Transcript A Skilled Nursing Facility Perspective on an Integrated

Skilled Nursing Facility: The New Med Surg.
An Integrated Approach in Reducing
Hospitalizations Through Value Based Healthcare.
Saka Kazeem MD, CMD
Arlene Latimer MS, RN
Dorette Smith, RN
Annett Ford, RD, RN
Igor Kiprovski, Assoc. Administrator
Speaker Disclosures
None of the speakers for the
Center of Nursing & Rehabilitation have
any relevant financial relationship with
any vendors of products or programs
mentioned in this presentation.
Learning Objectives
By the end of the session, participants will be
able to:
• Assess current systems and identify top 5 re-hospitalization drivers in
long and short term/sub-acute settings.
• Identify and develop collaborative interdisciplinary strategies and
plans for hospitalization reduction.
• Implement innovative systems and protocols to capture key clinical
metrics and improve clinical outcomes.
• Foster an integrated partnership among key business stakeholders to
identify best practices and create a formalized value based
hospitalization reduction process.
Background and Benchmark Data
The Center for Nursing & Rehabilitation, located in the Prospect
Heights section of Brooklyn, New York, is a 320 bed not-for-profit facility
and a member of the Center Light Health System. The Facility has a
dedicated 40 bed Sub-acute Care Unit, with 40 beds allocated for
medically complex residents. The remaining 240 beds serve the needs
of resident with a variety of physical co-morbidities and cognitive
challenges.
The facility reviewed the less than 30 day re-hospitalization data from
January 1, 2010 through December 31, 2010 for patients admitted to
the short term/sub-acute unit. The data identified that the facility had an
annual average re-hospitalization rate of 32%, significantly higher than
the New York State (21.89%), and Kings County average (29.58%).
The facility had a 97.21% average annual occupancy rate with
residents’ acuity levels at an average case mix index score of 1.01.
Cycle One (January-June 2011)
Concerns:
• Inadequate tools in capturing
dynamic changes in short
term/sub-acute residents
condition.
• Ineffective communication
between physicians and
licensed nurse
• Need to improve staff clinical
competency
Outcome:
22% reduction in the less than
30 day re-hospitalization rate for
patients on the short term/subacute unit as compared to our
2010 benchmark data.
Action Steps:
• Review of current assessment tools,
policy and procedures and competency
of clinical staff.
• Facility embarked on a six (6) week
intensive training for all licensed nursing
staff working on the sub-acute and
medically complex unit.
• Implementation of INTERACTNY tools:
SBAR, Stop and Watch.
• Weekly classes held by the Medical
Director focused on education of the
nursing staff on topics self identified as
requiring further development.
• Develop algorithms and protocols for the
incidence of severe hyper/hypo glycemia.
• Develop and implement protocol for IV
Lasix Therapy.
Cycle Two (July-December 2011)
Concerns:
Action Steps:
• Medication reconciliation process
• Medication reconciliation process was
did not adequately capture the true
revised to expand our focus on not only
medication profile of our patients.
the hospital medication list and what is
• Lack of medication reconciliation
process prior to discharge, resulting
ordered in the nursing home, but to
in potential poly pharmacy.
include medications that the patient was
• Lack of reconciliation for
taking prior to admission to the hospital.
medications taken prior to hospital
• Patients diagnosed with anemia or low
and skilled nursing facility
admission.
hemoglobin were identified as high risk
• Facility did not have an Anemia and
for re-hospitalization due to the need for
Low Hemoglobin hospitalization risk
transfusion. The facility developed a
assessment.
relationship with an outpatient, local
Outcome:
hospital sponsored, infusion center and
• Improved and adequate medication
developed a transfusion policy and
reconciliation process was developed to
protocol.
appropriately capture the true medication
profile of our patients.
• Transfer of patients to the infusion center for
treatment and have them return to the nursing
home rather than being hospitalized.
Cycle Three (January-June 2012)
Concerns:
• Long Stay Resident Hospitalizations
were high. 944 hospitalizations per
1,000 resident days.
• Culture of Hospitalize rather than treat in
place – clinical staff.
• Hospitalization Risk assessment tool for
short term/sub-acute patients did not
exist.
• System of hospitalization notification and
review did not exist.
• Advanced Directives
• Communication with Partnering
Hospitals
Outcome:
28% reduction in the less than 30 day rehospitalization rate for patients on the
short term/sub-acute unit as compared to
our 2010 benchmark data.
Action Steps:
• Review of current risk assessment tools, policy
and procedures and developed new risk
assessment tool to identify short stay patients at
high risk for re-hospitalization. A modification of the
Karnofsky scale dubbed the Baccash Acuity Scale
was developed.
• Focused “Culture Change” education sessions with
the Nursing and Medical staff to anchor the treat in
place mantra.
• A patient transfer policy was developed to
establish communication protocols which include
notification of the Medical Director whenever a
hospitalization is initiated.
• Monthly video conference meeting was established
with our partnering hospital. The Medical Director,
Director of Nursing and pertinent nursing staff from
the nursing home digitally meet with the Assistant
Chief Medical Officer and Chief of case
management from the hospital to discuss Medical
Issues that could have been addressed in the
hospital and Medical issues that could have been
addressed in the nursing home.
• Hospital partnered with the nursing to focus on
advanced directives.
Cycle Four (July-December 2012)
Concerns:
• Sustainability of implemented
action steps in cycles 1-3.
• Patients with dislodged
Gastrostomy Tubes.
Outcome:
28% reduction in the less than 30
day re-hospitalization rate for
patients on the short term/subacute unit as compared to our
2010 benchmark data.
External Patient satisfaction survey
rating 95% with a recommended
rating of 97%.
Action Steps:
• Stop and Watch program expanded to
both the clinical and non clinical team.
• Monthly (Short-term) and weekly (long term)
video conferencing sessions are held with our
primary business partners.
• Advanced Directive initiative had been instituted
to address hospitalizations caused by the
transfer of patients to the hospital for end-of-life
care which could have been provided at the
skilled nursing facility.
• Treat in place initiative evolved to include
evening Physician rounds, Gastrostomy Tube
insertions and an on site electrocardiographic
evaluation of patients exhibiting cardiac related
symptoms, such as chest pain.
• Develop GT Tube policy and protocol
• Diabetic management algorithm was reviewed
and further revised to include not only severe
cases of hyper/hypo glycemia but rather all
episodes.
Conclusion
Generalizability
The approaches outlined in this Initiative can easily
be implemented by any other Long Term care Facility.
The steps include:
• Review of current screening/assessment tools
• Revision/implementation of communication tools
• Review and revision of facility policy and procedure
to align with any identified revisions
• In-Service staff in fundamental hospitalization
reduction concepts and revised approaches
• Provide focused education on medical
management for complex cases
• Establish collaborative partnerships with primary
business partners
• Include interdisciplinary team in decision making
process
• Review the facility’s policies and procedures
addressing advanced directives to ensure best
practice and compliance with regulations
• Share the results of your efforts
• Celebrate your success
Impact of the Long Term Care Facility
• Reduction in the hospitalization rate
• Increase in staffs’ education and
competency
• Improve communication and trust
between the interdisciplinary team.
• Improved communication and trust
with our business partners.
• Increase in facility’s occupancy rate
• Increase in acuity level
Accomplishments
Long Stay Hospitalization Outcomes
Facility Short Stay Annual Outcomes
Year
2010
2011
2012
*2013
Re-hospitalization
Rate
32%
26%
23%
19%
Case Mix
Index/Acuity
1.01
1.02
1.10
1.13
Occupancy
Rate
97.21%
98.54%
98.66%
98.43%
Cycle
3
4
Outcome
Hospitalizations
994
523
487
Change
Decrease of 45%
Decrease of 52%
*2013 data reflects Quarter 1 and Quarter 2 results
Less than 30 Day Re-Hospitalization Rate Comparison
35%
29.58%
30%
25%
20%
21.89%
19%
Facility 2013
Facility Commitment
The Center for Nursing and Rehabilitation adapts a
multidisciplinary approach to reducing rehospitalization, by implementing a comprehensive
medical approach with the objective to manage and
treat in place.
County
15%
State
10%
5%
0%
Short Stay Hospitalization Rate
The team spear headed by the medical directors
was committed to improving the competency of the
Medical and nursing staff.
Q&A Session