Q&A:
THE DSRIP 1115 WAIVER PROJECT Improving the health care status of Texans For additional information, please contact: Heather Chung, director of nursing, Jones 11 HChung@houstonmethodist.org 281.755.5391 Texas is among the states using the Delivery System Reform Incentive Pool (DSRIP) to meet the challenge of health care reform. Under DSRIP’s Section 1115 waiver, the state can reward providers for meeting specific quality improvement goals. Hospitals are compensated by the state for planning and implementing programs that enhance access, quality and the overall health of patients.
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Is Houston Methodist implementing any type of program?
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How will it work?
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What is D2S2?
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Why is consent required?
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What agency will make these phone calls to the patient?
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Tell us about the home visit.
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Every new admission will receive all of this?
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Is this project available across the system?
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Yes, Houston Methodist has begun a program to identify patients with primary and secondary psychiatric symptoms who may be at a high risk for a 30-day readmission or ED visit. We use a two-phase program. Phase I takes place while the patients are still in the hospital. In the EDs, acute care and psychiatric units, RNs screen patients with the Discharge Decision Support System (D2S2) tool. Phase II is post-discharge work, following up after the patient’s discharge. D2S2 is a series of questions that evaluate cognitive status, comorbidities, symptoms and support. It identifies patients who are at high risk for a 30-day return to the hospital and is a part of MethOD. D2S2 is the first step because it generates a message to the team social workers to prepare patients and their families for discharge. The social workers collaborate with a clinical pharmacist to help patients understand any medication regimen. The social workers also get patient consent for the post-discharge program. Phase II involves outside agencies, so consent is necessary to maintain privacy. The postdischarge program consists of phone calls from an outside agency and at least one home visit by an aide. Our goal is to provide adequate follow-up and community resources to patients after they’ve left us. EMMI Solutions offers a month-long series of calls after patients are home. An automated system asks questions about mood, medical symptoms, compliance with taking current medications and if patients have made follow-up appointments. Medical team members then call patients who have been “red-flagged” by as a result of these calls. The team evaluates if a situation is urgent or merely a matter of encouraging a patient to fill a prescription. Every patient who agrees will have at least one visit from a Traditions home health aide. We call them bridge aides because they are a link from the hospital to the patient’s residence. These aides perform a number of skills, including taking blood pressure and assisting patients to complete screening tools for cognitive status and self-care. They also conduct medication reconciliation with the patient and the Nurse Practitioner. They have been trained to look for “triggers” or signs of urgent issues. Examples here might include a patient taking medications or home remedies that the hospital staff was unaware of, or an infected incision. For each visit, the bridge aide provides a telemedicine consult with a DSRIP nurse practitioner. The nurse practitioner can “see” the patient, look at any medications he or she is taking, and evaluate any problems. No. Every patient who scores as high risk on the D2S2 will be coached. Not every patient wants the full program. The program is currently approved for three hospitals. It was initiated June 16 at Houston Methodist Hospital then expanded to Houston Methodist Willowbrook Hospital, and will launch at Houston Methodist San Jacinto Hospital Sept. 16.
How was this program created?
CMS awarded this five-year grant to Houston Methodist in 2011, following a community needs assessment. At the inception, the program was funded through the leadership of Carolyn Belk. vice president of government relations, and Peyton Elliot, vice president of operations. Heather Chung, RN, MSN, PHD, NE-BC, director of the behavioral health transition of care program, joined the team in 2013 and developed the program for implementation at the three hospitals. LEADERS IN NURSING 15