Transcript Reducing Hospitalizations - AMDA Caring for the Ages

Carolinas Society for Post Acute and Long Term Care Medicine
November 4-6, 2016
Charles Crecelius MD PhD FACP CMD
Assistant Professor of Medicine
Washington University School of Medicine
Medical Director, Post Acute Care Services
Barnes-Jewish-Christian Medical Group
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Understand the factors which have made
hospitalization of nursing home residents an
important focus
Describe the types of diseases amendable to
treatment, and the resources necessary to
successfully do so.
Be able to utilize hospitalization reduction to
improve participation in new models of care
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Medicare spent $14.3 billion on NH resident
hospitalizations in 2011
For comparison Medicare spent
$32 billion on SNF stays
 $1.2 billion on nursing home physician
services
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The average hospitalized nursing home
resident cost a third more than the average
Medicare beneficiary
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25% of all NH patients are hospitalized yearly
Between 40- 60% of all hospitalizations may be
avoidable
72% of all avoidable hospitalizations are due to
4 common conditions:
Pneumonia (30.5%)
 Congestive heart failure (16.8%)
 Dehydration (12.9%)
 UTI (11.7%)
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OIG Report November 2013 OEI-06-11-00040
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Medicare costs hospitalized NH residents
Septicemia - $3 billion dollars
(average $17,000 per case)
 Pneumonia (all types) - $1.5 billion
dollars (average $10,000 per case)
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Costs of treating such conditions in NH
not well estimated
Undoubtable far less than the average
Medicare Part A hospital reimbursement
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Of 3.3 million persons in NH in 2011
 825, 765 individuals hospitalized
(24.8%)
 Total 1.3 million hospitalizations
Of all persons hospitalized
 67.8% were hospitalized one time
 22% were hospitalized two times
 7.2% were hospitalized three times
 5% were hospitalized four or more times
Annual Hospitalization Rate 2011
% Homes
Above 50 percent
0.6
40 to 49.9 percent
6.2
30 to 39.9 percent
22.1
20 to 29.9 percent
39.9
10 to 19.9 percent
26.9
Less 19.9 percent
4.3
20.4% SNF patients are re-hospitalized within 30 days
OIG Report November 2013 OEI-06-11-00040
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Billions of dollars be saved annually and
resident harm minimized if:
 Systems could be optimized to promote early
recognition of change in condition
 Homes & physicians could provide needed
services in the nursing home
 Physicians and homes could minimize
unneeded transfers
Unnecessary hospitalizations will be a
benchmark
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Hospital Value Based Purchasing /
Readmission Reduction Program
 Penalizes hospitals with high
rehospitalizations
Value Based Medicine
 Physicians fiscally affected by total cost of care
Bundled Care
 Single payment for episode of illness, cost
savings shared, hospital biggest cost
component
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Accountable Care Organizations
 Cost savings shared, outpatient care
preferred
Managed Care Plans
 Budgeted, outpatient care preferred
Nursing Home Value Based Purchasing
 Hospitalizations decrease reimbursement
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Individual Homes vary widely
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Office of Inspector General Report (11/13)
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1-70% residents per year
Five Star Rating
Size of Home
Status of NH
Geographic location
Report concludes: Hospitalization Rates should
be a Quality Measure
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CMS concurs in principle
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Clinical status
Adequacy of communication systems
Preferences of resident and family
Training and number of nursing staff
Availability and preference of practitioners
Payment / economic factors.
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Joint Initiative of the Center for Medicare and
Medicaid Innovation (CMMI or Innovation Center)
and the Medicare-Medicaid Coordination Office
(MMCO)
Primary objectives:
o Reduce frequency avoidable hospital
admissions readmissions in NF dual eligibles
o Improve resident health outcomes
o Improve the process of transitioning between
inpatient hospitals and nursing facilities
o Reduce overall health care spending without
restricting access to care or choice of providers
Communication Tools
Stop and Watch, SBAR, Med Rec, Transfer Documents
Decision Support Tools
Change in Condition File Cards, Care Paths
Advance Care Planning Tools
CP tools, AD, Comfort Care, Hospice, Hospitalization
Education on CPR, Tube Feeding
Quality Improvement Tools
Tracking Tools, Acute care transfer review
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Know-It-All Before You Call
Kit including laminated cards that describe
how to triage and what information to have at
hand for each condition
Know-It-All When You’re Called
Kit includes how to perform essential clinical
information exchange – for physicians, NP and
PAs.
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Facility needs to understand capabilities, areas
of strength and concern
 Ability to start and maintain IVs
 Ability to get diagnostic tests in a timely
fashion
 Ability to communicate effectively with
families
 Ability to work as a team with practitioners
Capability building will help the facility in the
new care paradigms coming forth
• Checklist explaining
nursing home
capabilities
• Opportunity to
discuss NH
resources among NH
leaders and staff
• Communication
about NH resources
to providers,
hospitals, and
families
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Must be a joint effort or failure will ensue
The facility must be willing to “raise the bar” to
allow the physician to perform well
Facilities must determine whether they need to
find new leadership, physician services, are
willing to pay for physician education
Physicians need to understand we in the future
will be measured on joint metrics in many
cases
The goal is the right care for the right patient at
the right time
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Staff need to understand the capabilities the
facility is expecting of them
Accurate and prompt investigator and reporter of
clinical conditions
 Effective communicator with family
 Effective team player
 Cooperates with quality improvement efforts
 Time management
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Administration must be willing to change
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Early recognition of condition changes
Prompt and appropriate communication with
health providers
Systems to ensure adequate transfer of
information to between facilities
Consistent monitoring of systems with constant
reinforcement
• Completed by direct care
staff when change is
detected.
• Regular evaluation of and
recognition of changes in
residents’ condition.
• Report changes to
licensed nurses.
• May be documented in
medical record (or other
location).
SBAR
• Designed to guide
clinical problem-solving
• Supports evaluation and
communication of acute
changes in condition to
physician, APRN,
and/or PA
• Guides documentation of
evaluation and
communications
• Completed by licensed
nurses
• Resource for licensed
nurses and primary
care clinicians.
• Educational tool and
reference for guiding
evaluation of specific
symptoms that
commonly cause
acute care transfers
Need strong champions committed to
project
Persistent focus on the project goals
Build capacity one staff person at a time
Focus on the “process” and not the “forms”
Use every opportunity to reinforce use of
tools to improve clinical problem solving,
communication, and follow-up
Monitor physician performance
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Hospitalizations account for 1/3 of two
trillion dollars spent per year in the USA
in all sites
One in six hospital admissions in older
adults is due to an adverse drug event
(ADE)
For persons older than 75 years, this
increases to one in three hospital
admission from an ADE.
AmFam Physician 2013 Mar 1:87:331-6
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“A medicine is a poison with a desirable sideeffect” (Wm. Osler MD, founder Internal
Medicine)
Reevaluate medications at regular intervals
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“Drug of the Month Club”
Family and physician education – awareness of
ceiling effect, changing risk to benefit ratio, risk of
adverse drug events, prioritizing health concerns
High benefit/risk
High Need
Low Need
Low benefit/risk
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Insulin & Diabetes
 set realistic HgbA1C goals (7-9)
 limit sulfonylureas (promote low sugars
??efficacy)
 simplify regiments (less errors, more staff time)
Warfarin
 use warfarin flow sheets
 reconsider use after falls
 consider newer agents esp. if poor control
 Avoid triple therapy (ASA + plavix + warfarin)
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Digoxin
 use no more 0.125 mg a day
 reconsider use when used with other Rx
 Ineffective in CHF
Antihypertensives
 set realistic BP goals (<160/90 in less 90 y.o.)
 limit / reconsider diuretic use
 Monitor orthostasis
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Osteoporosis Rx
 Stop Fosamax after 5 years
 Calcium once a day (less if on >bid
supplements)
 Vit D empirically once a month vs. testing
 Stop all Rx if less 3 years to live
Supplements
 Stop fish oil, vitamin E
 Use multivitamins for wounds and
nutritional issues – stop if EoL
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Antipsychotics
 Regular GDR – get tough with reduction
 Prompted reductions
 Physician comparative reports
 No prns
 Support non-pharmacologic efforts
Antidepressants, anxiolytics
 Follow GDR principles
 Lowest effective dose
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Some conditions more amendable to
interventions
All require early ID, effective intervention and
follow-up
Misconception that families want their loved
ones to go to the hospital
 Delirium, nutritional issues, pressure sores,
loss of function, complications all generally
more common with hospitalizations
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VS need to be relatively stable – oxygen
saturation most important
Quick provision of nebulizer, supplemental O2,
antibiotics, fluids as needed
Don’t forget prednisone!
Address volume status
Address risk factors (dysphagia, reflux etc.)
CXR, labs
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Empiric antibiotic pending cultures
Make sure you really have a UTI and not
something else
Hydration
Change Foley if appropriate
Reevaluate peri-care
Consider suppressive agents if recurrent
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Cellulitis
 IV antibiotics for severe cases
Suspected diverticulitis
 CT not always necessary or can be done as
output
 Broad spectrum IV antibiotics can work even
in abscesses and appendicitis
C. Diff
 Hydration key
 Vancomycin or dificid for severe cases
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CHF
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High dose diuretics often work as well as IV esp.
if coupled with metolazone or spironolactone
Low dose unloading agents
May need dietary restrictions
Compression stockings
Daily weight mandatory
ECHOs helpful along with frequent labs, CXR,
EKG
Treat co-morbid conditions
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Acute renal failure
 Treat underlying cause
 Urinary electrolytes needed re: prerenal or
not
 IV fluid support
 Consider temporary Foley
 Renal ultrasound as needed
 Outpatient consultation
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Dehydration
 Determine cause
 Urine and serum osmolality and lytes needed
 Adequate hydration
 Long term game plan needed
Hyperkalemia
 Kayexelate, dextrose and insulin
 Identification cause
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Need adequate shift to shift monitoring
Need planned communication with the
practitioner
Need close communication with the
family
Should be analyzed for QA purposes
Should prompt a reconsideration of
where the patient is on the path of life
CPR
DNR
Living Will
Durable Power of Attorney for Health Care
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Hospitalization
Palliative Care
Hospice Care
Symptom Management
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Be cured
Live longer
Improve/maintain
function/QoL/independence
Be comfortable
Achieve life goals
Provide support for family and
caregivers
Understand diagnosis or prognosis
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Treatment
Comfort
Setting Correct Expectations
Adapted from Mazanec, P, Daly, B. J., Pitorak, E. F., Kane, D., Wile, S. and
Wolen, J. (2009) A new model of palliative care for oncology patients with
advanced disease. Journal of Hospice and Palliative Nursing. Retrieved from
http://www.medscape.com/viewarticle/712742
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Restorative
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Maintenance
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If you cannot heal me, keep from worsening
Preventative
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If possible heal me
If you cannot prevent my condition from
worsening, try to prevent further harm
Palliative
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At all times keep me comfortable
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Hospice scares people
Palliative care confuses people
Try “advanced illness management”
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Encompasses all aspects of goals of care
Notes the illness and the management is advanced
Gives families a feeling of intensity of treatment
instead of abandonment
Acknowledges the multifaceted approaches that may
be needed
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New CPT code that allows reimbursement for
time spent with the patient (or designated
responsible party if incapacitated) to discuss
Advace Care Planning
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~ $86 first half hour, ~ $75 each additional half hour
Physician, NP, PA can bill
Based on medical necessity, no set frequency
More information via Society website / stored
webinars
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CMMI demonstation project to prevent
hospitalization has just entered Phase 2
Up to 40% reduction in most common areas using
combinations of APRNs, mentoring nursing staff
and technology in Phase 1
 New phase will pay the facility $218/day for 6
common conditions (pneumonia, skin infection, UTI,
fluid/electrolyte disorder/dehydration, CHF,
COPD/Asthma
 Physician will be paid a high level hospital level
visit for E/M to confirm diagnosis, and can bill a
nursing home care conference once a year or for a
change in condition
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Agency for Healthcare Research and Quality, National Guideline Clearinghouse
(2010). Heart failure in the long-term care setting. Retrieved from
http://www.guideline.gov/content.aspx?id=32492&search=heart+failure
Agency for Healthcare Research and Quality, National Guideline Clearinghouse
(2014). Acute heart failure: diagnosing and managing heart failure in adults.
Retrieved from
http://www.guideline.gov/content.aspx?id=48752&search=heart+failure
Bern-Klug, M. (2014). A conceptual model of family surrogate end-of-life decisionmaking process in the nursing home setting: Goals of care as guiding stars. Journal
of Social Work in End-of-Life & Palliative Care, 10:1, 59-79.
Mazanec, P, Daly, B. J., Pitorak, E. F., Kane, D., Wile, S. and Wolen, J. (2009) A new
model of palliative care for oncology patients with advanced disease. Journal of Hospice
and Palliative Nursing. Retrieved from http://www.medscape.com/viewarticle/712742
Porock, D., Parker-Oliver, D., Petroski, G. F., & Rantz, M. (2010). The mds mortality
risk index: the evolution of a method for predicting 6-month mortality in nursing
home residents. BMC Res Notes. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913927/
Yourman, L. C., Lee, S. J., Schonberg, M. A., Widera, E. W. & Smith, A. K. (2012).
Prognostic indices for older adults. Journal of the American Medical Association.
Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=1104837