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Keith Rapp MD, CMD Mary Pat Rapp PhD, RN

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1 Quality Improvement Using the Quality Indicators Reducing Hospitalization Rates
Keith Rapp MD, CMD Mary Pat Rapp PhD, RN Geriatric Associates of America, PA

2 Objectives Describe Quality Indicators [QI] and Quality Measures [QM]
Describe Medical Director / provider roles in impacting QMs Discuss avoidability of hospitalizations from nursing facilities Discuss tools to assist in reducing avoidable hospitalizations

3 Quality Measures 1990: Development of 24 QIs based on MDS 2.0 by the Center for Health Services Research Association [CHSRA] 2002: Nursing Home Compare Quality Measures 2005: CMS merged QIs & QMs Some risk adjustment Not a static process Continuing refinement by the National Quality Forum

4 Short-Stay Measures Influenza Vaccination During the Flu Season (October 1 thru March 31) Assessed and Given Pneumococcal Vaccination (Looks back 5 years) Delirium (Looks back 7 days) Moderate to Severe Pain (Looks back 7 days) Pressure Sores (Looks back 7 days)

5 Quality Measures – Chronic Care..
Need for help with daily activities has increased Moderate to severe pain Pressure Ulcers (high and low risk) Physical restraints Incontinence and Catheters Low risk residents who lost control of bladder or bowel Percent with indwelling bladder catheter Residents who spend most of their time in bed

6 ..Quality Measures – Chronic Care
Decline in ability to move in and around their room Urinary tract infection Worsening anxiety or depression Weight loss

7 Reporting of Measures Measures with small denominators are not posted on NH Compare Post-Acute Measures with less than 20 in denominator Chronic Measures with less than 30 in the denominator




11 Geriatric Associates [GAA] Quality Model Pilot Started June 2002
Physician/Nurse Practitioner Collaboration on Medical Direction

12 GAA Quality Model 25% NP time is contracted to facility
NP in facility 5 days per week 25% NP time is contracted to facility 75% of NP time spent seeing GAA pts Physician weekly or more visits Physician is Medical Director of facility

13 Quality Model Work Daily stand up rounds with NF team
Quality Assurance committee participation Mentoring and education for staff Available for assessment of all residents Available for “special projects” Use of resident level summaries to improve QM / QIs

14 Facility/Community Advantages
Masters trained nurse in the facility 5 days/week Increased level of communication Increased facility census More resources at the facility level Increased ability to care for higher acuity patients = discharging hospital physicians with a higher comfort level Lower hospitalization rates (keep the backdoor closed) Improved and increase in relationships with discharging Physicians and facilities Enhanced tracking of referral resources

15 Medication Reduction Pilot Outcomes
2 units with BID dosing Over 1,500 less pills/day dispensed Improvement of other associated QA/QMs Percent on 9 or more medications

16 Liability Outcomes Other GAA 2002 9 requests 0 requests 2004
2005 3 requests Totals: 25 4

17 GAA Quality Model Outcomes at 14 Facilities Benchmarking Provider Care

18 Privileged and Confidential - Proprietary Information
9 + MEDS Privileged and Confidential - Proprietary Information

19 Privileged and Confidential - Proprietary Information
COGNITIVE IMPAIRMENT Privileged and Confidential - Proprietary Information

20 Privileged and Confidential - Proprietary Information
NO TOILET PLAN Privileged and Confidential - Proprietary Information

Privileged and Confidential - Proprietary Information

22 Privileged and Confidential - Proprietary Information
UTI Privileged and Confidential - Proprietary Information

23 Privileged and Confidential - Proprietary Information
TUBE FEEDING Privileged and Confidential - Proprietary Information

24 Privileged and Confidential - Proprietary Information
Range Of Motion Privileged and Confidential - Proprietary Information

25 Privileged and Confidential - Proprietary Information
NO ACTIVITY Privileged and Confidential - Proprietary Information

26 ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Pressure Ulcer High Risk
Privileged and Confidential - Proprietary Information

27 Pressure Ulcer Low Risk
Privileged and Confidential - Proprietary Information

Privileged and Confidential - Proprietary Information

ANTIANXIETY Privileged and Confidential - Proprietary Information

30 Privileged and Confidential - Proprietary Information
BLADDER Low Risk Privileged and Confidential - Proprietary Information

RESTRAINTS Privileged and Confidential - Proprietary Information

32 Management Pearls Include MDS Coordinator in QA Committee
Focus on residents that have upcoming MDSs Use resident level summary Provider documentation Root Cause analysis of QM issues Understand MDS questions for indicators Obtain user manual for QMs Understand exclusions Prioritize focus One to Three action areas per month is reasonable Responsibility needs to be assigned Follow up on action items in QA meeting Sentinel events (dehydration, impaction, low risk PU) Indicators in 90 + percentile

33 Reference resources yInits/Downloads/NHQIQMUsersManual.pdf yInits/10_NHQIQualityMeasures.asp Google “Quality Measures Nursing Homes”

34 Improving Nursing Facility Care by Reducing Avoidable Acute Care Hospitalizations
Used with permission Joseph G. Ouslander, M.D. Director, Boca Institute for Quality Aging Boca Raton Community Hospital Mary Perloe, MS,GNP-BC Project Coordinator Georgia Medical Care Foundation 34 34

35 Background 40% of 100 admissions to 8 LA nursing homes rated as inappropriate1 68% of 200 admissions to 20 Georgia nursing homes rated as potentially avoidable2 1Saliba et al, J Amer Geriatr Soc, 2000 2CMS Special Study, 2008

36 Hospitalization of Nursing Home Residents
Background Hospitalization of Nursing Home Residents Common Disruptive for the resident and family Fraught with many complications deconditioning, delirium, incontinence/catheter use, pressure ulcers, polypharmacy Costly Sometimes an inappropriate and avoidable use of the emergency room and acute hospital 36 36

37 Background Reducing avoidable hospitalizations represents an opportunity to improve care and reduce costs Some of the costs avoided can be reinvested in the infrastructure for nursing homes to provide high quality care 37 37

38 Percent of Potentially Avoidable Hospitalizations
Georgia Medical Foundation N = 105 38 38

39 Expert Opinion Avoiding Hospitalizations
The same benefits can often be achieved at a lower level of care One physician visit may avoid the transfer Better quality of care may prevent or decrease the severity of acute change Better advance care planning is necessary The resident’s overall condition may limit the ability to benefit from the transfer Provider Resources Physician or NP/PA present in facility at least 3 days per week Exam by physician or NP/PA within 24 hours Availability of lab tests within 3 hours Intravenous therapy 39 39

40 Facility Assessment Appropriate reporting mechanisms to ensure that changes of condition are reported appropriately to the right person Ability to start treatment, e.g., antibiotics, pain medication in a few hours Ability to start intravenous or clysis therapy for hydration within 2 hours of the order Sufficient nursing staff coverage to oversee appropriate monitoring over 24 hours Sufficient nursing staffing to ensure daily assessment until the acute behavioral change has resolved or stabilized Sufficient nursing staffing to recognize and report possible complications of treatment within 24 hours of their identification AMDA CPG Recognition of Change in Condition 40 40

41 Advance Care Planning Tools
A Tool Kit to Improve Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations Developed based on the data collected, and Expert Panel ratings of importance and feasibility Communication Tools Care Paths Advance Care Planning Tools 41 41

42 Communication Tools Keeping it Simple 42 42

43 Communication Tools *Situation, Background, Assessment, Recommendation
Target Audience Tools Certified Nursing Assistants Early Warning Assessment (“STOP AND WATCH”) All nursing home licensed nursing staff SBAR* Communication (general) SBAR Communication Templates related to specific conditions Acute mental status change Fever Pneumonia/Lower Respiratory Illness Dehydration UTI CHF Communicating acute changes in status – file cards by the telephone Primary care physicians, nurse practitioners, physician assistants SBAR Communication Templates related to specific conditions Emergency room and acute care hospital staff Transfer checklist Administrative nurses, medical director Unplanned acute care transfer review *Situation, Background, Assessment, Recommendation 43 43

44 Recognize a Change in Condition
Seemed like himself/herself Talked the same Overall function the same Participated in usual activities Ate the same amount N Drank the same amount Weak Agitated or nervous Tired or drowsy Confused Help with dressing, toileting, transfers No? TELL A NURSE Nurses aides can be taught to recognize and report early signs and symptoms of illness. If reported, the LVN/LPN and/or RN needs to follow up with an appropriate assessment and follow up. This is also a valuable tool for families to have. They are often more in tune to subtle changes, especially if the resident is new to the facility. Positive signs here are a fairly good predictor of whether or not a resident is ill. Yes? Adapted from Boockvar, Kenneth et all, JAGS 48: ,2000. 44 44

45 Associated with Hospitalizations
Nurses aides frequently observe subtle changes in condition prior to showing more significant signs/symptoms of illness. The presence of these symptoms are associated with an increased risk of hospitalization. The negative predictive value is quite high. If absent, you can be reasonably assured the resident is not ill. Three important considerations of altered presentation of disease include altered mental status, which may present with lethargy, confusion, or agitation. Altered mental status may also manifest itself as a change in the ability to function. A decline in the ability to feed ones self, urinary incontinence, falls. These signs are often unrecognized by hospital nurses because of their unfamiliarity with the baseline of the patient. Families will usually pick up changes early. In one study in a nursing home population, nurses aides observed these changes 5 days prior to the licensed nurses documenting the change in the nurses notes. Boockvar KS, Lachs, MS [2003] JAGS, 51: Symptoms predict illness about 50% of the time. Likelihood ratios show there is a moderate increase in the likelihood of disease. However, if the signs are absent, you can be 90% positive the person is not ill. 45 45

46 Immediate Notification
Change in Condition Immediate Notification Any symptom, sign or apparent discomfort that is: Sudden in onset A marked change (i.e. more severe) in relation to usual symptoms and signs Unrelieved by measures already prescribed Sources: AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996 46 46

47 Care Card Conditions that usually warrant transfer to the hospital:
Acute abdominal pain with vomiting Chest pain not due to stomach pain, musculoskeletal pain, and not relieved with antacids or nitroglycerin Fall with pain and signs of fracture Hypertension with systolic BP over 230 mmHg and chest pain or signs of stroke Vomiting blood and low blood pressure and tachycardia Respiratory distress with rate over 28 and not relieved with oxygen, nebulizers, or suctioning 47 47

48 Care Card: Recognizing Pulmonary Signs and Symptoms
Labored breathing / shortness of breath New or worsened cough New or increased sputum production New or increased findings on lung exam Rhonchi: sputum Wheezes: restricted airway Crackles: fluid Chest pain with inspiration or coughing The STOP AnD WATCH includes non-specific symptoms of acute illness. Aides and families can be taught to look for the symptoms and signs. Nurses need to follow up on the observations with an appropriate assessment. In persons at risk for lower respiratory infections, nurses aides and staff should be taught to pay particular attention to the respiratory rate. LVN/LPNs and RNs should be reminded to count the RR for at least 30 seconds[60 seconds] is better. This will help to identify the rhythm as well as more accurately represent the actual respiratory rate. Higher respiratory rates in pneumonia are associated with poorer outcomes and higher mortality. 48 48

49 Teaching Moments Common causes of dyspnea
Lungs Asthma Chronic obstructive pulmonary disease Infection Viral [influenza] Bacterial Pulmonary embolism Heart Congestive heart failure Atrial fibrillation Myocardial infarction A common symptom of lower respiratory infection is shortness of breath. Other diseases cause shortness of breath. I may take more than the physical assessment to determine the cause. The primary cause of shortness of breath in cardiac disease is heart failure. Some mechanisms of heart failure are atrial fibrillation and myocardial infarction. Either one can contribute to pump failure which is the underlying cause of heart failure. 49 49

50 Communication Physician/NP/PA Notification
Resident unable to eat and drink Temp over 102ºF (38.9ºC) or less than 96.8ºF (36ºC) Apical heart rate more than 100 Respiratory rate > 30/min BP less than 90 systolic Oxygen saturation less than 90% Call urgently Diabetes mellitus Finger stick glucose Less than 70 or more than 400 Consider hospital transfer Results of chest radiograph show an infiltrate or pneumonia Critical values in blood count or metabolic panel WBC over 12, 000 or less than 4000 Sepsis occurs only in the presence of in infection. The earliest sign may be an increased heart rate. Fever and elevated white blood count are part of the early signs. Tachypnea and changes in pulse oximetry signal perfusion problems. Pulse oximetry less than 90% is a strong indication of poor prognosis. 80% is not just 10% worse, it is gravely, seriously worse than 90%. In septic SHOCK, the person becomes hypotensive. Urine output may decrease and delirium is common. *Suspect sepsis if there are two or more signs from red bolded parameters 50 50

51 SBAR: Situation, Background, Assessment, Recommendation
S Situation I am calling about __________ He/she has signs/symptoms of pneumonia: Shortness of breath, new/worse cough, new/increased sputum, fever, change in lung sounds, chest pain with breathing or with cough, other B Background Diagnoses New medications, started oxygen, gave nebulizer Able to eat/drink [yes or no] Vital signs, pulse oximetry A Assessment I think he/she has pneumonia Vital signs are stable, unstable R Recommendation Chest radiograph Maybe a CBC or BMP Possibly start antibiotic now, IM and/or PO Monitor every _____ hrs Transfer to the hospital [yes/no] Before Calling Physician/NP/PA Assess the resident Check vital signs Check pulse oximetry and/or finger stick blood glucose if indicated Read recent progress notes and nurses notes Be Ready to Report Advanced directives, code status, do not hospitalize, do not use IVs or subcutaneous fluids, do not use artificial nutrition Allergies Medications, especially warfarin [Coumadin] The SBAR is a way to standardize education about communication across disciplines. Nurses aides can be taught the SBAR. In addition to following the script, nurses who are going to call need to be ready with other information including advance directive. Ideally, they would also know if the resident is under the care of Fidelis. 51 51

52 Quality Improvement Measures
Care Paths Quality Improvement Measures 52 52

53 53 53

54 Minimum Criteria for Antibiotics
IF Temperature is more than102º F Respiratory rate more than 25/minute OR IF Temperature is more than 100º F or less than102º F Cough AND Pulse greater than 100/minute Delirium Chills IF temperature is normal AND resident has COPD Increased cough or increased sputum IF afebrile [no COPD] New cough Purulent sputum AND Respiratory rate more than 25/minute or delirium IF infiltrate on chest radiograph AND Respiratory rate over 25 Productive cough Temperature over 100º F These criteria are based on consensus of physicians/infectious disease specialists. 54 54

55 Minimum Facility Monitoring
The LVN/LPN/RN assesses the resident each shift for 3 days or until the symptom resolves At a minimum, the LVN/LPN/RN assesses: - How the resident feels - Vital signs and pulse oximetry - Level of alertness, aggressive, combative behaviors - Appetite and fluid intake 55 55

56 Establishing the Goals
Resident-Family-Facility-Provider Partnership 56 56

57 Discussing the Goals Cure Restoration/Rehabilitation Maintenance
Comfort 57 57

58 QM: Retrospective Chart Review
Demographics Staff on duty Urgency of the transfer Resources not available Pretransfer treatment Factors associated with transfer decision Physician orders Medical Instability Directives Authorizing person for transfer Diagnoses at time of transfer 58 58

59 Case Study CNA says resident “different”, more confused, tired, back pain, slept in chair last night. Resident says she feels okay. “Something is wrong, she is sharp as a tack.” History: No past history of dyspnea or chest pain, no cardiac history, no diabetes, usually capable of making her own decisions. No cardiopulmonary resuscitation, wants hospitalization. Did not sleep well last night, acetaminophen [Tylenol] did not relieve pain, slept in her chair because of coughing, non-productive, no fever reported. She has not fallen. Normally she eats well, today says stomach is upset, she’s nauseated, and did not eat breakfast or lunch. No change in bowel or bladder pattern, confirmed by nurse aide. Two days ago had one urinary incontinent episode which is unusual for her. She says she knew she had to go but was just too weak and out of breath. No burning, or frequency. In talking with her today she loses track of the conversation, “I’m not eating, but I don’t like waffles anyway. Didn’t we have waffles yesterday?” 59 59

60 Case Study 1 Should the nurse contact the physician/NP?
What do you expect the nurse to report? What is the urgency of her condition? orders do you anticipate? nursing interventions do you expect? is your rationale? 60 60

61 Case Study 2 A 76 year old with a history of COPD complains of weakness. He is not on oxygen at the nursing home. He is more short of breath than usual, and has a cough. He tells you he always has a cough. He denies fevers, chills, rigors, or chest pain. His wife and the nurses aide tell you he is weaker, more short of breath and seems confused. He has not been eating or drinking as much for several days. Advanced Directives: Code status undetermined, does want hospitalization. Past medical history: COPD, osteoarthritis mostly in the knees Medications: Albuterol and ipatropium via metered dose inhalers, both 2 puffs 4 times a day. Acetaminophen for knee pain twice a day. 61 61

62 Case Study 2 Vital signs: BP lying 132/72, pulse 80 and regular, sitting BP 110/60, pulse 90, standing unable to obtain due to unsteadiness, sensation of falling. Respirations 24, temperature orally, weight 140 [3 pounds less than last week]. HEENT: Mouth and throat dry Skin: Axilla dry Lungs: Decreased breath sounds over usual exam, course rhonchi in right base Heart: Regular rhythm, no cyanosis Neurological: Weak, but equal strength bilaterally in arms and legs Mental Status: Alert, rambling speech, easily distracted Gait and Balance: Cannot stand as he was too unsteady  The white blood cell count is normal, with a left shift The chest radiograph shows a small infiltrate on the right base. The nursing staff and his wife would like him transferred to the hospital. The facility has RNs on the skilled unit 24 hours/day and they do start and maintain IVs. The NP is in the building daily Monday – Friday and the resident can be seen by the NP daily for 3 days before the weekend. 62 62

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