Transcript Heart Failure Disease Specific Certification –The Joint

REDUCING
READMISSIONS
St. Luke’s Hospital Case Study
Cedar Rapids, IA
IHI National Forum
Orlando Florida
December 9, 2013
ST. LUKE’S HOSPITAL
MEMBER, UNITYPOINT HEALTH
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Private hospital – Cedar Rapids, Iowa
Affiliate in the UnityPoint Health
system
Licensed for 500 Beds with more than
17,000 admissions
Truven Top 100 Hospital – 5 years
(2013); Heart Hospital 3 years (2012)
Iowa Recognition for Performance
Excellence Gold Award - 2010
Magnet Designation – 2009
The Joint Commission DiseaseSpecific Certification in Advanced
Heart Failure, Stroke, Palliative Care
and Total Joint. Society of Chest
Pain Center – Chest Pain
Certification
Gold Award from Get with Guidelines
for Heart Failure 2010-2013
WHY IS REDUCING AVOIDABLE
REHOSPITALIZATIONS STRATEGIC FOR
ST. LUKE’S HOSPITAL?
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It is part of our mission: “To give the healthcare
we’d like our loved ones to receive”
It represents goals that are aligned with
healthcare reform: providing better value for
decreased costs. Learning has been incorporated
into our present work with development of
population management and ACO work
TRANSITION TO HOME TEAM MEMBERS
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CHAIR: Peg Bradke, VP-Post-Acute Care
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Sherrie Justice, Dir-PI
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Robinn Bardell, Mgr-Case Mgmt
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Carmen Kinrade, VP-Nursing Excellence
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Sarah Baumert, Mgr-5E
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Patty Koelker, PCC-5E
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Diane Pfeiler, PCC-3C
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Jennifer Mahoney, UPH Clinic - Northridge
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Alexis Benion, Living Center West
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Shirley McCloy, Resp Ther
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Dean Bleadorn, Mgr-RT
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Sandi McIntosh, Dir-ED
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Myrt Bowers, Assoc Exec Dir-Witwer Center
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Jennifer Owens, Med Soc Svcs
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Shelley Cahalan, Gen Mgr-VNA
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Julie Peterson, Mgr-Card Rehab
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Christy Charkowski, STL Hospitalists
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Karen Pierce, Data Analyst, PI
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Sara Claeys, Dietary Svcs
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Amrita Samra, MD - CRMEF
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Christina Djerf, Prog Coord-Lifeline
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Brandi Simmons, Living Center West
Elizabeth Eichhorn, ARNP-Living Center
West
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Amy Schweer, STL HF Clinic
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Marilinne Staub, UM Spec.
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Krissy Elder, PCC-5C
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Aimee Traugh, Mgr-3C
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Karen Forster, Pharm
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Sheila Tumility, Reg PI Proj Mgr
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Terri Grantham, APN-Card Outcomes
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Brook Van Dee, ARNP-OP Pall. Care
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Renee Grummer-Miller, OP Pall. Care
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Jean Westerbeck, Living Center West
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Barb Haeder, APN-Card Outcomes
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Pam Williams, JRMC Resp Care
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Sue Halter, ARNP-STL HF Clinic
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Sharon Zimmerman, Resp Care
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Signe Henderson, Coord-Home Care
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Amrita Samra, MD, CRMEF
Dr. Todd Langager, Cardiology Medical
Director
VOICE OF THE CUSTOMER
 Feedback
from Chronic Disease Management
class
 Patient and family members on our PatientFamily Advisory Council
 Feedback from follow-up phone calls
 Feedback from Cardiopulmonary Rehab
participants
 Feedback from High-Risk Clinic Patients
CROSS-CONTINUUM TEAM
 Meets
monthly
 Reviews readmissions for each month related
to core diagnosis to assess causes and
opportunities for improvement
 Reviews process and outcome measures
 Continually testing and improving,
aggregating the experiences of patients,
families and caregivers
 Each facility reports in testing occurring in
their area
SEVERAL SUBGROUPS REPORT INTO
THE LARGER TRANSITION TO HOME
TEAM
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Data Management
Patient Education processes
Home Care
SNF/Nursing Facilities work processes
Physician Clinic processes
Case Management/Social Work/Care Coordination
Several members of the Transition to Home team are members of
the hospital ACO and Population Health Management work.
Information is bidirectional between these teams.
Continuum of Care Process
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Standardized care through order sets.
Use of the clinical indicator sheet as a checklist for
evidence-based care being met.
Report developed to identified key core measure
patients – (e.g. BNP, Troponin etc)
Teaching:
• Utilizing Universal Health Literacy Concepts
• Enhanced teaching materials
• Teach back
Utilization of whiteboard to individualize patient’s plan
of care and communicate to team.
Continuum of Care (2)
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Bedside report to involve patient and family
caregivers as partners in care.
Daily huddles are facilitated with the patient care
nurse, charge nurse, and care coordinator. Daily
goals are reviewed providing opportunity to review
plan for the day, available support for patient,
discharge goals, and determine what it will take to
get the patient home safely. Assessment of
palliative care referral is part of discussion.
Standardized Disease specific on-line discharge
instructions.
Continuum of Care (3)
Touch points post discharge:
 Home Care - care coordination visit 24 to 48 hours post
discharge on high risk patients
 Physician Clinic follow up appointment made prior to
discharge for 3-7 days after returning home
 Follow-up phone call set up based on post discharge needs
at 5-9 days
 Standardized tool for transfer of information to nursing
facilities for next level of care .
 Telehealth monitor available through Home Care
 Chronic Disease Management Program for patients
 In addition staff participate in Integrated Chronic
Disease Management class
ENHANCED ADMISSION
ASSESSMENT
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During Admission Assessment, the patient and family
are asked, “Who would you like to have present when
we provide your discharge information?”
Information added to the whiteboard
RN and physician do medication reconciliation
Concentrated effort for Admission. Dedicated
Admission Center RN’s complete home medication list
and prepare an appropriate list for physician to address.
At times, the pharmacy or physician offices need to be
called to get additional information. If the patient is a
home care patient, the home care agency is called to get
the current list of medications
ENHANCED ADMISSION ASSESSMENT (2)
Referral to Palliative Care for patient with
advanced stages of disease - the referrals have
consistently increased. Team rounds daily on units
 Bedside report to involve the patient and family
caregivers as partners in their care. Daily discharge
huddle is facilitated daily with the RN caring for the
patient, the charge nurse, and unit-based case
manager
 Take 5 completed on patient at start of shift. Daily
goals are reviewed and written on the whiteboards
in each room, providing the opportunity to review
the plan for the day, anticipate discharge needs, and
determine what it will take to get the patient home
safely
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Interview Questions
For patients that are readmitted within 30 days of last
admission:
 Can you tell me in your own words why you think you
ended up sick enough to be readmitted again?
 Can you tell me what a typical meal has been for you
since you left the hospital? What did you have for
dinner last night?
 Have you seen your doctor since you were discharged
from the hospital?
 Do you have all of your medications? How do you set
up your pills every day?
 Were there any appointments that kept you from
taking any of your pills?
PARADIGM SHIFT
“The patient is noncompliant.”
vs.
Asking, “What is our responsibility as the
sender of the information?”
ENHANCED TEACHING AND LEARNING
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patient education materials facilitate the
use of Teach Back, and the same materials are
used across the continuum: in the hospital, with
home care, long-term care settings and the
clinic.
 Short, succinct material developed for each Core
Measure DRG. Teach Back question part of
packet for staff and patient reference.
 Patient teaching flowsheets set up to address
Teach Back and assure the documentation and
use of Teachback.
TEACH BACK WITH DISCHARGE
INSTRUCTIONS
Can you show me on these instructions:
 How you find your doctors’ office appointment?
 What other tests you have scheduled and
when?
 Is there anything on these instructions that could
be difficult for you to do?
 Have we missed anything?
 Who will you call if you have questions?
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ENHANCE TEACHING AND
FACILITATE LEARNING
Use Teach Back:
 In the hospital
 During home visits and follow-up phone calls
 To assess the patient’s and family caregiver’s understanding of
discharge instructions and ability to do self-care
Building Teach Back into our work
 Session in Nursing Orientation
 Session in Nursing Residency Program
 Net Learning module, competency validation, and in-house
prepared instructional DVD with Teach Back demonstration
 Closing staff meetings, walking the talk
 Staffs participate in Chronic Disease Management
HEART FAILURE MAGNET
LOW SODIUM EATING PLAN BROCHURE
Cover page
Back page
LOW SODIUM EATING PLAN BROCHURE
LOW SODIUM EATING PLAN BROCHURE
LOW SODIUM EATING PLAN BROCHURE
Heart Failure Workshop
Saturdays
9:00 a.m. to Noon
St. Luke’s Hospital
Nassif Heart Center
Third Floor
This workshop is taught by a registered nurse and registered dietitian.
You will learn about:
♥ Causes of heart failure
♥ Activity and exercise
♥ Low Sodium eating plan
♥ Guidelines for dining out
♥ Reading food labels
♥ Medications
♥ Living with heart failure
There will be displays of health information to look at and a packet of
heart failure information for you to take home.
This is an excellent program for people who have had heart failure or
have a heart problem that puts you at risk for heart failure. Learning
more about your heart failure is essential in controlling your heart failure
symptoms and preventing problems. Family members and caregivers are
encouraged to attend also.
This program is FREE No registration necessary
Walk-ins welcome!
To learn more, call St. Luke’s Heart Care Services
(319) 369-7736
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Where To Start?
 Go to the Unresolved
Education Tab
 Select the topic you
educated on
 Begin charting on the
right side of the screen
What you taught on
Additional comments
DISCHARGE ASSESSMENT - SMART TEXT
POST-ACUTE CARE FOLLOW-UP
Home Care Visit set up for 24-48 hours after
discharge. Home Care liaison in-house. Teach Back
questions part of visit .
 Partnership with physicians’ offices resulted in
redesign of scheduling follow-7p visits to allow office
visits within seven days for patients.
 Appointments are scheduled prior to discharge and
noted on discharge instructions.
 Advanced Medical Team Pilot in Pulmonology Clinic
with High Risk/High Resource patients.
 Consistent Care Plan Program in Emergency Dept.
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3W TEST OF CHANGE
EMERGENCY DEPARTMENT CONSISTENT
CARE PLAN
Consistent Care Program (EDCCP) for patients
who had visited the ED 12 or more times in the
previous 12 months.
 103 Care Plans were developed, mailed, and
implemented.
 Care Plans are a communication tool that provide
data specific to that patient’s medical history and
current medical needs, along with Goals of Care for
when patients present in the Emergency Dept.
 Using care plans and with intervention by a social
work case manager, there has been a reduction in
patient’s Emergency Department use.
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CONSISTENT CARE PROGRAM
REAL-TIME HANDOVER
COMMUNICATIONS
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Medication Reconciliation is a joint physician and nurse
accountability.
Patients going home are offered a care coordination visit with
Home Care in the first 24-48 hours after discharge. The home
care does a certified content visit including medication
reconciliation and determines eligibility.
St. Luke’s partnered with the hospital’s home care agency
(VNA) and two long-term care facilities to standardize and
enhance the quality of the handoff communication process. A
new interagency transfer form is now used. Warm handover
with those patients with complex issues.
Provided education for home care and long-term and skilled
care RNs and CNAs on HF, MI and Pneumonia and continuity
processes.
Base Event Discharge Disposition
Housewide Acute Inpatient Readmissions wi 30 Days
Jul 2012 - Jun 2013
Psych Hospital, 26,
2.1%
Other Institution, 2,
0.2%
LTAC, 6, 0.5%
Home, 718, 58.6%
Rehab, 20, 1.6%
MC Swing , 12, 1.0%
Hospice Facility, 8,
0.7%
Hospice Home, 11,
0.9%
Court, 1, 0.1%
Home Care, 200,
16.3%
ICF, 27, 2.2%
SNF, 195, 15.9%
Readmit Admit Source
Housewide Acute Inpatient Readmissions wi 30 Days
Jul 2012- Jun 2013
One Distinct Unit
to Another, 30,
2.4%
Hospice Facility, 5,
0.4%
SLH, 0, 0.0%
Court/Law, 6, 0.5%
Non-Acute Health
Care Facility, 0,
0.0%
Skilled/ICF, 72,
5.9%
Different Hospital,
23, 1.9%
Home & Clinic,
1,092, 88.9%
Histogram of Days Between Admissions (with Outlier removed)
Normal
Mean 10.36
StDev 8.389
N
56
12
Frequency
10
8
6
4
2
0
-6
-3
0
3
6
9 12 15 18 21 24
Number of Days Between Admissions
27
30
Histogram of Days between Initial Discharge Date and Readmission Date
Heart Failure as Initial Admission
• Incomplete medical management
• Wrong site of post- acute care
• Socio-economic factors
• Physician follow-up
• Med problems
7
• Patient compliance with regime
• Disease trajectory
14
30
Mean
StDev
N
12
11
10
Frequency
9
8
7
6
5
4
3
2
1
0
-6
0
6
12
18
Days between
24
30
36
15.10
8.773
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HCAHPS RESULTS
DISCHARGE INFORMATION (%
YES)
90
89
88
87
84
82
88
87
86
84
82
GOOD
84
82
80
78
2009
2010
St. Luke's
2011
Jan-Sep 2012
National
The following questions make up this composite measure:
#19 – During hospital stay, did doctors, nurses or other hospital staff talk about whether you would
have the help you needed when you left the hospital?
#20 - During hospital stay, did you get the information in writing about what symptoms or health
problems to look out for after you left the hospital?
Prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI)
http://www.mitre.org/work/health/news/bundled_payments/St_Lukes_Case_Study.pd
CRITICAL CAPABILITIES FOR CARE
REDESIGN INCLUDE:
 Cross-continuum
participation and
alignment
 The development and use of standardized
tools and compatible information
infrastructure
 Horizontal leaderships and executive
sponsorship and engaged physicians
 Effective external and internal learning
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LESSONS LEARNED
Importance of engaged executive leaders and
physicians.
 Patients and families help transform care in
profound ways.
 The patient and family home environment must be
understood.
 Involving front-line staff in the changes helps them
understand why they are important and grows
ownership by engaging them in redesign.
 The power of relationship building and collaboration
of the cross-continuum team builds new ideas to
work and removes many of the “silos’ in the care.
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LESSONS LEARNED (CONT)
The role of Information Technology in the process
should be addressed simultaneously with the work.
 Ongoing monitoring of Process and Outcome
Measures is important to hardwiring best practices.
 Using patient stories unleashes energy and
participation that becomes evident in process and
outcome results.
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QUESTIONS:
Peg Bradke RN, MA
Vice President, Post Acute Care Services
UnityPoint Health St. Luke’s
Cedar Rapids, IA
[email protected]