The IHC Drumbeat is a monthly email featuring hospital success stories, recorded IHC webcasts, and local/national educational resources.
March 1, 2017
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Featured in this issue:
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Community Memorial Hospital

Care Coordination Success Story
In June 2012, Community Memorial Hospital in Sumner, Iowa, lead the development of a Community Care Transitions Team (C2T2) and have since seen significant improvements in care coordination in their community. When getting started with their C2T2, they involved several members of Iowa Healthcare Collaborative including Dr. Tom Evans, and their HEN Improvement Advisor. Also, they engaged Telligen, IDPH, The Care Transitions Program, Iowa Health Systems, and others. Their purpose was to coordinate care between healthcare partners while transitioning patients from one level of care to another, share best practices within a network of community-based organizations, and eliminate preventable readmissions. They involved two patients, five family members/caregivers, area nursing homes, assisted living facilities, home health agencies, hospice agencies, EMS, the local area agency on aging, IHC improvement advisors, Telligen, hospital pharmacy staff, private area pharmacies, clinic manager and providers, private practice clinics and providers, local rehabilitation services groups, and several members of hospital leadership. Throughout this process, they were able to identify several issues and activities for improvement.
To date, the C2T2 has accomplished the following activities:
  • Implemented the use of verbal handoffs using the SBAR method.
  • Implemented the use of teach-back to educate patient and co-learner of new diagnosis and new medications.
  • Started notifying home health or hospice first, if the patient is enrolled, before sending to the ED.
  • Developed a unified transition form.
  • Communicated concerns and struggles with a state representative.
  • Developed a mission and vision statement.
  • Shared and data collection and performance improvement reports per agency.
  • Started discussing de-identified readmissions and unplanned transfers at every meeting. Those agencies involved can figure out if they had a hand in the patient’s care, making the discussion and improvement process, meaningful.
  • Bring education that every agency can use to every meeting. Some examples: Area Agency on Aging, Palliative Care, Antimicrobial Stewardship, MCOs, County Health Agencies, IPOST, Medication Reconciliation, and Behavioral Health.
In addition to their work with their C2T2, Community Memorial Hospital has implemented several strategies to improve discharge planning including:
  • Standardized assessment and evaluation process to determine patient needs at home.
  • Coordinate all services available to the patient including home health, assisted living, skilled nursing, hospice, palliative care, rehab therapies, etc.
  • Schedule all services before discharge.
  • Follow up appointments are determined by risk factors. Lace score is used to determine the risk factor. Patients at high risk of readmission are seen by their primary care provider within three days. All other patients are seen within five days of discharge.
  • Utilize a handoff note within the EHR that automatically pulls pertinent information from the record such as a vital sign, last bowel movement, activity, providers, immunization status, communication needs, etc. The nursing staff uses this note to give a handoff report to the facility or agency that will be caring for the patient. Also, a copy of the handoff report is sent to the facility or agency caring for the patient.
  • The care coordinator does follow up interview with the patients using the EHR to ensure the patient understood the instructions.                                                                                                                                                                                            Top
The logo for Iowa Healthcare Collaborative's Patient Safety Conference on March 14, 2017 at the Courtyard by Marriott in Ankeny, Iowa. The logo has a dark and light shade of blue with a golden stripe separating the two shades of blue.

Register for IHC's Patient Safety Conference

This conference will bring together healthcare professionals from across the state to learn about current patient safety topics prevalent in today’s healthcare environment. Best practices will be shared and discussed to increase knowledge of those in attendance.

Target Audience
CEOs, physicians, staff nurses, risk managers, nurse executives, critical care nurses, pharmacists, senior administrators, infection control professionals, quality assurance professionals, and trustees/board members.

Keynote Speaker 
Helen Haskell, MA, is president of the nonprofit patient safety organization Mothers Against Medical Error. Since the medical error death of her young son Lewis in 2000, Haskell has worked to improve healthcare safety and quality in the areas of medical education, patient-activated rapid response, infection prevention, medical error disclosure, and patient empowerment, among others.

The event promises to be a full day of engaging content and information sharing that you will not want to miss!

Click here to register today and access the agenda!
The picture is of the Iowa Healthcare Collaborative current staff members. There are three rows of men and women posing for a picture in front of windows. There are nineteen individuals in the photo.

Forces for Change:
Impact of the
MACRA legislation

By: Tom Evans, MD
The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA will affect every provider in this country. Signed in to law in April 2015, MACRA promotes the transition to quality-based payment by implementing two payment pathways for clinicians. MACRA permanently repeals or eliminates the Sustainable Growth Rate (SGR) formula, a mechanism created in 1997 to restrict growth in Medicare Part B spending. In practice, the SGR would have severely cut payments to providers paid under Medicare’s Physician Fee Schedule (PFS). Congress regularly has passed legislation temporarily averting those cuts. Passage of legislation permanently repealing SGR—in bipartisan fashion no less—gives providers much needed certainty around payments. Starting in 2019, clinicians will be required to choose from one of two pathways: The Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APM).
Click here, to view Dr. Evans's presentation.

Save the Date

Partnership For Patients (PFP)
Adverse Drug Events (ADE)
Affinity Group Learning Events

Three ADE Measures - Three Events
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Upcoming Calls and Events:
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Wednesday at 11:00 AM CST

HAI Community of Practice -
March 7, 2017
at 11:00 AM CST

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Patient Safety Conference -
March 14, 2017,
8:00 AM - 4:30

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Person & Family Engagement Community
of Practice -
March 16, 2017
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Falls Prevention Community of Practice - 
March 21, 2017
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Readmissions and
Care Transitions
Community of Practice -
March 28, 2017
at 11:00 AM CST
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HIIN Data Reporting Update
March 2017:

January HIIN
data due Wednesday,
March 15, 2017.
Contact your Compass
HIIN Team!

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The analyses upon which this publication is based were performed under Contract Number HHSM-500-2016-00070C, Entitled, "Hospital Improvement Innovation Network ", sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services.