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A Nurse-Led Multidisciplinary Team Approach to Improving Heart Failure Patient Transitions and Reducing Readmissions Christine Thompson, MS RN CNS CCRN.

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Presentation on theme: "A Nurse-Led Multidisciplinary Team Approach to Improving Heart Failure Patient Transitions and Reducing Readmissions Christine Thompson, MS RN CNS CCRN."— Presentation transcript:

1 A Nurse-Led Multidisciplinary Team Approach to Improving Heart Failure Patient Transitions and Reducing Readmissions Christine Thompson, MS RN CNS CCRN CHFN Charlene Kell, EMBA RN BSN CCRN Research Days - South San Francisco 22 October 2014

2 Reducing avoidable readmissions of heart failure patients on the national agenda
Heart failure (HF) currently affects 6.5 million adults in the US Prevalence of HF projected to increase by 25% by 2030 Hospitalizations are responsible for the majority of $39 billion spent annually for HF care The Centers for Medicare & Medicaid Services (CMS) has mandated reporting of hospital-level 30-day readmission rates for HF, acute myocardial infarction, PNA (now inclusive of other diagnoses) CMS penalties initiated Oct 2012 HF is a chronic CV syndrome that is growing in incidence and prevalence, due in part to effective therapies improving survival of cardiovascular diseases & the significant increase in our elder population. Programmatic and interdisciplinary approach to improving patient transitions Journal of the American College of Cardiology Vol. 60, No. 7, 2012 © 2012 by the American College of Cardiology Foundation ISSN /$36.00 Published by Elsevier Inc.

3 Acknowledgement Two year grant focused on reducing HF readmissions ( ) Triad leadership structure MD, Administrator, CNS Partnership with local clinic (PAMF)

4 Primary HF Patient Readmissions – where we were . . .
Baseline Data – CY 2011 Goals: Reduce 30-day readmissions by 30% Reduce 90-day readmissions by 15%

5 Using Clinical Effectiveness framework to ensure sustainable outcomes…
Our patients will be supported by… …a multidisciplinary care team… Physicians Nurses Pharmacists Dieticians Respiratory Therapists Social Workers Case Managers …whose work is shaped by a cross- functional SHC team… Patient Advisors Performance Excellence Clinical Informatics HIMS Coding Clinical Bus Analytics Aging Adult Services Quality Obtained funding for scales for high risk patients Obtained funding for medication boxes for high risk patients Created EPIC criteria to identify cohort Patient work bench report for creation of cohort list within 24 hours of admission Implementation of a risk assessment tool to identify high risk/moderate risk Authorization for HF nursing to assign Primary HF problem to the problem list Developed collaborative review monthly of coding discharge data and HF cohort list Expanded the Cardiology dot phrase education to APP’s in CT Surgery, Vascular, Cards HF RN review of Empathy Mapping interview data to identify areas for improvement Teach back rolled out to cohort units – EPIC documentation workflows established Active Daily management – huddles around Teach back topics: Meds, Follow up, Diet, etc . …and supported by the Cardiovascular Data Mart that provides the “single source of truth” data

6 Heart Failure Interventions: A LEAN-based Approach

7 Redesign of HF Patient Transitions of Care: Interventions
HF CNS Consult Order Risk assessment and flagging high-risk patient in EPIC Medication reconciliation processes redesigned, including MD workflows; enhanced medication education Enhanced patient/caregiver education using teach back Follow up appointments made prior to discharge Post-discharge phone follow up with template integration into EHR Follow up appointments mostly within 7 days of DC (definitely for those at high risk) Follow up calls generally within hours; high risk get additional call

8 Care Transitions: Community Stakeholder Meetings to Develop Standards for Skilled Nursing Facilities and Home Health

9 Readmission Metrics from Electronic Health Record to HF Dashboard
Individual or multiple rules can be selected to filter the patient cohort Current State displays 30 days readmit rate, 90 days readmit rate, and Balance measures for last 30 and 90 days Actual discharge and readmit counts for the rates are displayed below the gauge Trending Chart toggles between readmission rate and patient readmit count Readmission Trending Chart compares last 30 and 90 days rate to previous months, quarters or year Filter dashboard view by unit, age etc. Current filter selections displayed here The Bar Charts compare the Index Admission Length Of Stay to Readmit Length Of Stay and the Days to Readmit

10 Collaboration: Promoting Nurse as Educator
Two hour workshops on health literacy and teach back for staff on three key patient care units Creation of video Nursing Education website Stanford YouTube Incorporation of teach back into unit orientation Spread to multidisciplines, inpatient & outpatient Documentation in EMR & tracked on Dashboard Engagement of staff on key units; spread to other units/ outpatient clinics and across disciplines

11 Teach Back on the HF Dashboard

12 Collaboration: Medication Safety
Improved Medication Reconciliation processes on Admission and Discharge An accurate, understandable medication list at discharge Pharm Techs in ED to assist with creating current med list New Transitions of Care Pharmacist role implemented, 7 days/week for HF & complex Medicine patients Patient friendly medication list

13 Redesign of HF Educational Materials
Multidisciplinary; patient reviewed Updated & synchronized inpatient/outpatient materials Multilingual Hardcopy materials & SHC website

14 Communication Monthly “What’s New in Heart Failure Care” newsletter ed to staff Monthly multidisciplinary Heart Failure Operations Team meetings with community partners Weekly Heart Failure Clinical Effectiveness Council meetings (HF CEC) Use of HF Dashboard for “Active Daily Management” on patient care units Newsletter archived on SHC intranet

15 Collaboration: Community Outreach
Aging Adult Services partnership home visits Home monitoring pilot Patient Partners (P2) with Stanford School of Medicine (in-home health coaching) Skilled Nursing Staff education on HF patient assessment, care, and patient family education Quarterly roundtables with SNFs and Home Health providers Helping patients manage their own care within the context of their daily lives

16 Patient Engagement in our Heart Failure Program
Two committed volunteers for our Heart Failure Program serving 2 ½ years --- themselves HF patients Invaluable contributions to our HF Readmissions Reduction work Review/critique the HF patient education tools Attend monthly multidisciplinary HF Operations Team meetings Participated in Rapid Process Improvement Workshop (RPIW) using LEAN methodology for Medication Reconciliation Participated in Value Stream Mapping for Heart Failure Patient Care from point of entry into our system to transition home Active participants “Voice of The Patient”

17 Empathy Mapping: Overview
Interview completed by a trained hospital volunteer using open-ended questions SAY: What are some quotes and defining words the patient said? DO: What actions and behaviors did you notice? THINK: What might the patient be thinking? What does this tell you about his or her beliefs? FEEL: What emotions might the patient be feeling? Empathy mapping allows us to synthesize observations and draw out unexpected insights Previous admission for heart failure What patient thinks precipitated current admission to hospital Follow up appointment after last discharge? What a typical meal might be … able to follow a low sodium diet? Know and understand purpose for each medication Daily weights? Where are scale and calendar/log kept? In home support adequate?

18 How can Empathy Mapping help?
Identify prevalence of contributing factors or barriers to successful self-management for health, particularly in high-risk patients Insights on the patient’s experience of care processes and perception of communication Promotes patient reflection; feeling heard Opportunity to address patient-specific issues Evaluate aggregate data for themes and trends that can inform re-design of processes of care to better meet physical and emotional needs Design and refinement of a healing environment of care Provide feedback to clinical staff Drive patient-centered changes (improvements) in care delivery Shape how we engage patients, and frame self-care information Prompt use of techniques such as Motivational Interviewing for appropriate patients

19 SHC Primary HF Readmissions: April 2013 – March (Baseline CY 2011: 20% 30-day; 30% 90-day Readmit Rates) HF Readmissions Pre- and Post-implementation

20 Reducing Avoidable Readmissions Heart Failure: Moore Cohort Baseline to Project Implementation Statistically Significant Reduction Baseline Post Interventions start date to YTD (30 day d/c data availability)

21 Lessons Learned Designing & implementing a patient-centered program for HF care that improves outcomes and reduces readmissions is a cross-functional team effort, spanning the care continuum – not a project but a culture change Active collaboration with community partners essential Leveraging the EMR facilitates improved communication to and consistent care practices “Keep the patient at the center”: patient engagement and participation is critical to success Creating analytic tools that provide accessible, real-time metrics to frontline staff & managers reinforces the effectiveness of nurse-sensitive interventions (e.g. use of teach back, post-discharge follow up calls)

22 Future Directions Spread of HF readmissions reduction standards across other secondary HF populations to improve patient care transitions Continue to review/refine current patient care interventions and add new interventions after pilot-testing Collaborate with non-specialty providers (e.g. Primary Care, General Medicine) on Best Practices for HF management Strengthen community partnerships and create evidence-based community standard Continue to develop & analyze our own prospective risk assessment tool utilizing data elements in the EMR

23 Resources Christine Thompson: chrthompson@stanfordhealthcare.org
Coleman EA, Min SJ, Chomiak A & Kramer AM. Post hospital care transitions: patterns, complications, and risk identification. Health Services Research (5): Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; Available at Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2012.Available at Christine Thompson: Charlene Kell:


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