Patient Engagement Affinity Group Session 3 Listen to the Recording Here

Alicia Goroski: Welcome everyone to today's CJR Patient Engagement Affinity Group session number three. We are going to go ahead and get started. I am now going to turn it over to Harold Bailey for a brief welcome.

Harold Bailey: Thank you Alicia. Thank you for joining us for the third webinar in the patient engagement Affinity Group series. We look forward to hearing from you as we exchange promising practices, exciting innovations, and lessons learned. I will now turn it back over to Alicia.

Alicia Goroski: Alright, thanks Harold. And again this is Alicia Goroski and my colleague Hilarea Amthauer will be your facilitators were today. We will go on to the next slide.

Just a quick review of today's agenda; we always spent a couple of minutes welcoming you and reviewing logistics. We will quickly review the Patient Engagement Drive Diagram. Then we wanted to thank those of you that have actually shared tools and resources on the CJR Connect into the Patient Engagement Affinity Group private group. Thank you—we have had a lot of great sharing. We have a few poll questions in our presentation today. We’re very pleased to have Piedmont Athens Regional Medical Center on. We will follow that with a group discussion and a poll, and wrap things up with a few announcements and reminders.

Moving through a few of the logistics. All telephone lines are currently muted. We will keep those muted during the presentation, but following the presentation we will be unmuting everyone's phone lines so we really hope we’ll have a great discussion. We want to not only hear any questions you may have for our, but we want to hear from you and what strategies you’re are doing. Throughout today's webinar we do encourage comments and reactions through the chat, and here are many ways to participate—chat, polls, open phone line—and we always have a post-event survey.

On the next slide you can see, just a quick reminder, that when you are chatting to chat to “All Participants”. That way everyone on today's call will see your chat message. If you have technical issue or a question just for us, you can send that to “All Panelists”.

I also wanted to mention that the slides for today's event were uploaded to CJR Connect. We posted those in the Patient Engagement Affinity Group. If you cannot access those, you can either send a message to us through here—send it to “All Panelists”, or send us an email and my colleague Lauren Nir can chat in the email address to everyone: it’s [email protected]. We can email out a copy of the slides.

Today my colleague Lauren and Hilarea and I will be engaging in facilitating the group chat today. We also, in Addition to Harold, are going to have Isaac Burroughs on from CMS. We can move onto the next slide.

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We want to go ahead and have you introduce yourselves. If you could head over to chat and let us know what organization you are with, and tell us a little bit about what you are hoping to learn about optimizing patient’s health prior to surgery. Once we get into the webinar, if there are conversations back and forth we encourage you to use the “@” symbol and the person's name. If you’re responding directly to someone or you have a question for our presenter, make sure you put that “@” and that lets us know. That helps to figure out and keep track of who your questions are for. Thanks Margaret and Sarah you for introducing yourselves—now they’re rolling in. Moving onto the next slide.

I wanted to do one quick reminder that this is session number three out of four for the Patient Engagement Affinity Group. After today, we have one session remaining, and that will be held on Wednesday, July 19th—our typical time from 2:00 to 3:00 PM EST. And the topic for that session is Engaging Patients and Their Families -- Patient Perspective. We're also going to have a summary from our Patient Engagement workgroup. A small set of you have been meeting by telephone a couple of times, and we're continuing to talk about actions that you guys are taking related to patient engagement. We're also very excited on next month's session, we will have a patient from one of our hospitals who will be joining us. He will be talking about, along with the hospital, how they are helping out with the program.

Now I turn it back over to Harold to do a quick review of the CJR Driver Diagram, and Patient Engagement Driver Diagram.

Harold Bailey: Okay. This is the overall CJR Driver Diagram. You can see we have our primary drivers, secondary drivers and the overall aim. Today however we are going to focus on the patient engagement driver diagram for primary driver number three.

As you can see our primary focus is on patient and family engagements adherence to the care plan.

Tools shared on the Connect site. We want to thank Florida Hospital, and Indian River Medical Center joint replacement, and the joint replacement Institute at Willamette. Our post-survey will happen right after the webinar and we encourage everyone to participate. The one question we are going to have is how do you plan to ask on the information provided during today's event? Thank you. At this time I will turn it back over to Alicia.

Alicia Goroski: Thank you. Moving onto the next slide, slide 11, we are now going to pause and do our first poll. We have two polls during today's session, but what we what we want to do and thanks to Harold and give a shout out to everyone who has shared a tool on the Connect site. Poll question number one is asking: Have you used any of the patient engagement resources that have been posted to the Connect site? We will now try to open that poll up. You should be seeing that poll on the right-hand side of your screen. We will leave that open for about one minute. Let us know, and share in the group chat if you have taken any action since last month. While we are waiting for you to respond to those poll

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responses I will also point out that the Indian River Medical Center, one of the tools they have shared was the Joint Replacement Handbook. And they are going to be the organization presenting next month. They use that handbook in their joint class. We encourage everyone if you have not logged on to the Connect site and joined this group, to log in and take a look. There are other great resources to download as well. In just a couple of seconds the poll will end and it we will look at those results. I'm going to turn it over to Hillary to review those results and introduce our presenters.

Hilarea Amthauer: Thank you everyone for joining. For those of you who did answer, we should see the results coming up pretty quickly. In the meantime I will turn it over to the next slide.

When I am about to introduce Doctor Cole I would like everyone to consider these questions as they listen to his presentation, because it will help frame it--what strategies and tools can you use in the next month to optimize a patient’s health prior to surgery, and how can you actively engage the patient and family to optimize a patient’s health prior to surgery.

Hopefully as we get into the presentation, there are some questions we can answer and maybe put into the chat as well. So far—waiting for the poll to pop up—from what we can tell, 90 percent of you have said “yes” that you have used some of the engagement resources posted to Connect and 8 percent said “No” or “Not Sure”. Hopefully if you feel you have some resources that are useful, we would love to have them or you can send them to the LS-CJR website. A good percentage of you didn’t answer which is fine because you typed it into the chat, and a lot of you said “no” but we really want to make this useful so if you have something you think would be helpful to the group please send it our way.

I will now introduce our speaker today is Doctor Cole and he is from the Piedmont Athens Regional. He is the Executive Director of Operations, and provides executive oversight to the CJR program. Dr. Cole I turn the floor to you.

Dr. Geoffrey Cole: Think you Hilarea, I appreciate it. I am a retired clinician who is now an administrator here at the Piedmont Athens Regional Medical Center. I'm happy to talk about this today and how we have engage our patients in our CJR program here, and I hope this offers help to those of you listening. During the talk we’ll talk about our program and what kind of oversight and things we have in place here as we get to the CJR request for delay. We will talk about how we have engaged the patient's. I wanted to give you a little bit of background as to what our system is like here in Athens Georgia.

We are part of the MSA in Georgia that includes Athens and Gainesville, Georgia. There are three hospitals in that MSA and we are one of those three. We do have a competitor hospital across town. All of our orthopedic surgeons are independent. There are no orthopedic surgeons employed by our system, and there are three practices essentially. The game share was offered to each of those surgeons and each declined. They were in other arrangements that they thought may conflict. The original hospital that was mandated to be in the CJR was

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Athens Regional Medical Center, and then in October 2016, Athens Regional Medical Center merged with the Piedmont Clinic at the Piedmont Healthcare System that is out of Atlanta. We are the seventh hospital into the Piedmont Healthcare System. The name changed slightly to become Piedmont Athens Regional. If you knew of us before, now we’re now known as Piedmont Athens regional. The DCJ our program in the first year had to date we have had 220 patients, and our net payment reconciliation amount or account was positive in the first year and we did meet the quality standards so we are expecting some monies.

Here you are looking at Piedmont Athens Regional which is located at the corners of Prince Avenue and Talmage Drive, and you’re looking at one of the towers located on Prince Avenue there.

At Piedmont Athens Regional, the CJR governance works this way. We have two committees in place, one is the Episode Care Steering Committee and that includes our CEO, our CFO, the highest executives in the organization here in Athens. Beneath that is the working group for CJR in this case, and we would have other working groups for other episode payment models if they were to come into place. Of course we’ll be ready to shift when that happens. In that working group, that is where the real work takes place of managing the CJR program—and that includes representatives from nursing and the operating room, finance, we have a data team that helps, we have home health representatives, and our case management team.

Our CJR coordinator does reside in the case management department and reports up through the case management director and then ultimately to me. The medical staff has a UM Committee of course, and on the UM committee a subcommittee of the UM committee is our CJR UM subcommittee. The CJR subcommittee meets twice a month. The purpose for this is really what we're going to get into today. We are monitoring from report that we get all of our patients in the CJR program, and those cases are constantly being reviewed and then presented as they are about to occur to the CM subcommittee.

At the UM subcommittee for CJR, it includes several internists and orthopedic surgeons such as myself. We present the cases that might be of concern. Concern such as the high BMI—the patient looks like they may fail medical clearance or have failed it, the patient may not be ambulatory prior to the scheduled elective surgery, or there may be some drug use activity.

Here is what a request for delay might look like. We are very detailed and give the specifics of the case, what the committee has been concerned about. This of course is going with the orthopedic surgeon and then a request for delay is made for, in this case 4 to 6 weeks. What you're seeing is an idealized patient, because of the HIPPA rules and so forth. Then we would make a very specific request of activities such as being seen by an addiction counselor, referring for weight loss programs, and them ultimately come back to the orthopedic surgeon for reevaluation after the medical specialists in this case as far as COPD, insulin-dependent diabetes, whatever the case may be. And then a discussion—the contact information is given to the doctor to call myself or a CJR coordinator or if there are any questions or concerns. That is the way a request for delay comes into play.

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Our results so far have been, we have had to 220 episodes were cases, 84 in the first year. We have had six patients undergo request for delay, and with those delays we have successfully completed the cases ultimately. There is one patient still in an optimization phase. Some of the things—we have had excellent cooperation with our orthopedic surgeons and the staff in their offices, and some of the things, the other examples of how we have engaged the patients and families has been kind of explaining to the families that if your mother, your father, has been, wife, family member is about to undergo this surgery the kinds of things that will help them get through the surgery successfully are what we are considering and what you to consider and pre-habilitation recommendations may come from this. In coordination with the offices to delay a procedure while the prehab is taking place, and then scheduling the surgery at of that prehab period and then going right into the post rehabilitation phase is shortened or goes more smoothly. Families have actually been completely satisfied with that discussion because they see that that is the best interest to work with us.

To kind of review the process, we are looking at all of our upcoming patients. They have been reviewed by myself and the joint coordinator, and taken to the subcommittee of the UM committee and if the request for delay were to be considered then that would be made between ourselves and the orthopedic surgeon. The families are engaged at our joint class when that takes place, and then the joint coordinator—the CJR joint coordinator leads case management for the episodes both before, encased in certainly in the episodes after the case. Once our goal is met our patient is scheduled for surgery and this leads to better outcomes and patient buy-in is improved because of that.

That is the talk as I have it right now, and certainly I am open to any questions about our process here in Athens, Georgia and see if this would help those who are on the phone or on the webinar as to how you address these same concerns.

Alicia Goroski: Thank you Doctor Cole. This is Alicia again. What we’ll do is if we can move onto the next slide.

Take everybody back to the chat questions. First, if you do have specific questions for Dr. Cole about their process—their request for delay process, feel free to type those into the chat or we will open the phone lines here in just a few moments. We also really want to hear from you about what other strategies or tools can you use are you using to optimize patient's health, and then other ways that you are or can actively engage the patient and family to optimize. I am going to start us out here, think we will go ahead into a couple of questions to Dr. Cole before we open the phone lines. The first question is, how far in advance are you reviewing each of these cases?

Dr. Geoffrey Cole: As far in advance as we can do that, and it usually ends up as two to four weeks in advance of the first anticipated scheduled procedure.

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Hilarea Amthauer: Dr. Cole, people were curious about but the gain share, they asked why you think the surgeons rejected it.

Dr. Geoffrey Cole: The other hospital in town already had arrangements, so I will just leave it there.

Hilarea Amthauer: Okay. There was one from someone that asked: did you see any pushback from the surgeons when you delay?

Dr. Geoffrey Cole: Yes. There may be, and I am a surgeon myself, as I said, retired clinician so I understand how surgeons think. The pushback initially was why delay if nothing is going to improve in my patient and six weeks from now is going to be a better time we’re not going to be in a better situation. That is a fair criticism. We try to avoid that. We look for situations that are fixable or potentially fixable and offer that up. Because of that, the times which we made the request for delay the surgeons have been terrific and the family seven terrific about accepting this that this is in everybody’s interest. The surgeons want good outcomes, the families want good outcomes, and we have been successful in that way.

Alicia Goroski: Great. Thank you and just to let everybody know, Hilarea and I are tag-teaming asking questions. I'm going to combine two questions. The first we have Janet asked are you a joint commission advanced certified total hip and knee program?

Dr. Geoffrey Cole: We are not at this time.

Alicia Goroski: Okay. And Janet, thank you for sharing that you guys are piloting a pari- operative surgical home.

The next question Loraine asked: what types of guidelines were developed and followed regarding the patient optimization? The whole BMI blood glucose level anemia. Did you use national standards or what?

Dr. Geoffrey Cole: The guidelines were agreed to with the surgeons and the members of the UM committee and as I said here a BMI of 45 and not being in an optimal medical clearance state, and the need for prehab, non- ambulatory patient would be the key things.

Hilarea Amthauer: Thank you Dr. Cole. I think someone wanted to know-- what happens when a patient refuses your suggestions or the interventions that you suggest?

Dr. Geoffrey Cole: We abide by the Medicare beneficiary rules, and we work with the patient to get them the appropriate procedures that they are scheduled for and recommended by their physicians and we work through those issues with them and if they insist on the surgery despite the recommendations by all and we know they have had the informed consent than their surgery will get done.

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Hilarea Amthauer: There is a follow-up; around the non-ambulatory patients and canceling or delaying those patients. Hopefully surgery is expected to help them.

Dr. Geoffrey Cole: In two cases in particular I can think of, there were recommendations for a knee replacement and the patient at this point was predominately spending most of their time in bed or in a wheelchair. The physical therapist and other providers worked with these patients in an inpatient rehab setting or in an outpatient physical therapy setting to have them get to a more ambulatory state prior to the surgery so that they would be better able to participate in the need for rehab and physical therapy after surgery. In both of these cases, the patient became ambulatory and was more successful—the surgery went successfully or more successfully—we don’t have a control group. That is how that took place. In the coordination of those events so there was not a long delay after the end of a four week prehab, the surgery was initially planned at the exit of the prehab time, and they moved right into the surgery time. That is one of the better examples of the success of this.

Hilarea Amthauer: Thank you. I can see a comments that someone likes the idea of having a panel committee that you have as a great way to address the higher risk patients with the surgeons. If other people are going to have similar set up, please let us know. I will turn it over to Alisha for a second.

Alicia Goroski: Thanks Hilarea. Thank you Dr. Cole for answering all the questions and for your presentation. I think we have hit all the questions so far. People can definitely still, if you have additional questions, we can always come back and post those again to Dr. Cole but we're going to transition now to open up the phone lines. Just one moments before we do that, I just wanted to remind everyone that does mean everyone will hear anything going on. When you are not speaking if you can keep your individual telephone on mute that would be great. It helps cut down on the background voice. Also pleased about places on hold or we will all get to enjoy your music. Lauren will go ahead and unmute the phone lines.

The other thing I was going to say was if you have something you would like to share, you can raise your hand on the webinar. Under “Participants” it should say “View All Attendees”, and you should see a hand. If you hover over that will say “Raise Hand”. If you raise your hand we’ll scroll through to see if you have something and will call on you. What we are going to do is I am going to call out and hopefully—I gave a little heads up to Shawn Boice, you shared in the chat that you were using the BREE Collaborative—we would love to hear more about that. If you are out there, Sean are you willing to share a little bit more about that?

Shawn Boice: Yes. I can share more about that. The BREE Collaborative is put together by physicians, patients, nurses and others in the community, and it is based on scientific evidence, the latest scientific research on the different stages of a patient's journey through joint surgery. I think it is available online or that anybody can look it up. BREE Collaborative for hip and knee, they have it for other things also but it covers the four basic premises. It has conservative treatment three months, failure of conservative treatment, and fitness for surgery. And a lot of that is like the BMI—they’re already having a good patient care

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agreement with the patient and their caregiver. Hemoglobin A-1C at eight percent or less, adequate nutritional status—we’re currently working on that section and looking at carbo- loading and other things, and we are doing this with all of the area hospitals here in the Northwest. Avoidance of smoking and all of these things, immersive screening prior to surgery, preoperative care for postoperative returns to function, and then shared decision- making tools. There are a lot of people going around on that right now. Recommendations through surgery and discharge, we use a discharge--the Washington State Hospital Association discharge toolkit which is available online and right now we are working on assembling high- performing post-acute care partner networks.

The BREE Collaborative has a lot of good information and the science behind best practice on a lot of it with the latest research, the different groups meet monthly. We have a web conference that we attend, and that we constantly review the recommendations. What we are working on is striving towards meeting those goals and hitting each one of those sections for optimal improvement of all of our joint patient in CJR. It is easier to try to do for the patients and not just the CJR patients, and there’s other things we're looking at: the preoperative plan for opioid management's. It’s a good program. I would encourage others to look at it as maybe a template on where to start, and then we also recently created a joint class video. We found some of our patients were having a hard time coming here, and the joint classes are great. We do now have a video online the tries to covers much of this as we can and then we do the contacts with patients prehab. Prehab has been significantly helpful for us because there is something about getting out and sending people to the home to check living arrangements and see if maybe they are someone who could benefit with their skilled nursing facility and that leads us back to working with the post-acute care partner network. That is what the BREE Collaborative is in a nutshell.

Alicia Goroski: Thank you! I actually found the website and I think we can type that in. It looks like its breecollaborative.org. It does look like this is primarily for Washington state providers, but it appears that as you mentioned those tools and resources are on the public website.

Shawn Boice: That's rights. That is correct. And working with IHI, in the past and looking at a joint patient progressing through preoperatively and postoperatively, it fits in and you can overlay different things that your hospital is doing. That’s been guiding us and a lot of our work here. It may be helpful to someone.

Alicia Goroski: I’ll go ahead and push that link out. Thank you for sharing. I am scrolling through quickly. I do not see any hands raised which is fine, but I wanted to kind of go back. Jillian, you had shared that your hospital, that you have started a prehab screening where all CJR patients meet with you and your ortho navigator prior to surgery, and you are doing some screening for health or social issues. And then I know Sally Fiore had asked a great question, she is really curious and love to hear more about that social screening piece. Jillian, I did not know if you’re out there and you would be willing to share a little bit about what you are doing, and then I will also pose that question to others to jump in on chat. Are you doing anything or using any particular tools for that screening for social aspects? Jillian does not

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have a microphone. They could for letting us know. Feel free to type in chat. Is there a specific tool for screening that you are using, or is it more of a conversation? I will go ahead and open it up to others to speak up if you are also doing any sort of social screening.

Dr. Geoffrey Cole: This is Dr. Cole again. One of our cases we learned that our patient had just after 30 years of marriage had a divorce and was very heartbroken and his caregiver at that point so this is one of those other examples of the social basis that we worked with the surgeon on getting a request for delay and that’s been helpful for everybody.

Alicia Goroski: Think you for sharing that.

Hilarea Amthauer: Thank you Dr. Cole. I would be curious -- I see from Jillian. Thank you for answering. They created a screening tool on safety which is very detailed on aspects of their home caregiver support. As others are talking about home visits, because I know that is something that has been done, and I know we even heard it today to figure out the home environment, what tools are you using to assess? Who on your staff is doing those home visits? Because I think that gives a whole new look on the patient environment and you learn things that you do not necessarily get when they are in the hospital. If anyone would be willing to share over the phone or even in chat about their home safety visit. Just a brief reminder that if you're not wanting to share keep your phone on mute.

Margaret Delks: Yes. I was able to take myself off the mute. Can you hear me?

Hilarea Amthauer: We can in think you for letting us call you out.

Margaret Delks: That it's okay. We do what we called modified E-RAS program here. I don't know if you know what it is but it is expedited recovery after surgery, and our colorectal surgeons here at IU Health initiated that process where they actually give the patient's impact AR before they come in—theirs is IS decolonization, they also have a cleanse for showering. We had already done almost all of that except for the nutritional supplement prior because a lot of our patients don’t have nutritional issues, those that do we address separately. We had not done the allowing patients to drink carbohydrates and load up before surgery, so we have started doing that. We have been doing that about six months or eight months, and that has worked out really well. Our patients seem to be more awake, more ready to ambulate postop day zero when they come out to the floor the patients do not complain about being hungry, they do not complain about being thirsty. They don't seem to be as dry after surgery and that is nice for the patient scheduled for a, 4:00 in the afternoon that they don’t have to be NPO from midnight all the way to 3 or 4 in the afternoon. We do that here. We have a whole process to work with our preadmission area and our anesthesiologist. That is what we are doing here.

Hilarea Amthauer: Thank you. I'm sure your patients are a lot happier since being NPO…for that long I’m sure they would not be happy. How long have you been doing it? Did you say to two years is that right?

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Margaret Delks: No actually our colorectal surgeons have been doing it longer than we have. We started last fall. It has been about six months or nine months. I can't remember the exact time frame. We tried a couple of different things. We use either Gatorade or water or the D2 and water are our preferred methods. I think it is really such a relief for the patients to be able to drink anything up to three hours before surgery, they’re thrilled about that.

Hilarea Amthauer: It looks like one other person commented that they’re doing something similar or exploring the loading as part of their ERA. Would other people be willing to talk about some of the things they’re doing—anything similar with the carbohydrate loading?

Alicia Goroski: I was just going to say Beth or Brenna, you guys had both recently shared. Beth again your home health department visits your patients. So you are doing a two hour home visit in getting four pages of information before surgery and that is great.

Hilarea Amthauer: With Brenna, if we could call on you if you are able to speak?

Brenna Stidham: As it about our home visits that we do or our home assessment? We have had a perioperative surgical home department for almost 20 years at this point and we incorporated our preop education class for our joint replacement program into that, where it is all within the same day they go to their preop clearance appointment and then they will come to the class where a home assessment is completed, an internal tool we developed. There is no actual home visit at this point and now with the advent of CJR we have incorporated myself as the CJR navigator. I visit specifically with the Medicare patients in addition to them attending class I complete the WRAP tool and all of the PRO data with them at that time and get the feel of the patient so they know what to expect and they let me know any barriers that they think they might have at home, so if there are barriers we can hopefully address them to get them to be able to go home.

Hilarea Amthauer: I just thought of someone asked if you would be willing to share that tool with the group?

Brenna Stidham: Yes. That would be no problem.

Alicia Goroski: Great. Feel free to post it on Connect you can email it to us at the LS- [email protected] inbox. Just a quick reminder to put your phones on mute because we can hear all of your conversations. I'm glad you could share that as well. There is a question from Lori: this is the tool you use for it the psychosocial assessment. I don't know if you would be willing to speak on that as well.

Brenna Stidham: We do not use any sort of psycho-social tool other than the questions that are asked on the general questions, but nothing more specific.

Hilarea Amthauer: Thank you for answering.

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Alicia Goroski: This is Alicia and I am going to actually call on someone else. We had reached out a little bit before the call but Denise Evans, if you are out there, Denise is part of the workgroup and we met--the workgroup met last week. Again this is a workgroup that met by telephone also monthly to talk about actions and current activities they are undertaking. If you would like to join that workgroup send us an email and let us know and we will match you to that. They are doing some innovative things related to optimizing health prior to surgery using an app. Once Denise have dialed back in will hopefully hear from her. Thank you for chatting and Sonja responded. Thanks Brenna to go ahead and share that on CJR Connect. We have a slide later, but if Lauren Nir if you want to go ahead and post the link so that people can either go to login or request a CJR Connect account. Do not forget to request to join the Patient Engagement Affinity Group which is a private group and one of our more active groups. Denise are you connected again?

Denise Evens: Hi everyone. Listening today I think we're all doing a lot of similar things, a little of what I'm going to talk about is repetitive in content, however it is it different way of collection. What we doing here at Mercy Health—Mercy is 23 hospitals in Ohio and Kentucky—and we are organizing what we call a clinical institute. All of our facilities have representation on this committee, physicians as well as orthopedic surgeons. One of our orthopedic surgeons has developed an app and it is being piloted in one of our regions in Cincinnati at this time. What we do is similar to everything we have discussed here today. Once the patient has been identified as a candidate to have surgery they are registered on this app, and I believe in past conversations we have all talked about the fact that we have looked at multiple apps very that are very similar out there for patient engagement.

I think one unique thing about this app is the pre-op optimization or prehab in the patient engagement. So once the patient has been identified to have surgery they will be registered on this app were can download the app on the phone whatever device it is they will be using. At that point our current process through our is that our physical therapists are very engaged preoperatively helping to manage this app. The patient scheduled for a preoperative PT visit and strength assessment and evaluation. The PT at that time will perform a strength assessment as well as order bloodwork for the patient. All of this information is downloaded into the app at the patient's preop assessment. While we are waiting for all those results to come back, the patient will be sent a message and they will complete their history. All that information will be downloaded into the app for whoever they delegate to look into this. It is set up like a stoplight—red, yellow, green—if the bloodwork comes back within normal limits as identified by our lab they’ll get a green light. If we see that their BMI is above the range, I heard today 40 to 45 and I can give you the exact range, they’ll get a yellow light. At that point in time they’ll be referred to a bariatric clinic or depending on the patient and scoring to a bariatric surgeon. If they’re a smoker they’ll be asked to attend a smoking cessation class and given some dietary supplements.

They will show up on that path if either as a “green” ready to go or yellow or red if there’s a significant issue that needs to be taken care of. Once the patient has done everything asked of

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them and resolution has occurred, it will show up with all green lights and at that point they will be scheduled for surgery. So preop optimization in the app with patient interaction at home and then they can have access to all of this through the app. There is not a lot of interaction on the acute-care side, however once a patient is discharged to whatever level of care be it home with self, home with home help, there will be continued interaction at that point in time with the app. We are in the process of meeting with our SNIFF and teaching them about the app.

I am sure as most of you have realized, the vast majority of our readmissions come to us from a SNIFF. What we have found is a lot of the reasons for the readmission are not complications with the patient but the SNIFF not being accustomed to seeing swelling or redness at the incision site immediately. They think that the patient has an infection and sends the patient over to the ED and we of course remit the patient, and now we are going to be held accountable for a readmission. With this app postoperatively, the patient is expected to take pictures of their incision sites twice a day. They are sent home with a blood pressure cuff and a tape measure to measure their calf circumference, so we’re looking for DVT. They do this twice a day until the patient or caregiver are satisfied that they can begin to taper off of that. Also to do this process preoperatively we…, and then postoperatively this app will auto alert the patient to then take the post-op dose increase as well so that we can capture that. Again we are in a pilot phase with this. It is going very well and we’ve already been in discussions with our EPIC team here once we get past the pilot phase and everyone is happy with the results that we are seeing, we will then integrate this app with EPIC so that of course will open up visualization and many more opportunities for us to interact with that patient. This this is very similar to what we heard everyone is doing today. It is just a different way to interact with the patient population through technology. Any questions?

Alicia Goroski: Thank you Denise. This is Alicia and I don't see any questions yet. I had posed the question to the group asking if others are using technology and Beth Armstrong said they are also piloting an electronic platform, but more to push out information prior to surgery. I think these innovative uses of technology are fascinating.

We're going to go ahead because we are down to the final five minutes. Thank you, Denise and I also want to thank Dr. Cole. We did have one final question come in but we are going to multitask.

Lauren is going to push out the final poll question and I just wanted to clarify that what we are looking for is we, the Learning System Team, developed this Patient Engagement Driver Diagram that we use to frame this Affinity Group. We have already learned a lot and heard additional strategies and tactics and secondary drivers that you guys are working on so we will be updating that, but we would love to have additional information. What we are really asking is that if you have something else that you are doing, that you might be willing to talk with us and we can at least include that are make sure it is covered in the Patient Engagement Driver Diagram. We are planning to have webinar later in the year with this group will report back out to the larger CJR community and we plan to share that Driver Diagram at a broader level

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at that point. We want to make sure we are including all of that. That is what this is all about. Thank you for letting us know. If you answer yes, we may reach out for a quick call with you.

I also just wanted to go ahead, and Dr. Cole there was one final question if you could talk briefly about the roles of the people involved in your UM subcommittee.

Dr. Geoffrey Cole: These are all the physician members of the UM committee, and we have two internist an orthopedic surgeon, one nephrologist, myself, a retired neurosurgeon, and ER doctor. It’s a doctor-led subcommittee.

Alicia Goroski: Great. Thank you. We can go ahead and move on to the announcements and reminders. On slide 26 that is the information if you do not have a CJR Connect account you can click here. Lauren also posted that link which is about 10 comments up from the top end the chat. You do need to make a request to join the Patient Engagement Affinity Group. We typically approve those within an hour so we will get you right into that group. There been a lot of great resources shared. Sounds like we're going to have another resource after today’s shared. If you have the resources we encourage you to share that.

Moving onto 27, and while I do this one, Denise, if you can go over in the chat there are a lot of people wanting to know if the name or the type of app that you are actually piloting. If it is one that others can use, or I think you had mentioned that your physician had actually developed it so I’m not sure if it will be available. Also the final reminder again, mark your calendars for July 19th. You need to register for the final Affinity Group, and as I mentioned, those workgroup calls. It has been a fairly small group. We have had 8 to 9 individuals joining—it is very interactive and telephone only and everybody shares what they are working on. If you're interested in joining that group send us an email at [email protected].

Reminder that any questions about webinar events can come to us. Said those programmatic questions into [email protected]. If everybody could take just a couple of minutes to complete the post-event survey which should automatically pop-up when you exit today's event. Thank you to everyone who shared be it and group chat or verbally, and thank you so much to Dr. Cole for sharing your process for that request for a delay. We would love to hear from you if you actually let us know what actions you take after today's event. Thanks and I hope everyone has a great rest of the day and a great rest of the week.

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