Transcript SBAR - Primaris

INTERACT
To Reduce Hospital Readmissions
Kent P. McGeeney MPA MSE LNHA
Publication MO-13-78-NH GEN September 2013
This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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
1 in 4 patients admitted to SNF are
re-admitted to hospital within 30
days costing $4.3 billion
Mor et al. Health Affairs 29: 57-64, 2010
Are Readmissions Avoidable?
As many as 45% of admissions
of nursing home residents to
acute hospitals may be
inappropriate.
U.S. Healthcare System
Saliba et al, J Amer Geritr Soc 48:154-163, 2000
A CMS study reveals up to 68%
of skilled nursing facility (SNF)
hospital readmissions were
avoidable.
Ouslander et al: J Amer Ger Soc 58:627-635, 2010
Acute Care
Facility
Home
Care
Outpatient/
Ambulatory
Facility
Tranquil Gardens
Nursing Home
Long Term Care
Facility
The Human Cost of Hospitalizations
Distress and discomfort for the resident and family
Delirium
Polypharmacy
Falls
Incontinence and catheter use
Hospital acquired infections
Unintentional weight loss and poor nutrition
Immobility, de-conditioning, pressure ulcers
Environmental Changes
Hospitals are feeling the effects of payment reforms in
readmission penalties.
Hospitals are putting pressure on nursing homes to
reduce hospitalizations and basing referral on
readmission rates.
Accountable Care Organizations (ACOs)--financially
incentivized to reduce hospital transfers.
By the end of this year, the goal is to reduce hospital
readmissions by 20% nationwide.
Avoidable Hospitalization Focused Programs
INTERACT
Institute for Health Care Improvement
Care Transitional Model
Team STEPPS
Many more at:
http://www.cfmc.org/integratingcare/provider_resour
ces.htm
QAPI
Quality Assurance Performance Improvement
–
Affordable Care Act
–
Use of data to guide quality improvement efforts.
–
All homes will be required to have a QAPI program with PIPs.
–
Reduction of avoidable hospitalizations
–
Identifying change in condition
Hospitals are Paying Attention and Asking
Who has the highest rate of readmission?
What are you doing to correct this?
Who is willing to partner with us?
Contributing factors for Hospitalization
Limited On-Site Capacity to deal with medical issues
Physician preferences
Liability concerns
Financial incentives
Newly admitted residents/lack of relationship with family
Lack of Advance Care Planning
Impending death
Behavioral Issues
Family reluctance to intervene or second guess
Introduction to INTERACT
Communication Tools
Decision Support Tools
Advanced Care Planning Tools
Quality Improvement Tools
Everything can be found on the CMS website and it’s
FREE!
If Effectively Used, INTERACT can…
Prevent conditions requiring transfers through early
identification and assessment of changes in condition
Help better manage certain conditions in the facility
when feasible and safe
Can improve care planning and palliative care
Can improve communication with the physicians and
hospitals
Introduction to INTERACT
Flow Chart
At each point in the flow of potential hospital
discharge, there are tools to help your staff address
the issues.
Requires thoughtful planning with those people
closest to the residents to make this work.
Must Dos for INTERACT success….
Small steps--give yourself plenty of time
Measure outcomes
Select a Champion (Transition and Education Coach)
Highly Engaged Leadership
Continued Monitoring and Evaluation
Sustainability
INTERACT Strategies
Advanced Care Planning
Medication Reconciliation
Stop and Watch tool
Care Paths and Change in Condition File Cards
SBAR form/Acute Change in Condition Progress Note
PDSA
Some Highlights… some new, some old
Make sure the staff is ready for the admit! Educating
staff including aides, housekeepers and others. It’s also
great customer service! (Are you having Admission
Huddles?)
Reconcile the treatment plan; proactively plan for
change.
Make sure meds are accurate
Engage the family at once and stay engaged.
Equipment and room readiness
Start Out Right: The Effective Hand-off
Flawless transitions across care settings require that
all care providers share a common understanding of
the resident’s condition. Prior to transfer, an accurate
and thorough assessment of a resident’s needs based
on standard criteria contributes to an effective
transition plan. This crucial step reduces the
likelihood of a rehospitalization.
Institute for Healthcare Improvement, 7; 2013
The Hand-Off: Advanced Care Planning
http://www.youtube.com/watch?v=BfCR2yKnTYM
Avoid doing this in a time of crisis.
What skills and characteristics does a person need to
help support this process?
What support do you need from the physician?
What educational materials would residents or
families benefit from?
What is our current process?
The Hand-Off: Medication Reconciliation
MATCH Toolkit
–
http://www.ahrq.gov/professionals/quality-patientsafety/patient-safety-resources/resources/match/index.html
Analysis of medications, not just matching orders.
Critical component of any patient safety effort.
What is your current process? Let’s share!
What skills does the nurse need to have to make this
analysis?
Stop and Watch
When do I use this tool?
Who can have access to the
tool?
What are the barriers to using
this tool?
Stop and Watch–Early Communication Tool
Guides care staff through a quick review of EARLY
changes in resident condition. (The key word is
EARLY/at initial onset.)
Helps improve communication between frontline staff
and the nurse in charge.
It targets front line staff! (aides, housekeepers,
dietary, activities…)
Stop and Watch--Reporting?
Each facility must decide what works best for them
–
ASAP (Is that realistic?)
–
At shift change?
–
Huddle (My favorite and recommended by
STEPPS)
–
Keep the tool “handy” / easily accessible.
Other ideas??
Some Barriers
Inconsistent staffing
Unit nurse with insufficient knowledge of resident
Broken relationships between nurse/aide or
aide/aide, etc.
Resistance to change
“Just another thing to do”
Lack of leadership and no Champion
How to Make this Work**
Keep all tools accessible (pocket cards, in each room,
etc.)
Make it a priority. Make it important.
Follow up, check, monitor.
Consistent assignment/staffing.
The Huddle.
How to Make this Work
Upbeat, positive culture. Reward good performance.
A clear understanding among staff of why it’s important.
Circle back to the one reporting! This is critical! You
must decide who will get back to the front line caregiver.
Start small. One aide, or one hall. Don’t do the whole
building at once. Make it successful with a few staff
members, get them on board and they can help sell.
Care Paths & Acute Change in Condition Cards
What skills do our nurses need?
Do charge nurses have a designated clinical nurse
expert they can go to for assistance with assessment?
This WILL NOT make your nurses gain clinical
competence. It is a guide only.
What can we do to develop skills and competence in
our nurses?
How do we involve our physicians?
SBAR
Improve Communication with doctors and hospitals
by giving them the information they need in a format
they understand so the answer won’t be “Send them
to the ER.”
–
Consistent Language
–
Standardized Criteria
–
Clear guidelines
–
Communication and that is effective and efficient
SBAR
Calling the doctor
Let’s practice
When do we use SBAR?
What are the barriers to using SBAR?
How do we involve our physicians?
http://www.ahrq.gov/legacy/teamsteppstools/longtermca
re/video/02stry1_bad/
http://www.ahrq.gov/legacy/teamsteppstools/longtermca
re/video/13sbar_ltc/
SBAR Success
Have a Champion.
Train, train, train.
Start small, maybe with one nurse.
Meet continually and discuss/review.
Keep copies handy and available at all times.
Make it important.
Don’t give up… it will take time for some nurses to
master this.
Hospitalization Rate & QI Tool for Review of
Acute Care Transfers
Use: INTERACT, Advancing Excellence, Your Own tool
to collect data.
–
Data is necessary for developing benchmarks, tracking
progress, and driving decisions
–
What are the barriers to implementation?
–
System level vs. Individual level
Suggestions from the Field
INTERACT is about front line staff and getting them in
the loop.
Drill down on every readmit from beginning to end…
don’t assume you know.
Know where you are with level of care, equipment,
training, staffing, etc. and either address it or tell the
hospital you aren’t ready for all admissions. Take a
good hard look. Don’t fear what you might learn.
Suggestions from the Field
If Stop and Watch is not feasible for you, do
something to communicate. The Huddle is working…
include everyone in your Huddles… housekeeping,
dietary, etc.
The SBAR really works when communicating with
doctors and hospitals.
Be patient and train, train.
What’s available on the INTERACT Website
Advanced Care Planning/Communication Guide (Tool
on how to communicate with residents and family
member for those appropriate for palliative/hospice
or comfort care)
Medication Reconciliation Worksheet
Stop and Watch Early Warning Tool
SBAR communication tool
What’s available on INTERACT Website
Change in Condition File Cards (Provides guidance on
when to communicate acute changes in status to MD)
Care Paths (Reference for guiding evaluation of
specific symptoms that commonly cause acute care
transfers.)
Large list of hospital communication tools, including a
capabilities tool and a number of transfer tools.
Tools to engage your hospital.
Other--Institute for Healthcare Improvement
Promotes the paradigm shift from site-specific care to
patient-centered care
Cross-Continuum Team Collaboration/CrossContinuum Partnerships
Understanding mutual interdependencies between
care setting, the hospital based teams co-design
processes with their community based clinicians and
staff to improve patients’ transition out of the
hospital.
Institute for Healthcare Improvement (IHI)
As a cross-continuum team, complete periodic
diagnostic reviews of readmissions.
Have members of the cross-continuum team visit
each others’ sites and observe processes during
patient transitions.
As a team, create universal hand over forms to
improve communication.
Develop education and teaching tools.
IHI
Reconcile the treatment plan and PROACTIVELY
plan for condition change.
–
Be sure to reconcile previous acute care interventions
with the resident’s ongoing care needs then educate the
staff so that they are enabled and confident.
Reconcile the Medication list
–
“Confusion about medication administration, followthrough, and access are the largest contributors to
rehospitalizations”. (IHI, 12, 2013)
–
Set up a process and make it air tight.
IHI
Make a plan for timely consult when resident’s
condition changes. Be ready for a change… even
expect a change. Have a process in place for when
that happens.
–
STOP and WATCH will alert you.
–
A Rapid Response Team? (Before discharging to hospital,
get others on the phone.)
IHI
Engage the resident and their family caregivers in a
partnership to create an overall care plan.
–
Don’t be passive. Make families keep partners from the
beginning. A trust-based relationship must be formed. We
need to interview to learn their expectations and then
communicate realistic possible outcomes. This must happen
at or before admission.
IHI
Evaluate/assess how well the family understands the
care plan. Introduce them to all the key players and
care providers. (A transition nurse is now becoming
the term in place of admission nurse!)
Reconcile the care plan with the resident and family.
They need to know of any revisions.
Beliefs and Perceptions
A belief that you don’t have a problem with the way
you manage changes in condition and hospital
transfers if you aren’t using objective data.
Perception that you don’t have control over transfers
to hospitals. (INTERACT can be used to show that you
are managing acute changes; will help you more
effectively communicate with hospitals… will show
that you are on top of it!)
Road Blocks?
Lack of physician cooperation. (Get them on board
with INTERACT.)
Families who want residents hospitalized. (Education,
Trust in your abilities, Stop and Watch, let them know
about INTERACT.)
Road Blocks?
“We are in our survey window!”
No real Champion or “When she’s gone, things fall
apart.”
Fear of law suits. (INTERACT is evidenced based and
expert recommended; improves communication and
documentation, documentation, documentation.)
Resident Outcomes
Bottom line, this is about discovering acute changes
in condition early, assessing them appropriately, and
following the residents wishes for care.
COMMUNICATION!!
Testing then Implementation
* Analysis of team communication and norms
• Go back 3–6 months and review every readmission.
Look at the nurse/documentation/shift/the hand
off/the meds/the Physician. Find your weakest link
and fix it!
• When you are ready, start small.
Affinity Groups Now Forming
Let‘s work together, sharing knowledge and best
practices to reach a common goal.
I’m available to help with education, support during
team meetings, facilitate communication between
collaborative members, and provide additional
resources as able.
This is your group… your collaborative! You tell me.
QAPI? Root Cause? PDSA? Let me know and I’ll set
it up!
Questions ?
Kent McGeeney
[email protected] or 573.777.2165