recovery of the leg that occurs earlier and more completely. So. You know, when you evaluate stroke patients, a lot of times they can't move their whole side, and my leg moves today. It's like, Oh, fantastic, But the arm is always kind of lagging behind. Most recovery takes place in the first three months, and only minor additional recovery occurs after six months post onset and can continue up until a year post. So we usually, uh it's pretty much saying that rehab kind of in the beginning is very crucial for these patients. Predictors of motor recovery, uh, severity of upper extremity onset. So with complete arm paralysis at onset, it's a poor prognosis. 9% recover good hand function, the timing of return of hand movement. If motor recovery of the hand occurs by Four weeks, there is a 70% chance of fool or good recovery. Poor prognosis is usually no measurable grass by four weeks. Severe proximal spasticity or prolonged facet period. Um so which patients, uh, can come to us? They have to require at least PT ot and speech. But with that, you can't have a patient just with OT and speech needs. There always has to be a physical component to it. So if they're walking all around the the unit, but they can't feed themselves and they can't talk, they can't come to acute rehab. Unfortunately, um, the big thing has to be physical therapy needs, and then you add in occupational or speech therapy. Most often than not, those strokes need the whole three, And they have to be able to complete three hours, five days a week, Um, or at least a 15 hour a week role, which we call a 900 minute rule. So if patients are not able to do it exactly the five days, they'll try to spread out three hours kind of in seven days that they're there. Um, they must reasonably be expected to actively participate and benefit from intensive rehab. Requires physician supervision with face to face visits at least three times a week. That's called the medical complexity piece. When Insurance decides they want to deny a patient, UM requires intensive and coordinated team approach to rehabilitative care. The benefits of in patient Rehab This was A retrospective database study. Uh, they pulled, um, 200,000 patients from a big kind of Medicare stroke database And, um file and picked different categories about 2% randomly chosen a mild, moderate and severe impairment of stroke and logged their cognitive functional status, motor functional status, acute care hospital transfers, DC, the community and then the length of stay. And they found that earlier acute rehab admission was beneficial among severely and moderately impaired patients. So admission within seven days for once they're medically stable is recommended for stroke patients. Um, they've received. They have saw better gains in cognitive, um, Functioning within if they were admitted within seven days and better motor gains if they were admitted at least within 14 days Um, and then for skilled nursing facilities versus acute inpatient rehab, it's no surprise have There was many studies I picked this one. Uh, there was This was a cohort study done within 2013 to 2014 published in 2019. Demonstrated that acute inpatient rehabs was associated with substantially improved physical mobility and self care function compared with rehabilitation and skilled nursing facilities. Um, skilled nursing facilities only will allow about You get about an hour of therapy a week if that most I've had I had an insurance person once. Tell me, uh, that oh, they're only going to get an hour every single day. But every single patient in Anniston will say they'll get one hour, maybe every 3-4, if not five days. So it's a very big difference, whereas an acute rehab your they are getting up with occupational therapy in the morning. Uh, physical therapy, usually somewhere mid morning speech therapy, somewhere mixed in. And then they do another physical therapy in the afternoon. Um, so this study was actually published with from Medicare guidelines And, um, with the bundled payment plans and the the impact act that's coming with all these. Uh, there's a big shift towards, um, skilled nursing facilities instead of acute rehabs because of the payment plans, um, and that they say that it's just way more expensive. So it's a financial incentive for insurance companies almost to kick patients the skilled nursing facilities instead of going to the acute rehab. I was on a first name basis with Medicare Aetna Gold Insurance reviewer because of how many period of years I did for Medicare. Aetna Gold. So there is just you kind of know, the insurance companies and where they're going to go with it, which is really horrible because it's dictating care outside of what the patient truly needs. Um, so we, uh, define are different. Like what? Patients? How severe they are in terms of functional independence measure or film scoring. Um, no helper is pretty much people walking around in the community complete independence or modified independence if they're using a cane or a walker or some sort of crutch for some reason, Helper modified, dependent. So supervision, which is the patient, does everything. They just need to be watched either cognitively or for some other reason. Um, menace ist, uh, the patient will do about 75% of the work, modest, about 50%. The this is kind of like the sweet spot for acute rehab. It's like men, too modest cyst. Um, when you're coming into the complete dependence of Maxus and total assists, that's when you have to start realizing that patients may not get better within the 23 week time frame we have for them and the and depending on social supports. That's when kind of that plays a picture and whether they can get accepted or not, or whether they're going to even be able to go home. Because the goal for acute inpatient rehab is they get admitted for the X amount of time, and the idea is always to go home. Sending into a skilled nursing facility is actually a negative in a way so the Max assist patients always need to be really evaluated to see. Can these patients really go home? And what's the what is the family thinking? Because they're always like, Well, they're gonna walk after rehab and it's like, Well, that's not really the case, you know, depending how much time they have you got. Everything takes time, especially like what I tell all my patients just takes time. We can't just cure you with three hours of therapy a day. Uh, we use and pack, as you guys all probably know in the in the, um in the acute hospital setting. So the PTL evaluate, you know, the bed mobility standing, um, transfers, walking around and steps if they're able to ot does the feeding the hygiene dressing, toilet and bathing and these different esoteric numbers that you come up with they decided that L Tech is at about 11. But L Tech comes with a whole slew of other things that they always deny as well, uh, skilled nursing facilities and acute rehab. You can't really parse out with an impact all that well, they usually live around the 13 to 14 number range. Home with home care is around 17 and home, with no services around 19 to 20. So impact is great as far as it goes for determining if a patient actually needs post acute care services. But it's not very good in deciding whether a patient needs to go to skilled nursing facility versus the acute rehab setting. Um, but and for stroke patients, higher stroke severity is were observed to be most strongly associated with the odds of a destructive post acute care. So if you moderate or Max assist, patients definitely would need post acute care. But they don't decide for the two. Um, what has been shown to help is if you couple the impact with the stroke, severity, age, sex and race, they were better able to differentiate acute rehab versus skilled nursing. However, increasing age, pre morbid physical disability and inability to ambulance increased overall likelihood of discharging to skilled nursing facility. Um also, Um, neglect plays a really big part. I couldn't find a study on that one, unfortunately, but I know from being a residency hemi neglect tends to be one of the biggest issues of patients going back home as well, unless they have supervision or 24 hour, uh, AIDS at home when you have neglect. It's so difficult because nobody can essentially leave them alone because they don't realize that that side is out. Um, so again and pack of 13 for basic mobility of admission provides higher accuracy in predicting admission to acute rehab. Using this minimizes inappropriate referrals and an improved quality of care, so predictors of recovery. So again, pre struck disability rather than strokes the various strongest predictor of discharge destination. So if you're more debilitated before you had the stroke, the odds of you going back home are low. Uh, 35% of survivors with leg paralysis regain regain useful functions. 20-25% are unable to walk without full physical ist instance. 65% at six months. Post stroke cannot incorporate the affected hand in their usual activities. And only 25% return to level of everyday participation in physical functioning quality of life higher in those with higher function. So these are a little different modalities that, um, can be implemented in acute rehab. We don't have the electrical stem much in ours, but we used to use it all the time at Metro when I was a resident. Um, it's a big center there and at the Cleveland Clinic. And what we do here in our people and our department, at least on the outpatient sector for people with chronic shoulder pain, is peripheral nerve stimulators and and things like that. Another thing that's at U H and Beechwood is exo device. A lot of young strokes post covid that we've seen love this thing because they can walk around a little bit better, but it is super cumbersome, cumbersome. This was an industry funded studies, so obviously it's positive, but it is a little cumbersome for the therapist to use. But some of the young guys really like it showed improvement and lower limb gait and balance, along with better gate and quality in hip and knee muscle activation. So goals post acute rehab from stroke. By the time of discharge, the patient should be able to provide reliable yes and no responses to questions and express himself or herself. In short phrases. Use the unaffected hand much more effectively for self care. Walk about 50 m slowly with hands on supervision, aided by Kane and ankle foot prosthesis. He or she would be expected to need some physical help for self care. Uh, physical occupational speech therapy after discharge should be focused on training and tasks needed to increase independence for activities at home and in the community. So therapy needs to be absolutely ongoing, as it takes 20 or more hours of practice to master a personal skill. So therapy with an impatient we have been continuing onwards is crucial. So what does it take to go home. This is a very personal personal thing because I've seen patients in the hospital, their supervision and can't go home because they have nobody to watch them at home. But then you have Max assist patients on ventilators at home so you can run the gamut of who can actually go home. It really comes down to social supports. Who Who's in your corner when? When stuff happens, you know, family. How much help can you get? Friends. What's your case management like in order to to kind of coordinate your care and and get the best kind of what, what the best that can be offered, Um, and also where you live. I mean, if patients live on two story walk up and no elevator, it's really difficult to go back home. Whereas the patients that choose a ranch, it's like, fantastic. I mean, when I was looking for a house, I was like a ranch. This is a P M, and our doctors dream. So it's like, you know, Everybody on my coldest sac is like 80 90, because when you live in a ranch, you can live in your house forever. So Word to the wise on that one. Uh, so for equipment, you know, we coordinate the walkers, the wheelchairs, the hospital bed, Um, anything that they would need to go. Hoyer lift. Um uh, but we don't. Nobody ever really does house visits. They used to do it back in the day, but we don't really do it much. Just kind of talk through a house setting. And tell the family if you have a hemi on the left side, which toilet to use in order to, you know, grab on the right side and things like that. So acute rehab in the area university, we have three their ventures through kindred. So the physicians are University, Hospital, the therapist, the nursing staff. Pretty much the staff in general is kindred, but all the physicians or university, hospital. So on it. Like I take, I used to take work and take all of Detroit. Now I take call it karma. I actually used to take Holiday von, too. I worked at all three of them. They all have differences, Um, beaches on, you know, on the east side, Um, we get a lot of the transplants and from a Hoosier patients. Parma is the only one that's attached to a hospital, and they can get out of the, uh, the other two that are free standing. They at least get consults. We kind of struggle with physicians coming to our freestanding facilities. If you have like a really bad heart failure patient, we do have medicine. But it's not University hospital medicine team, which is where we're kind of trying to build with a beechwood with a Hoosier and things like that. Parma has its own system, that the medicine team comes in from Parma, which is great, and Avon also has a similar. But they kind of have local guys that come in and that's it. You guys have any question that should have left my email, but first name dot last name? Take care. Good afternoon. My name is Kathleen Mandel, and I am the care coordinator for stroke, neurology, epilepsy and heart failure. I have no disclosures the Transitional Care Coordination team. The goal is to support the patients as they transition out of the inpatient setting and into the post accused post acute care setting. We help facilitate medical services that support the individuals recovery or management of illness or disability. The Uhh system Goals focus on healing at home 80% of patients discharged to home should have provider follow up 80% of the patients that are discharged to home or have home health. The goal of services put into place should be least restrictive. Protect the patients independence and maintain their safety with a skilled nursing facility. Acute rehab facility and L Tech are needed. 80% of the patients should discharge to AUh pack when post acute quality network. The Transitional Care Coordination Team. The TCC team consists of a patient centered, interdisciplinary group whose focus is to collaboratively establish a safe discharge plan. The court team, the R N transitional care coordinator, a k a. Quarterback, which I am, was elated to hear that because when I was in high school, I wanted to be a quarterback for the NFL. Mhm. So who knew? The patient Care navigator, a k a running back, wide receiver and tight end social worker. Special teams. Okay, follow me. Right. Thanks. The physician, the play callers, they leave the inpatient medical care of the patient. The care navigation center CNC They're in the upper booth there are centralized team of off site specialists that oversee the clinicians, focus on securing resources, scheduling services and supporting patients. Post hospital the physical, occupational and speech therapists. Special teams focus on assessing patients to determine where they can rehabilitate to maximize their functional outcome. The bedside nurse is also special teams responsible for patient education and discharge process. With support from TCC at P. C. N, the transitional care coordinator. The TCC runs the planet care. We meet with the patient between 24 and 48 hours of discharge. We verify address insurance, primary care physician and the patient representative. We identify the patient's previous level of functioning and previous living arrangement. At this point, when the TCC initiative is initially assessing the patient and introducing themselves, we discussed with the patient what the anticipated plan of care and the anticipated level of care might be. Once the level of care from the medical services and the recommendations from the therapists are known, transitional care coordinator circles back with the patient and discusses what that level of care is. If the patient accepts that level of care, the transitional care coordinator calls in her running back the patient care navigator. Mm hmm. The patient care navigator takes the lead and preferences the patient and the level of care. She provides them with a pack win list of facilities or agencies. She confirms, then that the okay, So that's skipping ahead a bit. Um, she refers also, if she or he would like to use the c N. C. Um, that is the specialized support center that can help expedite the referral process. She is continually updating the interdisciplinary, interdisciplinary, interdisciplinary team on any progress or to advance the case progression any information that might slow things down to create avoidable days, such as pre certification, lining it up with the medical readiness of the patient. Um, and so on the social worker, the special teams they are available and the case find for any psychosocial issues that might hit might occur. Some of them are adjustment illness, mental health, domestic violence, substance abuse, uninsured patients, hospice referrals, palliative care referrals, um, and FMLA paperwork, disability and things of that nature. Okay, back to you. H system goals, the stroke patients. Um, since 2000 and nineteen's, we have, Uh, very good trend of sending our patients home. Up to the um reported quarter two of 2021. We have increased from, I believe, 37% to 46 now. I'll talk about the stroke Family assessment. It is a comprehensive assessment that determines the caregivers readiness, willingness and ability to provide or support self managed activities. Post hospitalization. The assessment includes a set of questions that are asked by the TCC or the Social Worker once it discharged to home. Decision has been identified with inpatient interdisciplinary team. The questions engage the family and our caregiver to weight in on the discharge plan. Their answers and concerns are then utilized to guide the transition to home. The assessment ensures that all needs are addressed so that the patient can safely recover at home. This is a best practice as defined by the Comprehensive Stroke certification requirement. The discharge planning note two is where you can find the stroke family assessment to complete, and those are the questions. Can the caregiver assist the patient in their activities of daily living? Can the caregiver provide mobility assistance in and out of bad car? Can the caregiver obtained prescriptions assist with medication administration, verbalized understanding of the medications and do they agree that they have the necessary resources and are capable to care for the patient at home? It gives caregivers an opportunity to ask additional questions and allows us to anticipate and resolve needs in real time with everything there's challenges, challenges and benefits. At times, it's difficult to identify and and connect with with the support person, which makes it challenging, especially in the patient who presents that they're good enough to go home. The caregiver, never the the care provider doesn't feel entirely sure that it's going to be a safe discharge. What can we do about that? Well, one of the things we do is we definitely provide them with our phone number and follow up so they can follow up and reach out to the staff or myself. Um, yeah, it's there's benefits to it because when the caregiver is engaged, it's an extra set of years. As we know when a patient is ill and in the hospital, their anxiety level is very high, and it's hard for them to retain the information that is shared. So it acts as a good checklist. That's about it. All right, we'll get our speakers back up here for questions. Dr. Pastries, Um, there's a question from the chat regarding payment. Um, is there a difference in payment by Medicare, supplemental and an advantage plan? I'm not sure I know that it's straight Medicare. We don't need a pre off if a Medicare with I. I asked our liaisons Medicare with, uh, AARP is, like the best thing ever because they don't even need to get authorization. Um, but the supplemental plans is what makes it really difficult because the patients always like, Well, that's my supplemental. Why do you need to ask them? It's like, Well, yeah, they're the guys that hold the the wallet. The worst is like Medicare with United is usually run by Navajo health. That'll kick back pretty much every single time. And you have to do an expedited appeal because they don't even let you talk for a period of here. It's horrible. So we do have these problems all the time where, um, you know, one of the things about patient satisfaction is you set an expectation and then you meet the expectation, um, so we think people should benefit from certain levels of services. We set this expectation. They wait around for several days not getting rehab, and then they get denied, and then it engenders this very negative experience. And how do you think we should navigate? I mean, just realistically navigate through this? Yeah, I struggled with that, too. Um, I think almost not promising where they would go from the beginning, just in case. Just because you never know Because we can say I always just tell the patients I'm very honest with them. It's like, we want you to do this. We think it's the best thing, but you kind of reassure them. Okay, if you need to go to the skilled nursing facility, if you're like to low level, just follow up. This is this is who you need to contact in two weeks I had a Max. Is is critical illness myopathy patient. She didn't want to go back to a nursing home, but she has no support. And she's Max independent. I'm like, Look, I want you to come to rehab. You are going to get better. You give them the reassurance. You said go to this first and in two weeks have your family member call will reevaluate and send it over. And then if you're doing at this level, can have to set the expectation like, okay, you're low level now. Once you get to this level, then call and then you'll get to this level again. So the problem is, people sift through the cracks if they're really medically complex. I actually pushed for L Tax more than skilled because the L tracks that's considered in the insurance as a higher level of care. So the L Tec is. I usually say it's acute hospital, then in post acute care. It's all tech acute rehab in Smith to go up a level is always more difficult than to go down a level. So if a patient, super medically complex, it's always sometimes better to just shoot for the L Tec and let them and see. But then there are transitions of skilled nursing to acute rehab. It's just hopefully they don't get lost in the shuffle and just get stuck there. Essentially, Kathie, I could maybe just add a hopeful peace and show that we're practicing connecting people. This the waist between fighting with insurance is truly ridiculous. I mean, it adds their cost and adds to our costs because they put an army of people to deny things. We put an Army people to fight it, and none of it adds value. It's doing, it's all waste. And so we, um, you know have been messaging this. But finally we just started a new program with Anthem, their national CMO. Uh, I used to work with at United and said, We're wasting everybody's money and time. Could you put a team? And we'll put a team to say, Where are these barriers exist? And let's truly try to solve them that we put the patient first and stop all this waste. And it's been, quite, uh, hopeful. We have four or five teams that are actively, uh, we're working on this to your point of denials. One of the pieces that they said was, You know, if you give us access to your EMR will expedite approvals and reduce denials, and we had previously done that and our denials went up. They used it against us, but we had a safe conversation to say, Okay, we're willing to do that. As long as you put constraints that are denials aren't going to go up and you, you know, you meet, Turn around time of 24 hours of getting these approvals and and so at least I'm hopeful that there's some momentum working to say the insanity of what we're doing is is is truly ridiculous. I mean, the estimates are 25% of healthcare expenditures are just in this administrative BS. I mean, think about the waste of, you know, fighting to, uh, do it claims processing administration. That does no good. So police were working on it. Excellent. This is good. This is good to hear. I'm sure there's lots of people that are frustrated about this. Um, So Kathleen, you talked about, you know, people who don't have support structures and, you know, there's not There's not a safe home discharge. Um, you know, we certainly experienced that a lot that people sort of end up in facilities because they really don't have the support that they need. Um, how do we How do we help, You know, kind of navigate some of that if we think somebody could go home, but we're not sure. That's very challenging. And I'm sorry. I'm sure, if desired, no more words. I got it. That is a very challenging situation. It happens more often than we wish. Um, in some cases, if the patient, um, is scalable, Um, not that that's the best solution, but it could be the safest solution. We do try to get them into a skilled facility, and some patients are willing to do that because home is just not safe and particularly a patient that may never be able to return home. We can start the process of looking at whether or not they have cars that can cover a longer length of stay. And that would be a patient with a dual plan coverage with Medicaid. Other than that, you really can't create a support system that doesn't exist especially, you know, and older, older people who are sort of alone and isolated. So it's very challenging. Kathy, if I could just add because there's some payment reform that is hopefully coming, you know, one of the blueness is with CMS is they don't pay for respite care. So some of these people, if we could pay for a non skilled caregiver, we would just pay for that person to go, come and take care of someone but our current policies don't pay for that. So we send them to sniffer and Altec or no to higher level care. That's much more expensive and included in the build back. Better reform, if it ever gets past is painting paying for non scared, you know, non skilled conditions. So if that gets passed, it would be so much better for our patients and for us to be able to allow someone to come and to care for people who live alone rather than having to go to some institution. And on that note, unfortunately, there's a huge shortage of home healthcare providers that are going into the home. I can't tell you how many referrals we have made in the past month where we haven't been able to secure a home health aide for a patient. Um, it's just the reality of the situation. Even before covid, it was difficult. And now, with the covid pandemic, um, we're very short staffed in the home healthy home healthcare, um, Spectrum. Yeah, So I've been telling patients who can go and drive to an outpatient setting to do outpatient therapy because it's just more reliable because they can get their versus. They're just so strapped with patients that really can't go and can't drive. So I I encourage patients that can drive or do have the support to do outpatient because I've had families that wow, the physiotherapist never came. It's like, Well, they're kind of strapped If you guys, you guys came here to an appointment, so just drive to a place. So a lot of people think that it's the home. Health will be better, So sometimes educating them that they can go to outpatient therapy has hopefully can diminish some of that need for patients that really need it. one of the benefits of COVID pandemic is the new of, like virtual visits and the program with Hospital at home. Unfortunately, patients that live in the outlier areas of the state, we're not able to to service them, and you know there's transportation issues for them. So, you know, if they have Internet access, virtual visits are better than nothing. Um, you know, hospital at home is great because anyone that goes into the home is able to, you know, continue to secure, you know, a safe plan for them to stay in their home. One of the patients that we see from time to earn the type of patient from time to time. That's challenging is the ambulatory patient who is confused and doesn't have or maybe a physic and doesn't have a p t need, right? So do you think that will ever change that we can get them more, more more therapy, more robust therapy even though they're ambulatory? From what I've seen? No, unfortunately, So then doing the speech therapy and making sure they're plugged in. Um, we have a very small P M and R department or division were not even a department yet here. So we're really small where I came from, a Metro. We would really follow up those patients, um, with a stroke rehab doctor and kind of coordinate their care as an outpatient. And and that made it a lot easier for doing kind of therapy at home kind of deal. Uh, so as our division grows, I think it would be a lot easier to plug these patients in. But as right now, we only have only me and Dr Charles, which is two of us. Uh, let's see General PM and our society patients. I'm also a pain physician. So I see my pain practice. And then I've been incorporating General P, m and R because there's a huge need, Um, at least in the U H system. So I think once we can get to that point, well, we could start seeing those stroke patients that kind of went home and kind of navigating the rehabilitation piece of it, because that's a lot for neurology to manage all the medical stuff. Plus, Hey, what are we going to get back to life kind of deal? So that's usually where PM in our kind of fills the gap, and that is that we can focus on more the functional aspect, getting them into vocational rehab, plugging them into all the resources that they would need to kind of live. This is your new normal. So what can we do to make this better? Um, and that kind of gives people a little bit more hope that Okay, this isn't so bad. We can probably come through this, but as far as insurance, they won't let us do that, which is really unfortunate. All right. Thank you so much. Thank you very much. Yeah, Created by
