Transcript HALTT Hospital Admissions Lessened Through Therapy

H.A.L.T.T.
Hospital Admissions Lessened
Through Therapy
Tuesday, April 28, 2015
HALTT: Hospital Admissions Lessened Through Therapy
Presented by
Heather Meadows, SLP
PREMIER THERAPY
701 Sharon Road  Beaver, PA 15009
800.875.7041
www.EmbracePremier.com
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OBJECTIVES
1. The attendee will be able to describe the
prevalence of readmissions as well as the targeted
diagnoses.
2. The attendee will identify the potential roles that
OT, PT, and Speech could play in reducing
readmissions.
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OBJECTIVES
3. The attendee will design a program which identifies
at risk residents utilizing root-cause analysis and a
comprehensive plan to address issues.
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The Accountable Care Act
• Nearly 18% of hospitalizations of Medicare patients
are the result of readmissions.
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The Affordable Care Act
• To reduce these costs, the Hospital Readmissions
Reduction Program was introduced through the
ACA.
• This requires CMS to reduce payments to hospitals
with excess readmissions effective 10/1/2012.
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Readmissions Defined
• Readmissions are defined as an admission to
subsequent hospital within 30 days of a discharge
from the same hospital.
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Adopted Readmission Measures
• CMS targeted diagnoses: Breakdown of readmissions
– CHF 24.8 %
– Pneumonia 18.4%
– Acute Myocardial Infarction 19.8%
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National Readmission Measures
• In the fiscal year 2014, IPPS final rule, CMS adopted
additional readmission measures for:
– Acute exacerbation of Chronic Obstructive
Pulmonary disease (COPD)
– Elective Total Hip Arthroplasty (THA)
– Elective Total Knee Arthroplasty (TKA)
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The Goal of ACA
• Hospitals will receive bundled payments covering
not just the hospitalization, but the care after the
hospitalization.
• Hospitals with high rate of readmission will be paid
less if patients are readmitted to the hospital within
the same 30-day period with those targeted
diagnoses.
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Expected Outcome
• The combination of incentives and penalties should
lead to better care after a hospital stay and result in
less readmissions.
• Savings of approximately $25 billion dollars over 10
years is expected.
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Current Data for SNF Readmission
• 2011 Q4 – 18.2 % sent back to hospital within 30
days of their SNF stay
• 2014 Q2 - 15.6 % sent back to hospital within 30
days of their SNF stay
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Results
• This is a overall 14.3% decrease from the 2011
readmission totals.
• An estimated 58,000 readmissions were
prevented, saving the health care system
almost $599 million.
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HR 4302 – Protecting Access to Medicare
2014-New for SNFs in 2015 and 2016
• A new bill calls for the U.S. Department of Health and
Human Services (HHS) to introduce an “all-cause, allcondition” hospital Readmission Measure for SNFs by Oct.
1, 2015.
• A Resource Use Measure began to reflect an all-condition,
risk-adjusted, potentially preventable hospital readmission
rate for SNFs by Oct. 1, 2016.
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HR 4302 – Protecting Access to
Medicare 2014-New Bill
• SNF performance would be reported publicly on the
Nursing Home Compare website, but HHS also would be
required to send quarterly reports to SNFs with
confidential feedback on their performance against the
measures beginning Oct. 1, 2016.
• SNFs will have the opportunity to review and submit
corrections prior to the information becoming public.
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HR4302
• You can access H.R. 4302 at:
http://www.gpo.gov/fdsys/pkg/BILLS113hr4302enr/
pdf/BILLS-113hr4302enr.pdf
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Assess Facility Readiness
• What corporate programs and outcomes are you using
(Quality Assurance/Performance Improvement, QAPI)?
• Do you have facility specific protocols in place?
• What current opportunities exist?
• Do you have tracking systems for readmissions?
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Partnering Opportunities
• Do you have integrated coordination opportunities
available?
–ACOs (Accountable Care Organizations)
–Bundled Payments for Care Improvement
(BPCI) Initiative
–Initiative to Reduce Avoidable
Hospitalizations Among Nursing Facility
Residents (RAVEN) UPMC
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Advancing Excellence
• America’s Nursing Homes National Campaign was
founded in 2006, by 28 organizations including nursing
homes, quality improvement experts, and government
agencies to improve the quality of nursing homes.
• Evidence-based resources were developed to support
quality improvement efforts in nursing homes, ensuring
better care for the residents and staff that care for them.
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Advancing Excellence
• It is the first national effort to measure quality in the
nursing homes through measurable clinical quality
goals and organizational improvement goals.
• Every nursing home can participate by focusing on
two or more goals, and utilizing resources developed
by group to meet their goals.
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Advancing Excellence
Goals choices are:
Clinical quality goals
Organizational improvement goals
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reducing pressure ulcers
improving pain management
increasing mobility
reducing infections
reducing antipsychotic use
increasing staff retention
improving consistent staff assignment
reducing unnecessary hospitalizations
promoting patient-centered care
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Advancing Excellence
• Many of these goals are interrelated. Improvement
in one area can impact other goals, such as
improving mobility with residents, and may reduce
pressure ulcers or improve pain with the residents.
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Advancing Excellence
• You are able to use resources from their website to
initiate quality improvement in your facility, and
utilize guidelines, forms, and tracking to report/track
progress and show improvement with each goal.
Source: Advancing Excellence, www.nhqualitycampaign.org, Accessed 3-23-2015
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INTERACT 4.0
• INTERACT stands for Interventions to Reduce Acute Care
Transfers.
• It is a quality improvement program to improve the
identification, evaluation, and communication about
changes in the residents’ status.
• Projects are supported by CMS and now funded through
Commonwealth Fund, involving nursing homes in Florida,
New York, and Massachusetts.
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INTERACT
• The overall goal of the program is to reduce the
frequency of transfers to the hospital, which have
been proven to be both difficult and costly.
• The program is comprised of communication, care
path, clinical and advanced-care planning tools for
care teams to use to reduce unnecessary
readmissions to the hospital.
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INTERACT
• Tools and algorithms are available for teams to use as guidelines
to implement systems and improve readmission rates.
• It is meant to improve the early identification, evaluation,
management, documentation, and communication of acute care
changes of the residents in SNF, HH, and AL environments.
• Implementation guidelines , tools, and resources can be found
on the website.
Source: INTERACT website: http://interact.fau.edu
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INTERACT
• Several of the tools can be utilized for at-risk quality
improvement and tracking programs:
– Stop and Watch Tool
– SBAR Form
– Hospital Rate Tracking Tool
– Quality Improvement Tool
You may use any of the resources from the website free
of charge but cannot modify them in anyway.
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INTERACT TOOLS
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INTERACT/HALTT
• The two programs are similar in that they both are
designed to illicit early identification of problems,
prompt timely and proper assessment of resident,
and implement a care plan.
• HALTT also allows for root cause analysis of resident
issues and assignment of duties to the appropriate
care team member to improve risk area of the
resident.
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HALTT Risk Areas
1. Unstable blood sugar
2. CHF or COPD
3. Fall history
4. Reduced intake by mouth
5. Change in medications
6. Unstable or changes in vitals
7. Fluctuating functional status
8. Behavior changes
9. Change in lung sounds
10. Pain
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HALTT
• Assignment of duties to IDT members are completed
at the first Stand Up meeting and/or UR meeting
following the identified issue of the resident.
• Communication of plan of care is given to entire care
staff and families.
• Accountability to complete duties are checked at the
next UR meeting when update to team is expected.
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Does Your Therapy Play a Role?
• Therapy can help support the facility in decrease
readmissions to the hospital through:
– Comprehensive assessments
– Alertness to vital signs and risk factors
– Communication to nursing, families and physician
– Education to caregivers
– Monitoring of status
– Consistent scheduling with resident
– IDT involvement
– Discharge planning with team
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What Role Can Therapy Play?
How can therapy reduce the risk of readmissions to
the hospital?
1. Complete comprehensive assessment with the
appropriate plan of care.
2. Be an extra watchdog for changes in vital signs.
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What Role Can Therapy Play?
3. Timely communication of change in status to proper
team members to address and possibly involve a
physician early in process (written communication).
4. Get residents moving or in better positions to
reduce risk of pneumonia, infection, or falls
(greatest % of readmissions).
5. Participate in Falls, Wounds, and Pain programs
consistently.
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What Role Can Therapy Play?
6. Educating resident and caregivers, so they
understand their risks, is the best way to control
disease process and achieve a safe and highest
functional level.
7. Communicate to home health agencies, equipment
companies, physicians, and caregivers the discharge
plans/needs to help resident return to a safe
environment .
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Begins at Admission
Prior Level of Function
1. Eating- indicates risk of poor nutrition or assist needed
2. Dressing- indicates what level of independence
resident may be
3. Ambulation/Transfers- indicates possible balance
problems or fall risk
4. Bathing/Bathroom use- indicates level of
independence
5. Cognition- indicates possible safety concerns
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Begins at Admission
Prior Level Of Function
– Swallowing- can indicate any choking or aspiration risks
– Functional Decline/Falls- if falling at home more likely to
fall in facility
– Previous therapy in present year- could indicate ongoing
problem
– Medication Review-can indicate side effects or poor
adjustment to new medications
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PLOF Form
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Vital Sign Checks
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Temperature
Blood Pressure
Respiration Rate
O2 Saturation
Heart Rate or Pulse
Pain
Shortness of Breath
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Vital Signs
• The vital sign check, along with our functional
assessment, during treatment could really help with
early detection of issues.
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Vital Signs
Temperature
– Baseline should be established and checked daily by
nursing.
– An increase of body temperature can indicate a
systemic infection, inflammation or hyperthermia.
– A spike in temp 20-30 minutes after eating could
indicate possible silent aspiration.
– A decrease in body temperature can also be a concern
(i.e. poor circulation, heart problems).
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Vital Signs
Heart Rate or Pulse
– Pulse rate varies with age.
– Normal adult beats per minute are typically 50-80
beats.
– An increase in pulse rate can occur with, but not
limited to, pain and infection.
– A decrease or irregular pulse rate could indicate a
serious health issue or illness.
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Vital Signs
Respiration Rate
– Should note if wheezing, exertion with breathing,
and other sounds occur
– Varies with age
– Normal adult rates are 12-28 breaths per minute
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Vital Signs
Respiration Rate
– Increased respiration rate could mean possible
infection or pain.
– Decreased respiration rate could indicate
weakness and system failure.
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Vital Signs
Blood Pressure
– It is indicative of how well the heart is functioning.
– It is comprised of two measurements:
• systolic pressure: measures the force of blood with
maximal contraction of the heart
• diastolic pressure: the resting pressure when the heart
relaxes
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Vital Signs
Blood Pressure
– Normal blood pressure is 120/80 (systolic/diastolic).
– Abnormal pressure would be anything over 130
systolic and 85 diastolic pressure.
– Hypertension is when the systolic pressure is
consistently between 140 -160 mmHg.
– Hypotension is low blood pressure below 120
systolic pressure consistently.
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Vital Signs
Pain
– This is considered to be an important, but often
overlooked, vital sign in adults.
– It can greatly impair a person’s function and lead to
other medical issues such as depression, contractures,
immobility, sleep deprivation, and wounds.
– Should be assessed at:
• Admission, quarterly with nursing review, each shift if pain
management is part of care plan, if change is noted during
review, and when intervention is implemented to see if
effective for pain reduction.
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Vital Signs
Pain Scales are used to show changes (good or bad)
with any intervention and to establish a baseline
– Nonverbal Pain Assessment
– Faces Pain Scale
– Visual Analog Scale
– Pain Thermometer Scale
– Comprehensive Pain Assessment-cognitively intact
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Vital Signs
Pain Scales
– Brief Pain Inventory
– Initial Pain Assessment Tool
– Memorial Pain Assessment Card
• Mood Scale
• Relief Scale
– Patient Comfort Assessment Guide
Source: www.rehabmeasures.com
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Vital Signs
Dyspnea- Shortness of Breath
– It is normal with heavy exertion, but it is abnormal if it
occurs with everyday functions.
– It can indicate problems with asthma, pneumonia, cardiac
ischemia, lung disease, congestive heart failure, acute MI,
COPD, and panic or anxiety disorders.
– It is important to report this to a nurse/physician in a
timely manner.
– Assess the intensity with any distinct sensation, such as
(effort, chest tightness, and air hunger) distress involved
and impact on daily functions.
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Vital Signs
Standardized tests
– Modified Borg Scale
– MRC breathlessness Scale- 5 grades of
dyspnea based on the circumstances in which
it arises.
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Vital Signs
Gait Speed
– Gait requires input from many different systems in
the body.
– Proper coordination of all these systems produces
normal gait, and if any systems are unhealthy then
gait can be affected.
– Gait speed changes or abnormalities can be an
indicator of system problems or failures in the
body.
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Vital Signs
Standardized Tests
– Tinetti
– 6 minute walk test
– Timed Up and Go test
– Timed 10 meter walk test
– Timed 10 meter walk test with 1-2 cognitive tasks
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Vital Signs
• A decline in gait speed predicts a decline in attention.
• A decline in gait speed predicts an increased chance
of mortality.
• The more normal gait speed ( 7 seconds = 3 mph for
10 meter walk) the better health and quality of life a
person will possess.
Source: Levine, Pete, BA, PTA, Using Gait Speed as a Marker for Progress, Advance for Physical
Therapy and Rehab Medicine, Vol.21, Read 3-26-2015
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Vital Signs
• Abnormal vital signs could be the first warning that an
impending medical decline may be occurring.
• Early detection and then treatment could ward off
intensifying symptoms and possible transport/admission to
hospital.
• Nursing monitors vital signs, but therapy could also report
them and be an added watchdog for issues that may be
arising with the resident.
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Know Your At Risk Patients
• Add patients who trigger upon admission either from
PLOF form or nursing/therapy assessments to Risk
List.
• Review these patients at the morning meeting or UR
with IDT .
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Target List
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Root Cause of Issues
• Use a tool to deep dive issues
– Pause: What is the Root Cause?
– Medical Necessity Form- Nursing Note to indicate
medical need for therapy or other intervention.
– If fall history or at risk- complete comprehensive Fall
Assessment.
– Look at all areas that could send patient back to
hospital and also positively impact your QMs: Pain,
Pressure Ulcers, Weight Loss, etc.
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Pause: What is the Root Cause?
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Medical Necessity Form
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HALTT: Hospital Admissions Lessened Through Therapy
Current Quality
Measures
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Utilization/Resident Review
• This should consist of a weekly comprehensive
review of all risk factors, not just for falls.
• Proper referrals to address needs are determined
by the IDT, and assignment sheets are completed.
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Assignment Sheet
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Daily/Weekly Monitoring
• Each resident will continue to be monitored and
their progress and status of plan reported in
morning meeting.
• Assignment sheets will be reviewed in weekly
meetings, and modifications may be made by
IDT.
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Communication and Training
• Document all information during Falls meetings and
interventions.
• A log can be used but should have nursing note or
IDT note 1x a week for everyone and everything
discussed in meeting. (Can use Medical Necessity
Note).
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Communication and Training
• Once the end result is achieved, communicate to all
care staff and make sure all training is complete.
• Use sign off sheets during training with dates
completed, who attended and who instructed.
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Communication and Training
• Update documentation that plan was put into place,
all care staff trained, and resident successful with
adaptations. Nursing will follow for next two weeks
for carry over.
• Nursing should write a note on carry over and
positive impact to function and quality of life for
resident.
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Nursing Log and Note
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Communication and Training
• Team will recommend discharge from At Risk List.
• Written status/adaptation should be present in a
private place, so care staff can access it easily during
care.
• Residents will be reviewed quarterly.
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Discharge
• Review of Discharge Checklist by the IDT will be
completed prior to discharge.
• All training of care staff and families must be done
prior to discharge from program.
• Updates are given at the morning meeting and the
resident is removed from target list.
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Discharge Checklist
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Case Scenario
• New admit from hospital status post CVA.
– 80 year old female admitted post CVA two weeks
ago with L- sided hemiparesis
– Past Medical History: DM, atrial fib, and right hip
fracture two years ago
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Case Scenario (con’t)
• Prior to a hospital stay, the resident was independent
with all ADLs, ambulation without a device,
homemaking skills, and lived in her own apartment
with supportive family nearby. She was able to do
light housekeeping and drove a car.
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Case Scenario (con’t)
• She has reported, and family indicates, a fall about
two weeks before going into the hospital.
• She has numbness in her feet from DM.
• Family reported that she has lost motivation since
her husband passed away two months ago.
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Case Scenario (con’t)
• New Admit: Nursing/MDS complete:
– PLOF assessment
– Fall Risk assessment
– What’s Your Risk assessment
• Resident triggered as a high risk for falls on the
assessments due to decreased functional ability,
significant decline from PLOF, uncontrolled DM, and
fall history.
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Case Scenario (con’t)
• Nursing places resident on Target List as “at
risk”.
• Resident is discussed with IDT in next morning
meeting as having issues, and all therapies are
ordered to complete evaluations.
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Case Scenario (con’t)
• Resident is discussed in morning meeting, and
update is given as preliminary plan.
• Resident discussed in Weekly UR/Resident Review
meeting by entire IDT.
• Utilize Tool for Root Cause.
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Case Scenario (con’t)
• Assignment sheets are completed by Nursing in UR
with issues identified, persons responsible, and date
of completion.
• Document on Log brief explanation of IDT decisions
and refer to assignment sheets.
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Progress and Review
• Update team each morning on plans.
• Review Assignment sheets at Weekly UR meeting
– Hold staff accountable.
• Write in actions taken for the previous week and if
completed or ongoing.
• Add new assignments if needed.
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Discharge
• IDT can recommend removal from Target List when
all parts of plan completed.
• Review Discharge Checklist in UR with IDT to make
sure all is done.
• IDT will recommend in next morning meeting to
remove resident from “at risk” target list.
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Quarterly Review
• This person, unless discharged to another
environment, would be reviewed quarterly upon
clinical rounds to make sure plan still appropriate or
if a comprehensive assessment is needed again.
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QUESTIONS?
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THANK YOU!
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Resources
1.
2.
3.
4.
Centers for Disease Control and Prevention. Adult Falls.
www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Accessed
February 2014.
Tools to Implement the Otago Exercise Program: A Program to Reduce
Falls 1st Edition, CDC. Accessed October 2013
Tinetti, Mary E. M.D., www.fallprevention.org/pages/fallfacts.html 2005.
Root Cause Analysis: www.health.state.mn.us/patientsafety/toolkit.html
Accessed April 1, 2014.
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Resources (con’t.)
5.
6.
7.
8.
Comprehensive Accreditation Manual for Long Term Care Refreshed
Core, January 2011
Internet: http://www.jointcommission.org Accessed February 3, 2014.
Internet: http://www.primaris.org/sites/default/files/resources
Accessed April 3, 2014
Internet: http://www.ahrq.gov/professionals/systems/longtermcare
Accessed April 3, 2014.
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Resources (con’t.)
9. Currie, Leanne, D.N.S., M.S.N., R.N., assistant professor, Columbia
University School of Nursing, Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Chapter 10, 2007.
10. Centers for Disease Control and Prevention, STEADI-Stopping Elderly
Accidents, Deaths and Injuries: Fall Risk Checklist: Accessed February 4,
2014.
11. Taylor, Jo. A., R.N., M.P.H., Parmalee, Patricia, Ph.D., Brown, Holly, M.S.N.,
A.P.R.N.-B.C., Ouslander, Joseph, M.D. The Falls Management Program: A
Quality Improvement Initiative for Nursing Facilities: AHRQ, October
2005.
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Resources (con’t.)
12. Guidelines for Nursing Homes: OSHA 3182-3R, 2009.
13. Internet: http://www.cms.gov/regulationsandguidance Accessed
February 2014.
14. The Centers for Medicare and Medicaid Services. MDS 3.0 Quality
Measures: User’s Manual v.5.0 03-01-2012
15. Bischoff-Ferrari, Heike, A., M.D., M.P.H., Dawson-Hughes, Bess, M.D.,
Willett, Walter, C., M.D., P.H.D., Staehelin,Hannes, B., M.D., Bazemore,
Marlet, G., M.D., Zee, Robert, Y., M.D., Wong, John, B., M.D., Effect of
Vitamin D on Falls, A Meta-analysis. April 28, 2004
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Resources (con’t.)
16. Internet: http://www.jama.jamanetwork.com/article Accessed April 4,
2014.
17. Rubenstein, Laurance, Z., M.D., M.P.H., Merck Manual Professional. Falls
in the Elderly. November 2013.
18. Journal of the American Geriatric Society. AGS Updated Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults: March 2012.
19. The AGS Foundation for the Health in Aging: www.healthinaging.org
Accessed February 4, 2014.
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Resources (con’t.)
• https://www.interact2.net, INTERACT Tool, Accessed 3/5/2015
• https://www.nhqualitycampaign.org, Advancing Excellence, Accessed
3/23/2015
• Measuring Vital Sign’s, http://www.healthline.com,2/24/2009
• Rehabilitation Measures Database, http://www.rehabmeasures.org,
accessed 3/5/2015
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Resources (con’t.)
• Vital Signs, http://en.wikipedia.org, accessed 3/5/2015
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