Presentation on theme: "A Community-Based Approach to prevent hospital readmissions"— Presentation transcript:
1 A Community-Based Approach to prevent hospital readmissions Brainerd Community Team:Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis HealthKathryn R. Miller, RN, BS, G-L C, Director Quality and Safety, Essentia Health St. Joseph’s Medical CenterGayle Nielsen, MSN, RN Care Coordinator, Essentia Health Clinics, Central RegionMarie Michlitsch, RN, Director of Nursing, Good Samaritan Society - WoodlandDeanna Abramson, RN, Assisted Living Manager, Good Samaritan Society - WoodlandKayla Farr, RN, Good Samaritan Society, Home Care & HospiceJanuary 8, 2014
2 A Community-Based Approach to Prevent Hospital Readmissions Stratis Healthhealth care quality improvement and patient safetyA Community-Based Approach to Prevent Hospital ReadmissionsRARE Webinar – January 8, 2014, noon – 1 p.m.Janelle Shearer, RN, BSN, MAProgram ManagerStratis Health
3 Session GoalsDescribe a community-based approach to improve coordination between settings of careIdentify how to collaborate with other organizations to improve care transitionsIdentify best practices you can implement to reduce avoidable hospital readmissions
4 Who is Stratis Health?Independent, nonprofit, facilitating improvement for people and communitiesFunded by federal and state contracts, corporate and foundation grantsMedicare Quality Improvement Organization (QIO) for MinnesotaFocus areas include rural health, health information technology, patient safety, cultural competence, and long-term care
5 Current Medicare QIO Work Stratis Healthhealth care quality improvement and patient safetyCurrent Medicare QIO WorkBeneficiary and Family Centered CareImproving Individual Patient careIntegrating Care for Populations and CommunitiesImproving Care Transitions Leading to the Reduction of ReadmissionsImproving Transitions of Care – community-based approachRARE CampaignImproving Health for Populations and Communities
7 The Community Providers across the continuum of care Acute care hospitalsClinicsHome health/hospice organizationsLong-term care facilitiesAssisted living facilitiesLocal public health departmentsPatients and/or patient advocatesOther community partners
8 Community-Based Approach Each organization conducted root cause analysis to identify gaps in care related to transitions of care and readmissionsIdentified community needs and resourcesIdentified best practice interventions to improve the gaps
10 Kathryn R. Miller, RN, BS, G-L C Director Quality and Safety Partnering to Prevent Avoidable Readmissions Essentia Health St. Joseph’s Medical CenterKathryn R. Miller, RN, BS, G-L CDirector 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 LabCentral Minnesota-Brainerd Lakes areaStaff composition RN and CNA teamsICU, Telemetry, Medical, Surgical, Mental Health and Chemical Dependency UnitsEH 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 NCQADescribe your organization (location, type, size, services provided, service area, staff, urban, rural, relevant information about your community, etc.)
12 Issue/ProblemNeeded to look at those diagnoses that had high readmission rates, particularly the Heart Failure populationWhat was the situation, issue, or problem that brought the community organizations together?Describe the issue/concern from your organization’s perspective
13 Main Areas of FocusDeveloped an Interdisciplinary team that met monthlyInitiated f/u telephone calls in hoursDeveloped a system for all d/c patients to be seen by PCP within 5 days of dischargeDescribe things you’ve focused on.
14 Development of Transitions Subgroup 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 dischargeDescribe things you’ve focused on.
15 ResultsWe have begun to see a downward trend in our readmission rates for Heart Failure, COPD and Pneumonia patient populationsWork still needs to be done on:1) Pharmacist reviewing medications with all patients at the time of discharge2) Continued work on formation of a Palliative Care Team to address end of life/quality of life issues with patients and their familiesDescribe any results to date.
16 Contact InformationKathy Miller RN, BS, G-L CDirector Quality and SafetyEssentia Health Central RegionSt. Joseph’s Medical Center523 North Third StreetBrainerd, MN(218)Include your name, and phone
17 Good Samaritan Society Bethany, Pine River and Woodland 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.Describe your organization (location, type, size, services provided, service area, staff, urban, rural, relevant information about your community, etc.)18
19 Issue/Problem 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.What was the situation, issue, or problem that brought the community organizations together?Describe the issue/concern from your organization’s perspective19
20 Success Strategy 1Noted 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.Describe things you’ve focused on.20
21 Success Strategy 1Hospital 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.Describe things you’ve focused on.21
22 Tools 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:Are there any tools that could be shared?22
27 SBARStructured 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)US LiteratureSafety literatureIHI
29 Results Noted decline in preventable hospital readmissions. Noted increase in changes in orders prior to admissions to the hospital in attempt to prevent hospital admission.Describe any results to date.29
30 Good Samaritan Society Woodland Contact InformationMarie Michlitsch RNDirector of NursingGood Samaritan Society Woodland100 Buffalo Hills LaneBrainerd, MN 56401(218)Include your name, and phone30
31 Good Samaritan Society Assisted Living Bethany, Pine River, Woodland Deanna AbramsonAssisted Living RN ManagerWoodland Campus
32 Bethany and Pine River Campuses In Brainerd37 Senior Living Apartments20-25 residents on A/L servicesPine RiverIn Pine River36 Senior Living ApartmentsRecently added A/L services1 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 MNSenior Housing- Apartments with Assisted Living and Cottage Style Units for Higher Level Assisted Living & Memory CareApartments- average 70 A/L residents (128 total Apartments), 16 beds A/L in Cottage Style, & 32 beds Memory CareUniversal 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 AimWe want to give our Assisted Living residents the best nursing care that we can possibleTo 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.35
36 Stop & Watch Forms Catch changes in condition early Empower our staff to bring up issues to Nursing StaffAll staff/All departments are educated.Easy access to formsGet away from writing notes on all types of pieces of paperEducation during our annual staff trainingStaff needs follow up & feedbackAt this point we haven’t seen too many utilized- oncoming reinforcementChallenge when have some residents who refuse to be seen by their Physician36
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 LicenseUsing a tracking form and a Data sheet & QI formNeed to get all staff to see importance of tracking & ways for reduction.Have data to show resultsCan 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 residents37
38 Good Samaritan Society Woodland Deanna AbramsonGood Samaritan Society WoodlandRN Assisted Living38
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 AppointmentsIn-patient and ED Ward Clerks are now able to make visit appointmentsWithin 5 days for high-risk readmissionsReserved anywhere from 0 to 4 slots daily for Same Day Visits.Released 5 p.m. the evening before or 8 a.m. day ofReserved 0-2 slots a week for Hospital Follow-up visitsReleased 24 hours before
42 Baxter Clinic/Long Term Care Long term care leadership came to a Baxter Clinic Department meeting for face-to-face discussionDoctors and nurses from the clinic attendMedication listsOrders
43 Care Coordination Program Program Goal: Triple Aim: Improve Quality Improve Patient Satisfaction Reduce Cost
44 Role of the RN Care Coordinator Program Goal #1 Improve QualityRegular contact, with one individualPre-visit calls to “package the visit” for PCPUpdates from specialists visitsChanges in function/ clinical conditionPatient’s agendaSelf management support, patient educationManagement of care transitions – post discharge, ER visits, other events
45 Role of the RN Care Coordinator Program Goal #2 Patient SatisfactionDevelop Care Plan with patient and familyOne stop summary of all problems, meds, instructions, plansIdentify patient’s personal goals and match them with the medical planOne trusted person to call when urgent matters ariseAdvocate and system navigator
46 Role of the RN Care Coordinator Program Goal #3 Reduce the total cost of carePrevent hospitalizationsImprove patient and family understanding of the planAttentive follow-upArrange appropriate home supportPrevent unnecessary ER UseCreate 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 6monthsGreater than 3 ER visits within 6 monthsGreater than 4 points noted on Risk Stratification ToolThreats 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 CoordinatorsEight Clinics33 PractitionersTotal Number Patients Enrolled: 10262 Female, 40 Male73% of patients are Medicare22% Medical AssistanceACO-BCBS and Medica
49 Readmission Data July 1 - August 1, 2013 35 discharges involving 31 patientsOne Care Coordination Patients9 readmissions involving 5 patientsNone of them were Care Coordination PatientsThree patients had two readmissions each-one of them is deceased and one on hospice
50 13 Care Coordination Patients Six months before enrollmentSix months after enrollment13 ED visits13 Hospital Admissions69% reduction in ED visits4 ED visits8 Hospital Admission61% reduction in Hospital Admissions
52 Good Samaritan Society Home Care & Hospice Kayla Farr, RNDirector
53 Good SamaritanHome CareHospiceAvg daily censusHC- 72Hos-1453
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 providersIncrease disease management for our patients.
57 Success Story Identification of our hospitalizations Who/Why Stratis HealthAcute Care Transfer Log (INTERACT tool) modified.Increase team awareness:HospitalHome CareHospice
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 InformationKayla Farr, Director Good Samaritan Society Home Care & Hospice
61 Contact Janelle Shearer, MA, BSN, RN 952-853-8553 or 877-787-2847 Stratis Healthhealth care quality improvement and patient safetyContactJanelle Shearer, MA, BSN, RNor
62 Stratis Healthhealth care quality improvement and patient safetyStratis 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,