Transcript patient safety

Ensuring Patient Safety at Home
Mary Ann Christopher, MSN, RN, FAAN
President & Chief Executive Officer
Visiting Nurse Service of New York
5th Annual Lorraine Tregde Patient Safety
Leadership Conference
June 14, 2012
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The Visiting Nurse Service of New York
VNSNY: Who We Are
• Founded in 1893 by Lillian D. Wald, VNSNY is the largest
non-profit community-based health care agency in the
U.S.
• Serves all five boroughs of NYC, plus Westchester,
Nassau, and Suffolk Counties
• Plans a statewide expansion
• Provides a range of services to an average daily census
of 31,000 patients, from newborns to seniors
• 16,000 employees – most are field staff providing direct
care
• Serve a socio-economically diverse population (36%
speak a foreign language)
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Presentation Framework
• Industry perspective
• Magnitude of Problem
• Patient Anecdotal
• Interventional strategies with qualitative
and quantitative outcomes
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Safety Issues at Home
• Falls Prevention
• Non-Healing Wounds
• Depression
• Transitions of Patients Across the Continuum
• Adverse events related to medication
administration
• Patient Preference
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Falls Prevention
 1 in 3 adults over 65 will suffer a serious fall this year
 70% of these falls occur at home
 1 in 2 adults 85 and older fall
 Falls are the leading cause of fatal and
non-fatal injury in older adults
 Every 17 seconds, an elderly person is taken to the
ER because of a fall
 High likelihood of a fall within 48 hrs of changes or
additions to medications
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Risk Factors for Falls
Multiple
Medications
Medical and
Falls History
Balance & Mobility
footwear & devices
FALLS
Muscle
Weakness
Environment
Safety
Vision
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Strong Foundations: Background
 “Strong Foundations” is a multidisciplinary initiative aimed at
patients at high-risk for falls. Falls interventions combine skilled
nursing care and physical therapy in a 4-part course of
treatment
 Data will be obtained from patient self-report and VNSNY
administrative and clinical systems on:
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Incidence of falls and hospitalizations
Quality of Life
Satisfaction with Care
Ambulation
Sustainability of exercise plan
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Strong Foundations: Risk
Assessment Tool
 Nurse and a physical therapist assess the following 8 factors
for falls, as consistent with the American Geriatrics Society
guidelines on falls prevention:
1) Medical History
4) Home Environment
7) Strength
2) Medications
5) Footwear
8) Gait
3) Vision
6) Balance
 The RN assesses the first 5 factors on the patient’s first visit
using OASIS measures
 For the remaining measures, the physical therapist performs a
number of standardized, quantitative assessments:
 Timed Up and Go
 Single Leg Stance
 Functional Reach
 Falls Efficacy Scale
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Non-Healing Wounds
 Affect over 1 million people, exceeding $11 billion in all settings
 Wound infection rates increased 27% from 2000 – 2005
 30% of patients have wounds and 42% have multiple wounds
 Unacknowledged impact of patient preference on quality
outcomes
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Non-Healing Wounds (cont.)
 Communication reminders to clinicians improve patient safety
 Management guidelines include WOCN (Wound Ostomy
Continence Nurse) Consultation
 New Jersey Hospital Association:
 Cross continuum collaborative involving 150 organizations
 Use of Braden Scale and implementation of 3 preventive
measures:
 Manage moisture
 Optimize nutrition and hydration
 Minimize pressure
 Outcomes: 70% reduction in decubitus ulcers
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Depression
 Affects more than 6.5 million (or 18%) of the 35 million Americans
aged 65 years or older
 major depression is twice as common in elderly patients receiving
home care than in those receiving primary care
 chronic illness is the most common factor associated with
depression (prevalence of depression can rise from 10% to 30%)
 Even if diagnosed, roughly 18% of the elderly are on the wrong meds
or have an ineffective dose; thus receiving inadequate therapy
 If untreated, depression can lead to:
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poorer outcomes for hip fractures, heart attacks & cancer
decline of cognitive abilities
avoidable hospitalizations
increased risk of suicide
 Of those elderly who attempt suicide, 80 percent are reported to
have major depression
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VNSNY Behavioral Health Program
 Employs psychiatric nurses, psychiatric nurse practitioners and inhome visiting psychiatrists and receives referrals from community
primary care physicians, hospitals and family members
 In 2011, 1100 patients were admitted to the VNSNY Behavioral
Health Program with the following 5 top diagnoses:
 depression
 anxiety
 dementia (early onset)
 bipolar disorders
 schizophrenia
 VNSNY Behavioral health specialists employ:
 PHQ-9 assessment tool
 Evidence-based practice treatments, using anti-depressive
medication and Cognitive Behavioral Therapy (CBT)
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Transitions of Patients Across the Continuum
 Rehospitalizations are costly and avoidable
 1 in 5 Medicare patients are rehospitalized in 30
days
 34% are rehospitalized within 90 days
 Half never see an outpatient doctor within 30 days
after discharge
 Costs $17.4B*
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*Coleman, Williams, et al. NE Journal of Medicine
Drivers of Hospitalization Risk
 Higher hospitalization risk is associated with:
Previous
Hospitalization
Illness &
Symptom
Severity
Unhealed
Pressure &
Stasis Ulcers
Diagnosis
Type
Urinary
Incontinence &
Catheters
Medication
Use
Respiratory
Symptoms
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ITAC 2012
Transitional Care Model
1) Predictive Algorithm with alerts to clinicians
2) Short and long-term transitions of care program
3) Adapted Brenner Model
4) Continuity of Care Challenges
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Transitional Care Program
Results: 30 Day Readmission Rates
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Opportunities for Improved Outcomes
ER
Visit
Continuity
of Care
Hospital
Readmission
+
ADL
Functioning
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Medication Management
 Patients who did not take medications as prescribed cost
the health care system $290B in available medical
spending
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2009 (New England Health Care Institute)
 In a study of patients, 1/5 had adverse events due to
inadequate medical care after returning home, with Rx
drugs accounting for most injuries after discharge
 Some medications get discontinued inadvertently (mostly
statins and anticoagulants) with a resultant adverse
impact on patient safety and hospital recidivism
 Non-geriatric friendly medications can result in
unnecessary falls and motor vehicle accidents
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Components of an Effective Medication Program
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Care Coordination
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Utilization Management
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A well thought out formulary structure
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E-prescribing
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Basing pharmacists and nurses at neighborhood and
senior centers
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Automatic medication dispensers
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Involvement of PharmD in interprofessional team
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VNSNY CHOICE Model has
Produced Measurable Outcomes
• Hospital Admissions: Utilization data for a cohort of 573
members enrolled in our care coordination program for 24
months showed significant reductions:
– 54% decrease in hospital admissions
– 24% decrease in readmits within 30 days to 16%
– 27% decrease in ER visits
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Vulnerable Patient Study
 Background:
• VNAA, in collaboration with the VNSNY Center for Home Care
Policy & Research, initiated a patient study in 2010 to collect
data on a range of patients and their associated costs
 Initiated by 9 VNAs across the country
 Now being replicated nationally with 50 home care
organizations
 Adequacy of Risk Adjustment:
• Identified variables: health literacy, stasis or pressure ulcers,
presence of caregiver, access to primary care, clinically
complex conditions, functional disability with poor rehabilitation
potential
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