Transcript Care Transitions Meetings

A Community-Based Approach to
prevent hospital readmissions
Brainerd Community Team:
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Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis Health
Kathryn R. Miller, RN, BS, G-L C, Director Quality and Safety, Essentia Health St.
Joseph’s Medical Center
Gayle Nielsen, MSN, RN Care Coordinator, Essentia Health Clinics, Central Region
Marie Michlitsch, RN, Director of Nursing, Good Samaritan Society - Woodland
Deanna Abramson, RN, Assisted Living Manager, Good Samaritan Society - Woodland
Kayla Farr, RN, Good Samaritan Society, Home Care & Hospice
January 8, 2014
A Community-Based Approach
to Prevent Hospital
Readmissions
RARE Webinar – January 8, 2014, noon – 1 p.m.
Janelle Shearer, RN, BSN, MA
Program Manager
Stratis Health
Session Goals
• Describe a community-based approach to
improve coordination between settings of care
• Identify how to collaborate with other
organizations to improve care transitions
• Identify best practices you can implement to
reduce avoidable hospital readmissions
Who is Stratis Health?
• Independent, nonprofit, facilitating improvement for
people and communities
• Funded by federal and state contracts, corporate and
foundation grants
• Medicare Quality Improvement Organization (QIO)
for Minnesota
• Focus areas include rural health, health information
technology, patient safety, cultural competence, and
long-term care
Current Medicare QIO Work
1. Beneficiary and Family Centered Care
2. Improving Individual Patient care
3. Integrating Care for Populations
and Communities
– Improving Care Transitions Leading to the
Reduction of Readmissions
• Improving Transitions of Care – community-based approach
• RARE Campaign
4. Improving Health for Populations
and Communities
Duluth
Brainerd
North Metro
The Community
Providers across the continuum of care
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Acute care hospitals
Clinics
Home health/hospice organizations
Long-term care facilities
Assisted living facilities
Local public health departments
Patients and/or patient advocates
Other community partners
Community-Based Approach
• Each organization conducted root cause
analysis to identify gaps in care related
to transitions of care and readmissions
• Identified community needs
and resources
• Identified best practice interventions to
improve the gaps
The Brainerd Area
Community Story
Partnering to Prevent Avoidable
Readmissions
Essentia Health
St. Joseph’s Medical Center
Kathryn R. Miller, RN, BS, G-L C
Director Quality and Safety
Essentia Health St. Joseph’s
• Type of provider-Acute care 162 bed full service
JCAHO accredited hospital (exceptions: Cardiac
and Neuro surgery) with on site Cath Lab
• Central Minnesota-Brainerd Lakes area
• Staff composition RN and CNA teams
• ICU, Telemetry, Medical, Surgical, Mental Health
and Chemical Dependency Units
• EH is one of the first two organizations in the
country (Essentia and HealthPartners) to attain
highest level of recognition as an Accountable Care
Organization (ACO) by NCQA
Issue/Problem
• Needed to look at those diagnoses that had high
readmission rates, particularly the Heart Failure
population
Main Areas of Focus
• Developed an Interdisciplinary team that met
monthly
• Initiated f/u telephone calls in 24-48 hours
• Developed a system for all d/c patients to be
seen by PCP within 5 days of discharge
Development of Transitions
Subgroup
• Intensive effort to work in a small group setting
with key community members (nursing homes,
home care, etc.)
• Identified barriers to a smooth transition:
– i.e. Lack of; incomplete documentation (MAR)
SOLUTIONS:
• Worked with our IT department to allow the
nursing homes view only access to our EMR
(Electronic Medical Record-Epic)
• Educated hospitalists on tying diagnosis with
medication ordered on discharge
Results
• We have begun to see a downward trend in our
readmission rates for Heart Failure, COPD and
Pneumonia patient populations
• Work still needs to be done on:
• 1) Pharmacist reviewing medications with all
patients at the time of discharge
• 2) Continued work on formation of a Palliative
Care Team to address end of life/quality of life
issues with patients and their families
Contact Information
Kathy Miller RN, BS, G-L C
Director Quality and Safety
Essentia Health Central Region
St. Joseph’s Medical Center
523 North Third Street
Brainerd, MN. 56401
Email: [email protected]
(218) 828-7435
Marie Michlitsch, RN
Good Samaritan Communities of
Brainerd and Pine River
• Woodland has 41 Care Center residents. Roughly
25% are on a short term stay for rehab.
• Bethany has 124 residents. There is a subacute unit
with capacity for 40 resident’s on this campus.
Roughly 25% of the campus is short term subacute
residents.
• Whispering Pines in Pine River has 56 residents with
roughly 20% residents on a short term stay.
• Noted increase in hospital readmissions within
100 days.
• Highest rate of readmission noted to be 6%.
• Increased cost with the readmissions to the
hospital.
• Increased resident and family stress and
depression with readmissions to the hospital.
• Noted problem with diagnosis listed on
discharge orders.
• Staff unaware of off label use of medications
unable to properly educate residents on
medication use.
• Worked with the hospital on obtaining
diagnosis for medications.
• Barriers noted with working with
computerized charting systems.
• Hospital worked on obtaining access to their
computer system for Care Center Staff.
• Care Center staff will have ability to review
records from the hospital to ensure quality of
continuum of care for the residents.
- This is a work in progress and all staff are
thrilled to have the ability to review residents
records to ensure quality care.
• Physicians Orders for Life Sustaining Treatment.
– Five staff trained as Advanced Care Planning Facilitators.
• INTERACT tools utilized for nursing staff included the
following:
– Care paths for resident condition changes.
– Acute change in condition file cards available to all nurses.
– Stop and Watch forms utilized for early detection of changes in
condition.
– SBAR - Situation Background Assessment or Appearance Request
forms utilized in Point Click Care.
– Designated staff audits all hospital admissions and Emergency Room
visits to determine if potentially preventable. Education occurs as
needed if determined potentially preventable.
– INTERACT website: http://interact2.net/
Care Paths
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CHF
UTI
Pneumonia
AMSC
Fever
Dehydration
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Change in Condition:
When to report to the MD/NP/PA
Immediate Notification:
Any symptom, sign or apparent discomfort that is:
1. Sudden in onset
2. A marked change (i.e. more severe) in
relation to usual symptoms and signs
3. Unrelieved by measures already prescribed
This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS),
an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 8SOW-GA-NH-08-37
Sources:AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home.
McGraw-Hill, 1996 When to report to the MD/NP/PA Change in Condition:
© 2010. Florida Atlantic University
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Vital Signs
(Report Why Vital Signs Were Taken)
Vital Sign
Blood Pressure
Pulse
Respiratory Rate
Weight Loss
Report Immediately
• Systolic BP > 210 mmHg, < 90 mmHg
• Diastolic BP >115 mmHg
• Resting pulse > 130 bpm, < 55 bpm, or
>110 bpm and patient has dyspnea or
palpitations
• Respirations > 28, < 10/minute
• Oral (electric thermometer) temperature >
101F
Report on Next Work Day
• Diastolic BP routinely > 90 mmHg
• Resting pulse >120 bpm on repeat
exam
• New Onset of anorexia with
or without weight loss
• 5% or more within 30 days
• 10% or more within 6 months
© 2010. Florida Atlantic University
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EARLY WARNING TOOL
“Stop and Watch”
If you have identified an important change while caring for a resident today, please
circle the change and discuss it with the charge nurse before the end of your shift.
Name of Resident ______________________________
Seems different than usual
Talks or communicates less than usual
Overall needs more help than usual
Participated in activities less than usual
Ate less than usual (Not because of dislike of food)
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Drank less than usual
Weight change
Agitated or nervous more than usual
Tired, weak, confused, or drowsy
Change in skin color or condition
Help with walking, transferring, toileting more than
usual
Staff_________________________________________________
Reported to ___________________________________________
Date _____ / _____ / ________ Time ________________
© 2010. Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000)
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SBAR
Structured and standardized
communication format between
health care workers.
S=Situation (a concise statement
of the problem)
B=Background (pertinent and
brief information related to the
situation)
A=Assessment (analysis and
considerations of options — what
you found/think)
R=Recommendation (action
requested/recommended — what
you want)
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• Noted decline in preventable hospital
readmissions.
• Noted increase in changes in orders prior to
admissions to the hospital in attempt to
prevent hospital admission.
Marie Michlitsch RN
Director of Nursing
Good Samaritan Society Woodland
100 Buffalo Hills Lane
Brainerd, MN 56401
[email protected]
(218)855-6601
Good Samaritan Society Assisted Living
Bethany, Pine River, Woodland
Deanna Abramson
Assisted Living RN Manager
Woodland Campus
Bethany and Pine River Campuses
Bethany
• In Brainerd
• 37 Senior Living
Apartments
• 20-25 residents on A/L
services
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Pine River
In Pine River
36 Senior Living
Apartments
Recently added A/L
services
1 Cottage Style House
with 16 higher level A/L
Good Samaritan Society Woodland Senior Living
Apartments & Samaritan Houses
• Good Samaritan Society Woodland Campus in
Brainerd MN
• Senior Housing- Apartments with Assisted Living and
Cottage Style Units for Higher Level Assisted Living &
Memory Care
• Apartments- average 70 A/L residents (128 total
Apartments), 16 beds A/L in Cottage Style, & 32 beds
Memory Care
• Universal Workers (NARs) 5 RNs & 3 LPNs
Issues/ Challenges
• Admitting Residents with higher level of care needs
• Limited amount of Licensed Staff in our buildings to
assess and monitor the resident’s health issues.
• Many times A/L staff not making the decisions for
residents going to ED (residents / families)
• Hospital staff & Physicians unaware of the limitations
the Assisted Living settings in meeting resident’s
health/ care needs
Goal or Aim
• We want to give our Assisted Living residents the
best nursing care that we can possible
• To decrease the ED visits and the hospitalizations for
our residents.
• If possible we want to catch as many symptoms as
necessary to alleviate the stress and discomfort of
sending the resident into ED.
• Build communication and trust with local providers
to give the residents a smooth transition when
hospitalized and/or transferred back to home.
Stop & Watch Forms
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Catch changes in condition early
Empower our staff to bring up issues to Nursing Staff
All staff/All departments are educated.
Easy access to forms
Get away from writing notes on all types of pieces of paper
Education during our annual staff training
Staff needs follow up & feedback
At this point we haven’t seen too many utilized- oncoming
reinforcement
• Challenge when have some residents who refuse to be seen
by their Physician
Pilot to develop and begin tracking Assisted Living
Resident’s hospitalizations & re-hospitalization
• Look for trends and to look for ways to decrease some of our
ED visits and hospitalizations;
• Be part of our QI/QA process that will be required with our
new Comprehensive License
• Using a tracking form and a Data sheet & QI form
• Need to get all staff to see importance of tracking & ways for
reduction.
• Have data to show results
• Can be used for Marketing reasons, that if your facility can
show the data that they have fewer ED visits the hospital and
other would recommend your facility to the potential
residents
Deanna Abramson
Good Samaritan Society Woodland
RN Assisted Living
[email protected]
218-855-6632
Essentia Health Clinics
Central Region
Gayle Nielsen, MSN, RN Care Coordinator
St. Joseph’s-Essentia
Clinics
Baxter, Brainerd, Crosslake,
Hackensack, Pequot Lakes,
Pierz, Pillager, Pine River
Appointments
• In-patient and ED Ward Clerks are now able to
make visit appointments
– Within 5 days for high-risk readmissions
• Reserved anywhere from 0 to 4 slots daily for
Same Day Visits.
– Released 5 p.m. the evening before or 8 a.m. day of
• Reserved 0-2 slots a week for Hospital Followup visits
– Released 24 hours before
Baxter Clinic/Long Term Care
• Long term care leadership came to a
Baxter Clinic Department meeting for faceto-face discussion
• Doctors and nurses from the clinic attend
• Medication lists
• Orders
Care Coordination Program
Program Goal:
Triple Aim:
Improve Quality
Improve Patient Satisfaction
Reduce Cost
Role of the RN Care Coordinator
Program Goal #1 Improve Quality
•Regular contact, with one individual
•Pre-visit calls to “package the visit” for PCP
Updates from specialists visits
Changes in function/ clinical condition
Patient’s agenda
•Self management support, patient education
•Management of care transitions – post
discharge, ER visits, other events
Role of the RN Care Coordinator
Program Goal #2 Patient Satisfaction
– Develop Care Plan with patient and family
• One stop summary of all problems, meds,
instructions, plans
• Identify patient’s personal goals and match
them with the medical plan
– One trusted person to call when urgent
matters arise
– Advocate and system navigator
Role of the RN Care Coordinator
Program Goal #3 Reduce the total cost of care
– Prevent hospitalizations
• Improve patient and family
understanding of the plan
• Attentive follow-up
• Arrange appropriate home support
– Prevent unnecessary ER Use
• Create a “Primary Care Home”
• Emergency plan of care – what to do
when…
Referral Criteria
(At Least 1 of the identified)
• Regular Care with 3 or more sub specialists for
significant medical conditions
• >3Hospital readmissions in 6months
• Greater than 3 ER visits within 6 months
• Greater than 4 points noted on Risk Stratification Tool
• Threats to self care ability identified by RNCC
(inadequate support, financial barriers, impaired medical
literacy, language barrier)
• 2 or more chronic conditions identified on problem list
(outside of quality targets).
General Information about our
Program
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Two RN Care Coordinators
Eight Clinics
33 Practitioners
Total Number Patients Enrolled: 102
62 Female, 40 Male
73% of patients are Medicare
22% Medical Assistance
ACO-BCBS and Medica
Readmission Data
July 1 - August 1, 2013
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35 discharges involving 31 patients
One Care Coordination Patients
9 readmissions involving 5 patients
None of them were Care Coordination Patients
Three patients had two readmissions each-one
of them is deceased and one on hospice
13 Care Coordination Patients
Six months before
enrollment
Six months after
enrollment
• 13 ED visits
• 13 Hospital Admissions
• 4 ED visits
• 8 Hospital Admission
• 69% reduction in ED
visits
• 61% reduction in Hospital
Admissions
Contact Information
Gayle Nielsen, MSN, RN Coordinator
Essentia Clinics
Email: [email protected]
218-454-5967
Good Samaritan Society
Home Care & Hospice
Kayla Farr, RN
Director
Good Samaritan
• Home Care
• Hospice
• Avg daily census
• HC- 72
• Hos-14
Location
• Located in Nisswa, MN
• Coverage area within 45 miles from the office,
remote locations we utilize telemedicine.
• We have nursing divided for both service lines.
Concerns
• Return hospitalizations
• Notification from our home care patients of
going into the hospital
• “Repeat offenders”
• Tracking of telehealth patients who go into the
hospital.
Goal
• Reduction of our hospitalization rate
• Collaboration effort between providers
• Increase disease management for our
patients.
Success Story
• Identification of our hospitalizations
– Who/Why
– Stratis Health
– Acute Care Transfer Log (INTERACT tool) modified.
– Increase team awareness:
• Hospital
• Home Care
• Hospice
Challenges
• Acknowledgment of issues that need to be
addressed.
• How to stay focused on the collaboration for
the “patient” versus feelings of “pointing
fingers”.
• Getting team members to “attend” to a after
hours call.
Contact Information
Kayla Farr, Director
Good Samaritan Society Home Care & Hospice
[email protected]
218-963-9452
Q&A
Contact
Janelle Shearer, MA, BSN, RN
952-853-8553 or 877-787-2847
[email protected]
Stratis Health is a nonprofit organization that leads
collaboration and innovation in health care quality and
safety, and serves as a trusted expert in facilitating
improvement for people and communities.
Prepared by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 10SOW-MN-C8-14-42 010214
Upcoming RARE Events….
Stay tuned for the next RARE Webinar…
Team Care for the Chronic Disease Patients:
Using lay “Care Guides”
February 21, 2014 (1-2 p.m.)
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact Kathy Cummings,
[email protected]