Heart Failure Disease Specific Certification –The Joint ...
Transcript of Heart Failure Disease Specific Certification –The Joint ...
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/26/2013
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REDUCING
READMISSIONS
St. Luke’s Hospital Case Study
Cedar Rapids, IA
Reducing Readmission Seminar
April 2014
San Diego
ST. LUKE’S HOSPITAL
MEMBER, UNITYPOINT HEALTH
Private hospital – Cedar Rapids, Iowa
Affiliate in the UnityPoint Health
system
Licensed for 500 Beds with more than
17,000 admissions
Truven Top 100 Hospital – 5 years
(2013); Heart Hospital 3 years (2012)
Iowa Recognition for Performance
Excellence Gold Award - 2010
Magnet Designation – 2009, 2014
The Joint Commission Disease-
Specific Certification in Advanced
Heart Failure, Stroke, Palliative Care
and Total Joint. Society of Chest
Pain Center – Chest Pain
Certification
Gold Award from Get with Guidelines
for Heart Failure 2010-2013
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/26/2013
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WHY IS REDUCING AVOIDABLE
REHOSPITALIZATIONS STRATEGIC FOR
ST. LUKE’S HOSPITAL?
It is part of our mission: “To give the healthcare
we’d like our loved ones to receive”
It represents goals that are aligned with
healthcare reform: providing better value for
decreased costs. Learning has been incorporated
into our present work with development of
population management and ACO work
TRANSITION TO HOME TEAM MEMBERS
CHAIR: Peg Bradke, VP-Post-Acute Care
Robinn Bardell, Mgr-Case Mgmt
Sarah Baumert, Mgr-5E
Diane Pfeiler, PCC-3C
Alexis Benion, Living Center West
Dean Bleadorn, Mgr-RT
Myrt Bowers, Assoc Exec Dir-Witwer Center
Shelley Cahalan, Gen Mgr-VNA
Christy Charkowski, STL Hospitalists
Sara Claeys, Dietary Svcs
Christina Djerf, Prog Coord-Lifeline
Elizabeth Eichhorn, ARNP-Living Center
West
Krissy Elder, PCC-5C
Karen Forster, Pharm
Terri Grantham, APN-Card Outcomes
Renee Grummer-Miller, OP Pall. Care
Barb Haeder, APN-Card Outcomes
Sue Halter, ARNP-STL HF Clinic
Signe Henderson, Coord-Home Care
Amrita Samra, MD, CRMEF
Sherrie Justice, Dir-PI
Carmen Kinrade, VP-Nursing Excellence
Patty Koelker, PCC-5E
Jennifer Mahoney, UPH Clinic - Northridge
Shirley McCloy, Resp Ther
Sandi McIntosh, Dir-ED
Jennifer Owens, Med Soc Svcs
Julie Peterson, Mgr-Card Rehab
Karen Pierce, Data Analyst, PI
Amrita Samra, MD - CRMEF
Brandi Simmons, Living Center West
Amy Schweer, STL HF Clinic
Marilinne Staub, UM Spec.
Aimee Traugh, Mgr-3C
Sheila Tumility, Reg PI Proj Mgr
Brook Van Dee, ARNP-OP Pall. Care
Jean Westerbeck, Living Center West
Pam Williams, JRMC Resp Care
Sharon Zimmerman, Resp Care
Dr. Todd Langager, Cardiology Medical
Director
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/26/2013
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VOICE OF THE CUSTOMER
Feedback from Chronic Disease Management class
Patient and family members on our Patient-Family Advisory Council
Feedback from follow-up phone calls
Feedback from Cardiopulmonary Rehab participants
Feedback from High-Risk Clinic Patients
CROSS-CONTINUUM TEAM
Meets monthly
Reviews readmissions for each month related
to core diagnosis to assess causes and
opportunities for improvement
Reviews process and outcome measures
Continually testing and improving,
aggregating the experiences of patients,
families and caregivers
Each facility reports in testing occurring in
their area
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/26/2013
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SEVERAL SUBGROUPS REPORT INTO THE
LARGER TRANSITION TO HOME TEAM
Data Management
Patient Education processes
Home Care
SNF/Nursing Facilities work processes
Physician Clinic processes
Case Management/Social Work/Care Coordination
Several members of the Transition to Home team are members of
the hospital ACO and Population Health Management work.
Information is bidirectional between these teams.
Continuum of Care Process
Standardized care through order sets.
Use of the clinical indicator sheet as a checklist for evidence-based care being met.
Report developed to identified key core measure patients – (e.g. BNP, Troponin etc)
Teaching:
• Utilizing Universal Health Literacy Concepts
• Enhanced teaching materials
• Teach back
Utilization of whiteboard to individualize patient’s plan of care and communicate to team.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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Continuum of Care (2)
Bedside report to involve patient and family caregivers as partners in care.
Daily huddles are facilitated with the patient care nurse, charge nurse, and care coordinator. Daily goals are reviewed providing opportunity to review plan for the day, available support for patient, discharge goals, and determine what it will take to get the patient home safely. Assessment of palliative care referral is part of discussion.
Standardized Disease specific on-line discharge instructions.
Continuum of Care (3)
Touch points post discharge:
Home Care - care coordination visit 24 to 48 hours post discharge on high risk patients
Physician Clinic follow up appointment made prior to discharge for 3-7 days after returning home
Follow-up phone call set up based on post discharge needs at 5-9 days
Standardized tool for transfer of information to nursing facilities for next level of care .
Telehealth monitor available through Home Care
Chronic Disease Management Program for patients
In addition staff participate in Integrated Chronic Disease Management class
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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ENHANCED ADMISSION ASSESSMENT
During Admission Assessment, the patient and family are asked, “Who would you like to have present when we provide your discharge information?”
Information added to the whiteboard
RN and physician do medication reconciliation Concentrated effort for Admission. Dedicated Admission Center RN’s complete home medication list and prepare an appropriate list for physician to address. At times, the pharmacy or physician offices need to be called to get additional information. If the patient is a home care patient, the home care agency is called to get the current list of medications
ENHANCED ADMISSION ASSESSMENT (2)
Referral to Palliative Care for patient with advanced
stages of disease - the referrals have consistently
increased. Team rounds daily on units
Bedside report to involve the patient and family
caregivers as partners in their care. Daily discharge
huddle is facilitated daily with the RN caring for the
patient, the charge nurse, and unit-based case manager
Take 5 completed on patient at start of shift. Daily goals
are reviewed and written on the whiteboards in each
room, providing the opportunity to review the plan for
the day, anticipate discharge needs, and determine what
it will take to get the patient home safely
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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Interview Questions
For patients that are readmitted within 30 days of last
admission:
Can you tell me in your own words why you think you
ended up sick enough to be readmitted again?
Can you tell me what a typical meal has been for you
since you left the hospital? What did you have for
dinner last night?
Have you seen your doctor since you were discharged
from the hospital?
Do you have all of your medications? How do you set
up your pills every day?
Were there any appointments that kept you from
taking any of your pills?
“The patient is noncompliant.”
vs.
Asking, “What is our responsibility as the
sender of the information?”
PARADIGM SHIFT
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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ENHANCED TEACHING AND LEARNING
The patient education materials facilitate the use of
Teach Back, and the same materials are used across
the continuum: in the hospital, with home care,
long-term care settings and the clinic.
Short, succinct material developed for each Core
Measure DRG. Teach Back question part of packet
for staff and patient reference.
Patient teaching flowsheets set up to address Teach
Back and assure the documentation and use of
Teachback.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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TEACH BACK WITH DISCHARGE
INSTRUCTIONS
Can you show me on these instructions:
How you find your doctors’ office appointment?
What other tests you have scheduled and
when?
Is there anything on these instructions that could
be difficult for you to do?
Have we missed anything?
Who will you call if you have questions?
ENHANCE TEACHING AND
FACILITATE LEARNING
Use Teach Back:
In the hospital
During home visits and follow-up phone calls
To assess the patient’s and family caregiver’s understanding of
discharge instructions and ability to do self-care
Building Teach Back into our work
Session in Nursing Orientation
Session in Nursing Residency Program
Net Learning module, competency validation, and in-house
prepared instructional DVD with Teach Back demonstration
Closing staff meetings, walking the talk
Staffs participate in Chronic Disease Management
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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HEART FAILURE MAGNET
LOW SODIUM EATING PLAN BROCHURE
Cover page Back page
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LOW SODIUM EATING PLAN BROCHURE
LOW SODIUM EATING PLAN BROCHURE
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LOW SODIUM EATING PLAN BROCHURE
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Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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Where To Start? Go to the Unresolved
Education Tab
Select the topic you
educated on
Begin charting on the
right side of the screen
What you taught on
Additional comments
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DISCHARGE ASSESSMENT - SMART TEXT
POST-ACUTE CARE FOLLOW-UP
Home Care Visit set up for 24-48 hours after
discharge. Home Care liaison in-house. Teach Back
questions part of visit .
Partnership with physicians’ offices resulted in
redesign of scheduling follow-7p visits to allow office
visits within seven days for patients.
Appointments are scheduled prior to discharge and
noted on discharge instructions.
Advanced Medical Team Pilot in Pulmonology Clinic
with High Risk/High Resource patients.
Consistent Care Plan Program in Emergency Dept.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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3W TEST OF CHANGE
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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EMERGENCY DEPARTMENT CONSISTENT
CARE PLAN
Consistent Care Program (EDCCP) for patients who had visited the ED 12 or more times in the previous 12 months.
103 Care Plans were developed, mailed, and implemented.
Care Plans are a communication tool that provide data specific to that patient’s medical history and current medical needs, along with Goals of Care for when patients present in the Emergency Dept.
Using care plans and with intervention by a social work case manager, there has been a reduction in patient’s Emergency Department use.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
3/26/2013
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CONSISTENT CARE PROGRAM
REAL-TIME HANDOVER COMMUNICATIONS
Medication Reconciliation is a joint physician and nurse
accountability.
Patients going home are offered a care coordination visit with
Home Care in the first 24-48 hours after discharge. The home
care does a certified content visit including medication
reconciliation and determines eligibility.
St. Luke’s partnered with the hospital’s home care agency
(VNA) and two long-term care facilities to standardize and
enhance the quality of the handoff communication process. A
new interagency transfer form is now used. Warm handover
with those patients with complex issues.
Provided education for home care and long-term and skilled
care RNs and CNAs on HF, MI and Pneumonia and continuity
processes.
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Acute Inpatients Discharged and Readmitted within 30 Days
Initial Principal Diagnosis
2010 2011 2012 2013
486 Pneumonia, organism unspecified 48 51 57 58
38.9 Unspecified septicemia 37 37 35 58
428.33 Acute on chronic diastolic heart failure 18 14 22 56
491.21 Obstructive chronic bronchitis with exacerbation 31 37 31 54
518.84 Acute and chronic respiratory failure 20 38 32 32
410.71 Acute myocardial infarction, subendocardial 36 29 17 30
300.02 Generalized anxiety disorder 1 0 27
428.23 Acute on chronic systolic heart failure 6 19 10 26
482.83 Pneumonia due to other gram-negative bacteria 26
584.9 Acute kidney failure, unspecified 22 22 33 25
414.01 Coronary atherosclerosis of native coronary artery 24 17 35 22
493.22 Chronic obstructive asthma with exacerbation 4 7 1 22
427.31 Atrial fibrillation 15 12 13 21
298.9 Unspecified psychosis 0 1 1 20
715.96 Osteoarthrosis, unspecified whether generalized or 31 35 33 19
518.81 Acute respiratory failure 31 24 22 16
578.9 Hemorrhage of gastrointestinal tract, unspecified 7 8 13 14
562.11 Diverticulitis of colon (without mention of hemorr 18 18 9 13
303 Acute alcoholic intoxication in alcoholism, unspec 6 4 3 13
300 Anxiety state, unspecified 13
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Acute Inpatients Discharged and Readmitted within 30 Days
Readmitted Principal Diagnosis
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302724211815129630-3-6
12
10
8
6
4
2
0
Number of Days Between Admissions
Fre
qu
en
cy
Mean 10.36
StDev 8.389
N 56
Normal
Histogram of Days Between Admissions (with Outlier removed)
363024181260-6
12
11
10
9
8
7
6
5
4
3
2
1
0
Days between
Fre
qu
en
cy
7 14 30 Mean 15.10
StDev 8.773
N 49
Histogram of Days between Initial Discharge Date and Readmission Date
Heart Failure as Initial Admission
• Incomplete medical management
• Wrong site of post- acute care
• Socio-economic factors
• Physician follow-up
• Med problems
• Patient compliance with regime
• Disease trajectory
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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HCAHPS RESULTS
DISCHARGE INFORMATION (% YES)
76
78
80
82
84
86
88
90
2009 2010 2011 2012 3Q 2012 -
2Q 2013
Pe
rce
nt
Ye
s
St. Luke's
State
National
Composite Score
• Q19 – During this hospital stay, did doctors, nurses or other hospital staff talk to you about whether you would
have the help you needed when you left the hospital?
• Q20 – During this hospital stay, did you get information in writing about what symptoms or health problems to
look out for after you left the hospital?
Prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI)
http://www.mitre.org/work/health/news/bundled_payments/St_Lukes_Case_Study.pdf
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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CRITICAL CAPABILITIES FOR CARE
REDESIGN INCLUDE:
Cross-continuum participation and
alignment
The development and use of standardized
tools and compatible information
infrastructure
Horizontal leaderships and executive
sponsorship and engaged physicians
Effective external and internal learning
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LESSONS LEARNED
Importance of engaged executive leaders and physicians.
Patients and families help transform care in profound
ways.
The patient and family home environment must be
understood.
Involving front-line staff in the changes helps them
understand why they are important and grows
ownership by engaging them in redesign.
The power of relationship building and collaboration of
the cross-continuum team builds new ideas to work and
removes many of the “silos’ in the care.
Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar
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LESSONS LEARNED (CONT)
The role of Information Technology in the process
should be addressed simultaneously with the work.
Ongoing monitoring of Process and Outcome
Measures is important to hardwiring best practices.
Using patient stories unleashes energy and
participation that becomes evident in process and
outcome results.
QUESTIONS:
Peg Bradke RN, MA
Vice President, Post Acute Care Services
UnityPoint Health St. Luke’s
Cedar Rapids, IA