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A Community-Based Approach to prevent hospital readmissions Brainerd Community Team: Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis Health Kathryn.

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Presentation on theme: "A Community-Based Approach to prevent hospital readmissions Brainerd Community Team: Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis Health Kathryn."— Presentation transcript:

1 A Community-Based Approach to prevent hospital readmissions Brainerd Community Team: Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis Health Kathryn R. Miller, RN, BS, G-L C, Director Quality and Safety, Essentia Health St. Joseph’s Medical Center Gayle Nielsen, MSN, RN Care Coordinator, Essentia Health Clinics, Central Region Marie Michlitsch, RN, Director of Nursing, Good Samaritan Society - Woodland Deanna Abramson, RN, Assisted Living Manager, Good Samaritan Society - Woodland Kayla Farr, RN, Good Samaritan Society, Home Care & Hospice January 8, 2014

2 RARE Webinar – January 8, 2014, noon – 1 p.m. Janelle Shearer, RN, BSN, MA Program Manager Stratis Health A Community-Based Approach to Prevent Hospital Readmissions

3 Session Goals Describe a community-based approach to improve coordination between settings of care Identify how to collaborate with other organizations to improve care transitions Identify best practices you can implement to reduce avoidable hospital readmissions

4 Who is Stratis Health? Independent, nonprofit, facilitating improvement for people and communities Funded by federal and state contracts, corporate and foundation grants Medicare Quality Improvement Organization (QIO) for Minnesota Focus areas include rural health, health information technology, patient safety, cultural competence, and long-term care

5 Current Medicare QIO Work 1.Beneficiary and Family Centered Care 2.Improving Individual Patient care 3.Integrating Care for Populations and Communities –Improving Care Transitions Leading to the Reduction of Readmissions Improving Transitions of Care – community-based approach RARE Campaign 4.Improving Health for Populations and Communities

6 Brainerd Duluth North Metro

7 The Community Providers across the continuum of care –Acute care hospitals –Clinics –Home health/hospice organizations –Long-term care facilities –Assisted living facilities –Local public health departments –Patients and/or patient advocates –Other community partners

8 Community-Based Approach Each organization conducted root cause analysis to identify gaps in care related to transitions of care and readmissions Identified community needs and resources Identified best practice interventions to improve the gaps

9 The Brainerd Area Community Story

10 Partnering to Prevent Avoidable Readmissions Essentia Health St. Joseph’s Medical Center Kathryn R. Miller, RN, BS, G-L C Director Quality and Safety

11 Essentia Health St. Joseph’s Type of provider-Acute care 162 bed full service JCAHO accredited hospital (exceptions: Cardiac and Neuro surgery) with on site Cath Lab Central Minnesota-Brainerd Lakes area Staff composition RN and CNA teams ICU, Telemetry, Medical, Surgical, Mental Health and Chemical Dependency Units EH is one of the first two organizations in the country (Essentia and HealthPartners) to attain highest level of recognition as an Accountable Care Organization (ACO) by NCQA

12 Needed to look at those diagnoses that had high readmission rates, particularly the Heart Failure population Issue/Problem

13 Developed an Interdisciplinary team that met monthly Initiated f/u telephone calls in hours Developed a system for all d/c patients to be seen by PCP within 5 days of discharge Main Areas of Focus

14 Intensive effort to work in a small group setting with key community members (nursing homes, home care, etc.) Identified barriers to a smooth transition: –i.e. Lack of; incomplete documentation (MAR) SOLUTIONS: Worked with our IT department to allow the nursing homes view only access to our EMR (Electronic Medical Record-Epic) Educated hospitalists on tying diagnosis with medication ordered on discharge Development of Transitions Subgroup

15 We have begun to see a downward trend in our readmission rates for Heart Failure, COPD and Pneumonia patient populations Work still needs to be done on: 1) Pharmacist reviewing medications with all patients at the time of discharge 2) Continued work on formation of a Palliative Care Team to address end of life/quality of life issues with patients and their families Results

16 Kathy Miller RN, BS, G-L C Director Quality and Safety Essentia Health Central Region St. Joseph’s Medical Center 523 North Third Street Brainerd, MN (218) Contact Information

17 Marie Michlitsch, RN

18 Good Samaritan Communities of Brainerd and Pine River Woodland has 41 Care Center residents. Roughly 25% are on a short term stay for rehab. Bethany has 124 residents. There is a subacute unit with capacity for 40 resident’s on this campus. Roughly 25% of the campus is short term subacute residents. Whispering Pines in Pine River has 56 residents with roughly 20% residents on a short term stay.

19 Noted increase in hospital readmissions within 100 days. Highest rate of readmission noted to be 6%. Increased cost with the readmissions to the hospital. Increased resident and family stress and depression with readmissions to the hospital.

20 Noted problem with diagnosis listed on discharge orders. Staff unaware of off label use of medications unable to properly educate residents on medication use. Worked with the hospital on obtaining diagnosis for medications. Barriers noted with working with computerized charting systems.

21 Hospital worked on obtaining access to their computer system for Care Center Staff. Care Center staff will have ability to review records from the hospital to ensure quality of continuum of care for the residents. - This is a work in progress and all staff are thrilled to have the ability to review residents records to ensure quality care.

22 Physicians Orders for Life Sustaining Treatment. – Five staff trained as Advanced Care Planning Facilitators. INTERACT tools utilized for nursing staff included the following: – Care paths for resident condition changes. – Acute change in condition file cards available to all nurses. – Stop and Watch forms utilized for early detection of changes in condition. – SBAR - Situation Background Assessment or Appearance Request forms utilized in Point Click Care. – Designated staff audits all hospital admissions and Emergency Room visits to determine if potentially preventable. Education occurs as needed if determined potentially preventable. – INTERACT website:

23 Care Paths CHF UTI Pneumonia AMSC Fever Dehydration 23

24 This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, 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. Publication No. 8SOW-GA-NH Sources:AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996 When to report to the MD/NP/PA Change in Condition: © Florida Atlantic University When to report to the MD/NP/PA Change in Condition: Immediate Notification: Any symptom, sign or apparent discomfort that is: 1. Sudden in onset 2. A marked change (i.e. more severe) in relation to usual symptoms and signs 3. Unrelieved by measures already prescribed 24

25 Vital SignReport ImmediatelyReport on Next Work Day Blood Pressure Pulse Respiratory Rate Systolic BP > 210 mmHg, < 90 mmHg Diastolic BP >115 mmHg Resting pulse > 130 bpm, 110 bpm and patient has dyspnea or palpitations Respirations > 28, < 10/minute Oral (electric thermometer) temperature > 101F Diastolic BP routinely > 90 mmHg Resting pulse >120 bpm on repeat exam Weight Loss New Onset of anorexia with or without weight loss 5% or more within 30 days 10% or more within 6 months Vital Signs (Report Why Vital Signs Were Taken) © Florida Atlantic University 25

26 EARLY WARNING TOOL “Stop and Watch” If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Name of Resident ______________________________ Seems different than usual Talks or communicates less than usual Overall needs more help than usual Participated in activities less than usual Ate less than usual (Not because of dislike of food) N Drank less than usual Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual Staff_________________________________________________ Reported to ___________________________________________ Date _____ / _____ / ________ Time ________________ © Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000) 26

27 SBAR Structured and standardized communication format between health care workers. S=Situation (a concise statement of the problem) B=Background (pertinent and brief information related to the situation) A=Assessment (analysis and considerations of options — what you found/think) R=Recommendation (action requested/recommended — what you want) 27

28 28

29 Noted decline in preventable hospital readmissions. Noted increase in changes in orders prior to admissions to the hospital in attempt to prevent hospital admission.

30 Marie Michlitsch RN Director of Nursing Good Samaritan Society Woodland 100 Buffalo Hills Lane Brainerd, MN (218)

31 Good Samaritan Society Assisted Living Bethany, Pine River, Woodland Deanna Abramson Assisted Living RN Manager Woodland Campus

32 Bethany and Pine River Campuses Bethany In Brainerd 37 Senior Living Apartments residents on A/L services Pine River In Pine River 36 Senior Living Apartments Recently added A/L services 1 Cottage Style House with 16 higher level A/L

33 Good Samaritan Society Woodland Senior Living Apartments & Samaritan Houses Good Samaritan Society Woodland Campus in Brainerd MN Senior Housing- Apartments with Assisted Living and Cottage Style Units for Higher Level Assisted Living & Memory Care Apartments- average 70 A/L residents (128 total Apartments), 16 beds A/L in Cottage Style, & 32 beds Memory Care Universal Workers (NARs) 5 RNs & 3 LPNs

34 Issues/ Challenges Admitting Residents with higher level of care needs Limited amount of Licensed Staff in our buildings to assess and monitor the resident’s health issues. Many times A/L staff not making the decisions for residents going to ED (residents / families) Hospital staff & Physicians unaware of the limitations the Assisted Living settings in meeting resident’s health/ care needs

35 Goal or Aim We want to give our Assisted Living residents the best nursing care that we can possible To decrease the ED visits and the hospitalizations for our residents. If possible we want to catch as many symptoms as necessary to alleviate the stress and discomfort of sending the resident into ED. Build communication and trust with local providers to give the residents a smooth transition when hospitalized and/or transferred back to home.

36 Stop & Watch Forms Catch changes in condition early Empower our staff to bring up issues to Nursing Staff All staff/All departments are educated. Easy access to forms Get away from writing notes on all types of pieces of paper Education during our annual staff training Staff needs follow up & feedback At this point we haven’t seen too many utilized- oncoming reinforcement Challenge when have some residents who refuse to be seen by their Physician

37 Pilot to develop and begin tracking Assisted Living Resident’s hospitalizations & re-hospitalization Look for trends and to look for ways to decrease some of our ED visits and hospitalizations; Be part of our QI/QA process that will be required with our new Comprehensive License Using a tracking form and a Data sheet & QI form Need to get all staff to see importance of tracking & ways for reduction. Have data to show results Can be used for Marketing reasons, that if your facility can show the data that they have fewer ED visits the hospital and other would recommend your facility to the potential residents

38 Deanna Abramson Good Samaritan Society Woodland RN Assisted Living

39 Essentia Health Clinics Central Region Gayle Nielsen, MSN, RN Care Coordinator

40 St. Joseph’s-Essentia Clinics Baxter, Brainerd, Crosslake, Hackensack, Pequot Lakes, Pierz, Pillager, Pine River

41 Appointments In-patient and ED Ward Clerks are now able to make visit appointments –Within 5 days for high-risk readmissions Reserved anywhere from 0 to 4 slots daily for Same Day Visits. –Released 5 p.m. the evening before or 8 a.m. day of Reserved 0-2 slots a week for Hospital Follow- up visits –Released 24 hours before

42 Baxter Clinic/Long Term Care Long term care leadership came to a Baxter Clinic Department meeting for face- to-face discussion Doctors and nurses from the clinic attend Medication lists Orders

43 Care Coordination Program Program Goal: Triple Aim: Improve Quality Improve Patient Satisfaction Reduce Cost

44 Program Goal #1 Improve Quality Regular contact, with one individual Pre-visit calls to “package the visit” for PCP Updates from specialists visits Changes in function/ clinical condition Patient’s agenda Self management support, patient education Management of care transitions – post discharge, ER visits, other events Role of the RN Care Coordinator

45 Program Goal #2 Patient Satisfaction –Develop Care Plan with patient and family One stop summary of all problems, meds, instructions, plans Identify patient’s personal goals and match them with the medical plan –One trusted person to call when urgent matters arise –Advocate and system navigator

46 Role of the RN Care Coordinator Program Goal #3 Reduce the total cost of care –Prevent hospitalizations Improve patient and family understanding of the plan Attentive follow-up Arrange appropriate home support –Prevent unnecessary ER Use Create a “Primary Care Home” Emergency plan of care – what to do when…

47 Referral Criteria (At Least 1 of the identified) Regular Care with 3 or more sub specialists for significant medical conditions >3Hospital readmissions in 6months Greater than 3 ER visits within 6 months Greater than 4 points noted on Risk Stratification Tool Threats to self care ability identified by RNCC (inadequate support, financial barriers, impaired medical literacy, language barrier) 2 or more chronic conditions identified on problem list (outside of quality targets).

48 General Information about our Program Two RN Care Coordinators Eight Clinics 33 Practitioners Total Number Patients Enrolled: Female, 40 Male 73% of patients are Medicare 22% Medical Assistance ACO-BCBS and Medica

49 Readmission Data July 1 - August 1, discharges involving 31 patients One Care Coordination Patients 9 readmissions involving 5 patients None of them were Care Coordination Patients Three patients had two readmissions each-one of them is deceased and one on hospice

50 13 Care Coordination Patients Six months before enrollment 13 ED visits 13 Hospital Admissions 69% reduction in ED visits Six months after enrollment 4 ED visits 8 Hospital Admission 61% reduction in Hospital Admissions

51 Contact Information Gayle Nielsen, MSN, RN Coordinator Essentia Clinics

52 Good Samaritan Society Home Care & Hospice Kayla Farr, RN Director

53 Good Samaritan Home Care Hospice Avg daily census HC- 72 Hos-14

54 Location Located in Nisswa, MN Coverage area within 45 miles from the office, remote locations we utilize telemedicine. We have nursing divided for both service lines.

55 Concerns Return hospitalizations Notification from our home care patients of going into the hospital “Repeat offenders” Tracking of telehealth patients who go into the hospital.

56 Goal Reduction of our hospitalization rate Collaboration effort between providers Increase disease management for our patients.

57 Success Story Identification of our hospitalizations – Who/Why – Stratis Health – Acute Care Transfer Log (INTERACT tool) modified. – Increase team awareness: Hospital Home Care Hospice

58 Challenges Acknowledgment of issues that need to be addressed. How to stay focused on the collaboration for the “patient” versus feelings of “pointing fingers”. Getting team members to “attend” to a after hours call.

59 Contact Information Kayla Farr, Director Good Samaritan Society Home Care & Hospice

60 Q&A

61 Contact Janelle Shearer, MA, BSN, RN or

62 Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. Prepared by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, 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. 10SOW-MN-C

63 Upcoming RARE Events…. Stay tuned for the next RARE Webinar… Team Care for the Chronic Disease Patients: Using lay “Care Guides” February 21, 2014 (1-2 p.m.)

64 Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings,


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