Transcript Our Journey to Improve Transitions of Care

Lee Memorial Health System
Our Journey Through Transitions of Care
Joan Carroll RN, BA, CDMS, CCM
Director Care Transitions
Lee Memorial Health System
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1,423 Acute Care Operational Beds
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Not For Profit Public Hospital System with 10
Member Elected Board of Directors
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10,000 Employees, 4,300 Volunteers & 1,200
Staff Physicians, 85 Employed Physicians
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6 Hospitals, Sub Acute, Physician Group,
Convenient Cares, Home Health, Skilled Nursing
Facility, Rehabilitation, Regional Cancer Center,
LPG united Way House
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81,531 Admissions Annually
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CT is a 4 week program to help patients transition
from hospital to home, while learning how to manage
their chronic condition
The LMHS model for Care Transition Coaching is a
combination of the Coleman Model, Project RED,
BOOST
5 basic areas of our coaching program include
Patient self management assessment
Medication Management
Personal Health Record
Diagnosis / Red Flags / Actions
Communicating with health care professionals
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Didn’t know their diagnosis
Had no idea what it was
No understanding of acute or chronic
Believed the hospital cured them
Recovery is a rest period
No knowledge of their role
No knowledge of red flags
Reverted to meds they already paid for
No medication management system
Couldn’t remember 3 of their meds and their
purpose or side effects
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Patient had prescription meds that were not on the
discharge instructions
Patient had no prescriptions for new meds on the
discharge instructions
Patient had no idea of their limitations
DME had not been delivered
BIPAP not delivered / patient in trouble
Patient extremely SOB 1days post discharge/ ankles
still showing extreme edema / Poor discharge
Home not safe
Patient depressed or lonely
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Couldn’t find their discharge instructions
Didn’t remember anyone going over them
Had not filled their new prescriptions
Taking OTC meds unapproved
Believed the salt shaker (which they didn’t use)
was the only source of sodium
Had not scheduled their PCP appointment
Drank 10-15 glasses of water a day (per Dr. Oz)
Used their inhalers incorrectly
Couldn’t read and/ or follow direction
Were unstable on their feet
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Had 50 feet of Oxygen tubing
Nebulizer was filthy
Alcoholics?
No money for meds or groceries
No transportation to the doctor
No caregiver assistance
Couldn’t get an appointment for 1 month
Caregiver was worse than the patient
Depression
Electricity had been turned off
No food
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Patient Activation Assessment
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Discharge Evaluation
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Medication Discrepancies
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Readmissions
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Patient Activation Assessment showed
patients prior to discharge– Scores 1-3/10
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Discharge Evaluations March 2011 -60%
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Med Discrepancies – 92% in January of 2011
Hospitalists and Specialists
Case management
VP of Nursing
Discharge Nurses
Staff Nurses
Nursing Education
Pharmacists
Respiratory Therapists
Physical Therapists
Nutritionists
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Discharge order sets for CHF and COPD/ simplified /
disease specific
CHF Unit opened and certification completed
Physicians include specific discharge orders for
screening for balance/ medication review
Improved cognitive assessment
Palliative Care Training
Increased Home Health Referrals
Teach Back education
Standardized Handouts
Caregivers are identified in the EMR
LMHS System Initiatives
Acute Care
• System Wide Risk Stratification Tool
• Tracking Readmission reasons
• Care Transitions
• Care Management Website – Community
Resources
• Teach Back and F/U appointment
• Pharmacy Collaboration on Medication
Discrepancies
• CHF Unit / Cardiac Decision Unit for Obs
patients
• Readmission work groups- Pulmonary &
CHF
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CHF Unit opened / Certification completed/
readmissions reduced at HP
Pharmacy providing Medication prior to discharge
EPIC update of Discharge orders improved
Rounding initiated at ¾ facilities
COPD Management Program
GC Reduce LOS/ Readmissions Committee
CCH Readmissions Committee
Home Health protocols for diuresis in home
completed
Home Health Telehealth using 400 units in the
community
Home Health frontloading
Nutrition Assessment with Food Bank Vouchers
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SNF Administrator and DON
Case Management & Medical Social
Workers
Hospitalist
ED Physician
SNF Medical Directors
ED Nurses
Care Transitions Director
Infection Control
Educator
Palliative Care
Home Health Care
Cause aHome
nd EfHealth
fect DiCare
agram (fishbone)
Cause and Effect Diagram (fishbone)
Patient
Pt/family lack understanding of HHC
Physician
Hospitalist will not sign HHC order
Pt needs higher level of care then HHC
Delay in order
Hospitalist does not communicate with PCP
Caregiver fatigue
Pt has increased co-pay for HMO
Caregiver does not have skills to care
for the patient
Delay in face to face
Lack of orders related to condition-wound care
Incorrect or no diagnosis-especially with
with depression
No copy of discharge order
Lack of discharge summary
PCP does not know that HHC ordered
Lack of discharge date in information
HHC referral sent to multiple agencies
Lack of balance of payers to HHC
Incorrect patient demographics on referral
Lackcare,
of supplies
Lack of supplies, wound
ostomyfor
Patient is not informed that a JJC has
been ordered
Special needs not identified
Pertinent social issues not communicated
Pt is not educated on HH level of care
Referral delay or delay in order
Hospital
Date 1/23/2013
Communication
Readmission
Rate High
SNF Coalition and workgroup/ Quarterly
meetings
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Review Lee County readmission data
Discuss 2 facilities Readmissions initiatives
Create Readmission Task Force
Developed a tool to collect transfer data for SNF
on CHF, COPD and MI
Root Cause Analysis completed
Action Plan completed
Completed INTERACT Training
Training 13 facilities
Readmission Root Cause
Analysis
Patient
More complex
Medically unstable,
Impacts therapy
Lack of patient
education
Unrealistic patient
expectations
RN to RN
communication
Medication
communication
Orders
Unrealistic family
expectations
Advance directive
issues
Lack of family
education
Lack of
communication
to ED from SNF
Medication orders
not received timely
Lack of
standing orders
from SNF
Family
Communication
Fear of liability
Inappropriate
admission
Medication
Lack of care path
Physicians
Insufficient
ancillary service
coverage
Patient not seen at
bedside by familiar
caregivers
Assessing rehab
services potential
Lack of
knowledge
Lack of SNF Attending
seeing patient promptly
Medication
Reconciliation
Coordinated Care
Unknown
Prognosis
Lack of medical
record access
Inappropriate
admission
Information
Discharge planning
info not accurate/
comprehensive
Causes of
Readmission
Small Tests of Change
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Discharge Summary faxed to SNF 24- 48 hr
Updating the automated referral near discharge
INTERACT II utilized at a few SNFs
Include Transition of Care with all new physician
Orientation
Nurse to Nurse Hand off communication
Epic transfer information printed and sent to SNFs
Standardized PT / OT post acute
recommendations
Pharmacy completes Medication Reconciliation
all SNF transfers
LMHS - SNF - 30 DAY READMISSION RATE
FY2010 - FY2012 (THROUGH MAY)
25.0%
20.0%
15.0%
10.0%
5.0%
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System Wide High Risk Assessment
• Age 70 or greater
• Chronic Conditions (CHF, AMI, Pneumonia, Diabetes,
etc.)
• Polypharmacy
• Takes Anticoagulants, ASA, Plavix, Insulin, Digoxin
• Previous Admissions within last 3, 6 or 12 months
• Living Situation
• Health Literacy & Language
• Cognitive Impairment
• Patient Self-Health Rating
• Fall Risk
• Palliative Care
• Psych/Social- Depression
Chronic Disease Self-Management Program
• An evidence-based health promotion program for persons
with chronic diseases
• Teaches participants self-management techniques
• Brings community agencies together to tackle chronic
illness in a unified manner; thus, maximizing utilization of
resources and minimizing overlap of initiatives
• Train-the-trainer format to improve self-management and
build self-confidence
• Generic enough to cover a variety of different conditions
CDMP Program Overview
 Six weekly 2.5 hour sessions
 Each class is led by two trained lay leaders
 Focusing on:
- Nutrition and exercise
- Using community resources
- Learning about medication use
- Relaxation techniques
- Solving health-related problems
Care Transitions Update
The Personal Health Record and handouts are
available in Spanish
Expansion to all the hospitals (7 coaches, 2 RT, 1
MSW)
HPC+RC / PT CT Coach
Provided Teach back education for several HHA /
acute care units
CHF handouts available in Spanish
See patients twice, at discharge and 15 days
May add Grand Aides
Developing a Caregiver Assessment tool
Nutritional assessment program with supplementation
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Discharge education begins on admission
Providers are alert to all the possible care
needs after discharge
Compassionate teach back is provided by all
disciplines
Literacy and health literacy are assessed and
education is provided at the patient‘s level of
understanding
Appropriate caregivers are included in the
discharge education
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Care Transitions coaches follow the patient for
30 days
Patients are referred to appropriate agencies for
additional services
The patient has transportation to the PCPs office
within 8 days of discharge
The patient has food and has obtained his
medications
The patient has knowledge of his medications
and self management details
The Patient’s primary caregiver knows about the
hospitalization
Thank you for your attention. Transition home safely!