Transcript Care Coordination: Improving Clinical Outcomes in Patients

Care Coordination: Improving Clinical
Outcomes in Patients with Chronic
Kidney Disease (CKD) Receiving
Dialysis
Debra Castner, MSN, RN, APNC, CNN
Disclosures
Castner
– Speaker bureau – Sanofi, Amgen
Objectives
Examine care coordination in patients with
chronic illness, focusing on "costs" of
hospitalization in patients with CKD on
dialysis.
List nationally recognized priorities and
goals toward providing well coordinated
care.
Explore nursing strategies aimed toward
improved care coordination.
Case Presentation
JM is a 78 year old female with ESRD
secondary to diabetes mellitus 2. She was
hospitalized for 5 days for an infected ulcer on her
right foot.
Other comorbidities include HTN, COPD, CAD with
h/o MI and h/o CHF. She presents on Friday for her
first dialysis after discharge.
The charge nurse calls the doctor on call for orders
and is told to “continue previous orders.” He does
not order continuation of her IV medication nor does
he adjust the dose of ESA. No adjustments are
made to her dry weight.
Case Presentation
No discharge summary is available
and JM did not bring in her discharge
sheet. She is unsure of any new medications.
JM presents at her target weight. Her blood pressure
is 172/90. She undergoes dialysis without
complications. No fluid is pulled as she is at her
target weight. No labs are checked. The usual
meds are given.
The discharge coordinator is off today. Attempts to
reach JM’s family are unsuccessful.
Case Presentation
Five days after discharge JM is readmitted
to the hospital with c/o SOB and fever.
Hospitalizations and
Readmissions
19.6 % of nearly 12 million Medicare
beneficiaries (1 in 5) discharged from the
hospital were re-hospitalized within 30 days;
34% within 90 days
Leading diagnosis
CHF, PNA
Predictors
# of Rehospitalizations, LOS > DRG
ESRD
Jencks, et al., NEJM, 2009, 360: 1418-1428.
Financial Costs
Cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion1
ESRD - $23.9 billion on dialysis care (5.8%
of Medicare budget) - 1/3 spent on
hospitalization2
Bundle – Empty dialysis chairs – cost $$$
– hospital stays reduce monthly reimbursement
1.Jencks, et al., NEJM, 2009, 360: 1418-1428.
2.USRDS, 2009.
Financial Incentives
Medicare Payment Advisory Counsel
recommended to Congress (MedPac)
– penalize hospitals with higher than expected
readmission rate
– Beginning 10/2012 – payments  1%
2013 – payments  2%
2014 – payments  3%
Patient Protection and Affordable Care Act of 2010
Patient “Costs”
Decline in functional capacity
Nosocomial Infection
Adverse event
Decreased quality of life
In hospital - mortality
Care Coordination
“Care coordination is a client-centered,
assessment-based interdisciplinary approach
to integrating health care and social support
services in which an individual’s needs and
preferences are assessed, a comprehensive
care plan is developed and services are
managed and monitored by an identified care
coordinator following evidence-based
standards of care.”
Brown, R. 2009.The National Coalition on Care Coordination N3C
Care Coordination
Coordinated Care
Transitions of Care
Transitional Care
Disease Management
Case Management
Guided Care Model
Patient-Centered Medical Home
Care Coordination - Challenges
Decreased length of stay (LOS),
continuing therapy after discharge
Aging population – greater complexity,
many co-morbidities
Many care venues, many providers
Practice defined by location (i.e hospitalist,
PCP)
Current Fee for Service does not
reimburse care coordination
Increase Risk of Rehospitalizaton
Risk Assessment Tool: 8Ps
– Problem medication
– Psychology
– Principle diagnosis
– Polypharmcy
– Poor health literacy
– Patient support
– Prior hospitalization
– Palliative Care
http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/06Boost/03_Assessment
.cfm
Medication Errors
Adverse events after discharge
Examined random discharges at a
Canadian teaching hospital
23% (76 of 328) of patients experience an
AE
Most common cause: drug events 72%,
therapeutic errors 16%, nosocomial
infections (12%)
Forster, A. J. et al. Annals of Internal Medicine, 2003. 138: 161-167.
.
Adverse Drug Events (ADEs)
Transitions - care setting change
ADEs - > 50% follow discharge, readmissions
up to 25%, increases cost, morbidity and
mortality
Risk Factors
– Drug change (especially discontinuation)
– High risk drugs (antibiotics, CV drugs, insulin,
warfarin)
– High risk medical conditions (PNA, COPD, UTI,
CHF, AKI, Dehydration, blood sodium or K+
disorder)
Boockvar, KS et al, Arch Int Med, 2004. 165; 545.;Forester AJ et al, Ann Int Med. 2003, 138: 161.
Forster AJ et al. 2004, Can Med Assoc J, 2004. 170:345-9.
Patients with ESRD
The “Perfect” Storm
• Prior hospitalization – 2/year
14 hospital days per year
• Polypharmacy – pill burden
• Problem medications
• Problem diagnosis (DM, CHF)
• Psychology - Depression
Patients with ESRD
The “Perfect” Storm
“Resume Previous Orders”
Components of Successful
Care Coordination
Targeting patients at risk of hospitalization
In- Person Contact – did use telephonic contact with face
to face once per month
Access to timely information
Demonstrated close interaction between care coordinators
and PCP
Provided services that focused on assessing, care
planning, educating, monitoring, coaching on self
management, teaching how to take medications, and
assistance with social supports
Relied on registered nurse to deliver the bulk of the
intervention
Brown, R. 2009.The National Coalition on Care Coordination N3C
Care Coordination Models
Care Transition Model for Heart Failure
Insurance Driven Disease Management
Programs – Kaiser, Aetna, BCBS
Fresenius Right Start, DaVita Impact
Renal Venture Care
JCAHO “Hand Off” Initiative & “SPEAK UP”
Initiative
BOOST – Better Outcomes for Older adults
through Safe Transitions
ESRD Demonstration Projects
BOOST
Better Outcomes for Older adults through Safe Transitions
Developed from 1.4 million dollar grant
National initiative led by Society of Hospital
Medicine
Vision:
–
–
–
–
Reduce readmission rates
Improve patient satisfaction related to discharge (DC)
Improve flow of information
Identify high risk patients and target intervention to
mitigate risk for AE
– Improve patient and family preparation for DC
http://www.hospitalmedicine.org/boost
BOOST
Better Outcomes for Older adults through Safe Transitions
BOOST toolkit available at
http://www.hospitalmedicine.org/boost
Risk assessment tool, Patient Pass:
transition record, education rescources
Early Data (60 sites): 21% reduction in 30
day all-cause readmissions
http://www.hospitalmedicine.org/boost
ESRD Demonstration Project
Fresenius Health Partners – care management
team
Nurse Care Managers – centerpiece of the
integrated care model
Included in activities:
– Address the needs of high-risk patients (followhospital patients and assist with discharge planning
and conduct follow-up contacts post discharge
– Assist patient with new or changed medications
– Work with patient’s healthcare team to facilitate
continuity of care
http://www.fmchp.com
Fresenius Health Partners
http://www.fmchp.com
Preventing Hospitalization
Patient Assessment
Worsening
anemia
Medication
Errors
Malnutrition
Volume
Overload
JM
Infection
The Perfect Storm!
\ The Perfect Opportunity!
Nurses lead the way!
Barriers to Care Coordination
Lack of resources
Lack of education and/or understanding
Lack of communication
Lack of effective systems
Lack of nursing leadership
The General Nature of Nursing
Nursing is collaborative with all other
healthcare professions.
– Florence Nightingale
NIH
The Institute of Medicine has identified
care transitions as a priority area for
performance measurement.
Assessing the quality of transitional care: further applications of the care transitions measure. Parry C, Mahoney E, Chalmers SA,
Coleman EA.
National Quality Forum
National Quality Forum
CKD Certification
The Joint Commission's Certificate of Distinction
for Chronic Kidney Disease recognizes
organizations that make exceptional efforts to
foster better outcomes for CKD patients.
The Joint Commission and the National Kidney
Foundation have identified that the most
successful CKD programs possess the following
critical attributes:
– A standard method of delivering or facilitating
coordinated care from diagnosis to management,
based on the National Kidney Foundation’s KDOQI
evidence-based clinical practice guidelines.
– A secure and timely system for sharing information
across settings and providers, which safeguards
patient rights and privacy.
“Readmissions are not primarily about
people being rehospitalized because
of mistakes made in the hospital.
Readmissions are about making
transitions effectively. Taking care of
people with ongoing problems or
chronic illnesses and frailty.
Transitions of care not done
well…evidence suggests they wind
up back in the hospital.”
Stephen Jencks, M.D., former senior clinical adviser to
CMS
Case Presentation
The real story
It is 4 days post discharge and JM is speaking to
the RN assigned to her and shares she is feeling worse
than when she was in the hospital. She is very weak,
dizzy, and short of breath. She just doesn’t feel like
eating.
The nursing assessment finds that JM has 4+ pedal
edema and crackles, though she is at EDW, there is
green drainage on her foot dressing.
The RN calls the acute facility RN to review data from
discharge and finds Hb was 8.4, WBC 12,000, her
ESA doses pre and post DC do not match, and
albumin was 2.3. She makes a call to the NP on call.
Case Study (continued)
The NP orders a CBC to be sent to an outside lab and
JM’s EDW is readjusted. Her family was called and they
tell the NP JM does not have any supplements to take
and they are just giving meds like they “always do”.
They also are concerned that JM was not given any
antibiotics to take for her foot infection.
The next day the NP is called and told the Hb is now 7.5
and WBC is 20,000. JM is set up for transfusions and
an RD consult, IV Antibiotics are ordered which were
missed on discharge.
We’re Not In Kansas Anymore,
Toto
12 Ways To Reduce Hospital
Readmissions
•
•
•
•
•
•
Discharge Summaries within
24hrs
Lengthen the Handoff
Process
Provide Medications on
Discharge
Make a follow up plan before
discharge
Telehealth
Identify Frequent Flyers
•
•
•
•
•
•
Understand What’s
Happening After Discharge
Provide Home Care on
Wheels
Consider Physician
Medication Reconciliation
Make Sure Patients
Understand – “teach back”
Focus on High Risk Patients
Listen to the Patient
JCAHO Hand- Off Communications
JCAHO Survey found………..
37% of the time hand-offs were defective & did not
ensure safety for patient care
21% of the time receivers were dissatisfied with the
quality of the hand-off
And
80% of serious medical errors involve miscommunication
when pts are transferred or handed off
Poor hand-off is a contributor to sentinel events, delays
in treatment, inappropriate treatment, and increased
length of stay
Communicate, Communicate, Communicate
Review, Don’t Just Resume
7 day window post discharge
As professional nurses we can no longer
accept “resume previous orders”
SHARE
S tandardize critical content
H ardwire within your system
A llow opportunities to ask questions
R einforce quality and measurement
E ducate and coach
www.centerfortransforminghealthcare.org
Standardize Critical Content
Provide details of the patient history to the
receiver
Emphasize key information
Synthesize patient information from
separate sources before passing to the
receiver
Hardwire Within Your System
Develop standardized forms, tools, and methods
such as checklists
Use a quiet workspace or setting that is
conducive to sharing information
State expectations on how to conduct a
successful hand-off
Identify new and existing tools to assist in handoff
I visited with_________________________today.
To assist with their continued care I am asking you to:
Send in an updated medication list.
Send in all medications for me to review on _________.
Call me at the office, 732- ______________to discuss my
suggestions or concerns.
Make the following change,
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______
Thank you for your assistance, and please call me if you have any
questions,
Debby Castner RN, MSN, APNC, CNN
Nurse Practitioner Jersey Coast Nephrology & Hypertension
Coordination of Care Checklist
Check all that apply within 7 days of discharge and confirm
changes with physician or NP
ESA dose, form or method of administration changed
Vitamin D analog dose or form changed
Phosphate binder placed on hold or dose adjusted
Heparin dose been put on hold or adjusted
Dialysis treatment changes: dialyzer, dialysate, hours, frequency,
access in use
EDW changed
Protein supplement added or other diet changes
Follow-up labs or tests needed
New medication(s)
Patient discharged to home with home care services, to a rehab, or
skilled nursing facility. If so where, duration, treatment provided?
BOOST 8Point Risk Assessment
BOOST Universal Checklists
Allow Opportunities to Ask
Questions
Use critical thinking skills when discussing a
patient case
Share and receive information as an
interdisciplinary team
Expect to receive all key information from the
sender
Exchange contact information for additional
questions
Scrutinize and question the data
Reinforce Quality & Measurement
Demonstrate leadership commitment to
successful hand-offs
Hold staff accountable for managing a
patient’s care
Monitor compliance with standardized
forms, tools, and methods
Use data to determine a systematic
approach for improvement
Educate and Coach
Teach staff what constitutes a successful
hand-off
Standardize training
Provide real-time performance feedback to
staff
Make successful hand-offs an organization
priority
Reconciliation of Medication List
Patients carry a complete list of their
medications (purpose, dose, typical side effects)
Discrepancies between new orders and prior
meds are identified and explained to the patient
and caregiver (in writing)
Reconciliation of med lists occur throughout
hospitalization especially upon a transfer and as
close to discharge as possible
Consider implementation of an electronic system
Effectiveness of Dialysis Specific
Patient Education Programs
Right Start (FMC) – 120d
IMPACT (DaVita) – 90d
RV Care (Renal Ventures) – 120d
Right Return (FMC ) – nursing directed
education program
ESRD Seamless Care Organization
(ESCO)
ESCO is now Comprehensive ESRD Care (CEC)
• CMS Innovation Center new service delivery and
payment model
• Will test if offering providers financial risk arrangements
with guaranteed discounts to MCR will improve health
care outcomes and reduce costs
• To promote comprehensive medical care and care
coordination
• Request for quality measures appropriate for ESRD,
promotes care beyond renal issues and will slow costs to
CMS
Patient Directed Interventions
My Health
doctor visits
names of specialists and nurses
medications and what they treat
laboratory test results
activity status
overall knowledge of kidney disease and its side
effects
stored in a safe, secure location that is
accessible anywhere there’s an internet
connection.
JCAHO Speak Up Initiative
S peak up if you have questions or concerns
P ay attention to the care you are receiving
E ducate yourself about your diagnosis, medical
tests, treatment plan
A sk a trusted family member or friend to be your
advocate
K now your medications
U se a facility that has undergone evaluation
based on quality standards
P articipate in all decisions about your treatment
2002 www.jointcommission.org
Case Study
How would the case study change if there
was coordination of care?
Case Presentation
Care Coordination
The Acute Care Liaison NP at the acute care facility faxes JM’s
dialysis discharge checklist to the NP and Charge RN at the
outpatient center. The dialysis primary care nurse and the acute
care dialysis team have been in contact by phone during her stay..
The NP and charge nurse have a conference call to review and ask
questions about her transition plan. The medication list is reconciled and
dialysis orders are revised. ESA and Vitamin D analog doses have
changed, antibiotics are to continue for 5 more days, her EDW is
decreased and she is to continue Nepro at home
JM’s primary care nurse, PCT, RD, and Renal
SW are updated on the changes planned and
schedule time to update JM’s comprehensive
care plan. JM is instructed and given a written
handout on the changes from this admission.
Nurses Lead the Way
A phone call to the IP case manager or family
Compare orders & ask questions
Make or borrow forms for checklists
Have a brainstorming session
Review and use the ANNA Standards
Develop a process to get the discharge
summary
Comprehensive Care Plans that are meaningful
Educate and empower patients
S even day target date
E valuate data
V alidate orders
E ducate patients
N ursing assessment &
interventions
Web Sites
American Nephrology Nurses Association
http://www.annanurse.org
American Nurses Association
http://www.nursingworld.org
BOOST:Better Outcomes for Older adults through Safe
Transitions. Retrieved 02/26/11 from
http://www.hospitalmedicine.org/Boost
Web Sites
Facts about hand-off communications, 2010.
Joint Commission Center for Transforming Healthcare
accessed online on 11/18/2011 at
http://www.centerfor transforminghealthcare.org/projects/
about_handoff_communication
Facts about speak up initiatives, 2002. Joint Commission
accessed online
on 2/13/2011 at
http://www.jointcommission.org/GeneralPublic/Speak+Up/about
_speakup.htm
Fresenius Health Partners. Retrieved 02/26/11 from
http://www.fmchp.com/
Web Sites
Health Leaders Media Retrieved 02/28/2011
http://www.healthleadersmedia.com
National Quality Forum. Retrieved 02/26/11 from
http://www.qualityforum.org/projects/care_coordination
.aspx
ESRD Disease Management Demonstration Project
Report Retrieved 2/28/2011
http://nephronline.com/features.asp?F_ID=611
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