ASPIRE to Transform Care #8
Amy Boutwell, MD, MPP
Founder and President @ Collaborative Healthcare Strategies | Healthcare Delivery Transformation
Brought to you by the season of giving.
TL;DR: R = Reach out and collaborate. Your offer to collaborate is a gift that will be willingly received and will enhance your success.
Key point: reducing readmissions is a co-produced outcome; high performing teams foster active collaboration between "senders" and "receivers."
Bonus: Check out the "Circle Back" video to see how practical and valuable cross-continuum collaboration is.
"Reach out to collaborate" is the "R" in the A-S-P-I-R-E framework.
"R" is an active - actually, proactive - action step. It calls upon us - we who are accountable for outcomes - to:
Who are "those who share in the care of" our patients? We get this information from the A + S + P part of the framework. (Analyze your data; survey internal and external assets, and plan a portfolio of strategies to achieve your aim). Your list may vary, but typical subgroups include: SNFs, behavioral health centers, community agencies, special services like HF clinic or complex care teams, etc.
The key is to ask yourself who else is involved (or should be)- and then find them and offer to work together.
Our experience catalyzing cross-continuum collaboration started with the STAAR (state action on avoidable readmissions) initiative, when we designed a strategy to reduce readmissions statewide. 3 key concepts from STAAR were:
One of the system failures is that we don't collaborate across settings and over time. The system performance (readmission rate) reflects that. When we mitigate that failure mode - collaborate - readmission rates go down.
How do you "reach out" and who do you collaborate with?
We'll turn back to a recent story I shared about the teams in Alaska. They analyzed their data, found that alcohol-related issues were among the top reasons for readmission in their community. Did they have a strategy for this? No. Did they have on-site SUD counselors? No. Were they going to hire a bunch of new people for this role? No. Did the hospital director of quality know the person who runs the SUD agency in the community? No.
All of these things are typical current state, and reflective of everywhere USA. Same exact stories in Kansas, Philly, central New York, rural Maryland, Houston - and just today, in Rhode Island.
So, what do we do in this situation? Do we say "there are no resources?" Do we say "there's nothing we can do?" Do we ignore the data and solve a different problem, preferring to use the tools we already have in our toolbox?
You already know the answer: tempting, but no. In order to be more effective, we need new tools in the toolbox. This new tool is cross-continuum collaboration.
Good thing we have google! In Alaska, Maryland, Philly, Kansas, Houston, and New York, when we needed to find a partner to help better meet a need of a group of patients, we literally googled it. It's ok to start there. "SUD services [my county]." Look up the Executive Director. I remember each of these moments with each of those teams as if it were yesterday, because it was significant. A moment of doing something different.
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At the time, it was not obvious this would work out. At the time, it felt vulnerable. Reaching out to make a new connection, to ask for a new relationship, to initiate a new effort. Rejection was possible. Criticism was possible. Wasted time was possible.
But it didn't happen that way.
The request is simple. Something like, "Hi I'm the [VP of Care Management] at [the hospital] and we have a [subgroup of patients] who have [this issue] and we'd like to do a better job for them so they don't need to return to the hospital so frequently. Would you be interested in working together to improve our ability to link them to your services?"
You know what the answer is? And I quote, "we would be thrilled."
Once you have a cross-continuum partner, resist the temptation to get into analysis paralysis! The good news is that we have a steady stream of people who need help, every day. So we have plenty of opportunity to take action.
Action looks like this: how can we identify who has [the need] and who [is a good fit for your services] and how [can we get them linked] to you? Try it for one person, tomorrow. Do it again 5 times, then 10. In weeks, you will create a process to facilitate linkage; and linkage is the bridge to effective collaboration across settings and over time.
A fantastic example of this is the "circle back" process. [credit to Emily Skinner, MSW] The concept is simple: provide a warm handoff and a call back.
As with everything, the key to success with this process is purposefulness. The purpose is to be available and helpful to each other. The purposefulness in the circle back process is exemplified by the last question the "sender" asks the "receiver:"
"Have we provided you with everything you need to successfully care for this patient?"
That is a profound culture change. It creates team-ness. It pulls us together as collaborators invested in successful care of our shared patient.
If you're not a clinician, you may not know why this is such a big deal. In healthcare, the prevailing norm across departments, settings, and organizations, is "us" and "them" mentality. It is real, and it is the opposite of team-ness. For those of you who are clinicians, you'll recognize that a hospital asking a SNF if "we" have done not only a good job, but everything possible to help them - is a jaw-dropping paradigm shift. Way to go, Emily!
Check out this Circle Back video, created by my friend Carla Thomas at HQI and featuring nurses Joyce Perkins and Cheryl Miller. Joyce and Cheryl exemplify the willingness to "reach out" and the value created by a very practical day to day collaborative relationship between a point person from the hospital and a point person at a SNF. Questions arise, clarifications made, joint problem solving was available, which measurably reduced readmissions.
Offering to collaborate in a way that pulls forth another's best performance is servant leadership. It creates a virtuous cycle. In this season of giving, remember that "reaching out to collaborate" is a gift that can be freely given that will be well received and highly valued by all involved.
Happy holidays and very best wishes to all your efforts to transform care in 2024!
Deputy Program Director at Advocates for Human Potential, Inc.
11 个月Well said Amy, as always!
Director of Transition Care Services at SUNY Upstate Medical University
11 个月Let’s do this! This work has never been more critical- thanks for the rallying cry, Amy…and a big shout out to those on this impressive list!??
Value Based Care| Home Health| Health Equity| Care Transitions | Operations |Digital Health | Care Management |
11 个月Always grateful for your mentorship and guidance throughout my career Amy Boutwell, MD, MPP
Healthcare Transformation Evangelist? Clinical Data Analytics Lead ? Medicaid/Medicare Advantage SME ? Value-Based Contracting ?DSRIP Project Manager ?Singer Extraordinaire
11 个月Amy Boutwell, MD, MPP I learned all about the power of collaboration from you through working with affiliated hospitals on the DSRIP Medicaid Accelerated eXchange (MAX) Series, a six-month program focused on improving care for high utilizers. In my opinion, collaboration = modern consumer experience! Not sure if you remember years ago while a colleague and I were “brainstorming” ways to engage the medical village on collaboration, you said, “Yesss, Let’s innovate towards empowering the connection between patients and providers through collaboration”. Thanks for introducing me to true power in numbers through healthcare collaboration. I see you!
Manager of Call Center/ Community Navigation at Holyoke Medical Center, Manager of Call Center at Holyoke Medical Center
11 个月One of the biggest challenges to collaboration and keeping our eyes on the prize, ( the Quadruple Aim) enhancing patient experience, improving population health, reducing costs and improving the work life of health care providers, is the thought process that only one of these aims can be achieved at a time, They are all interlocked, I have seen over my 30 years in healthcare, process improvement efforts that focus only on one and drop the other aim during that focus. Gains made in one area DO impact each aim, We all need to be champions, believe in the small successes that are achieved and maintain those visions even during tough situations such as COVID brought . We cannot stop moving forward to a place we are more comfortable during times of stress, That is when you will see the successes, and understand why these improvements must be made, There has never been a more urgent time to see healthcare from our patient's eyes!