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1 Keith Rapp MD, CMD Mary Pat Rapp PhD, RN Geriatric Associates of America, PA.

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Presentation on theme: "1 Keith Rapp MD, CMD Mary Pat Rapp PhD, RN Geriatric Associates of America, PA."— Presentation transcript:

1 1 Keith Rapp MD, CMD Mary Pat Rapp PhD, RN Geriatric Associates of America, PA

2 2  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 3  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 4  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 5  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 6  Decline in ability to move in and around their room  Urinary tract infection  Worsening anxiety or depression  Weight loss

7 7  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

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

12 12 GAA Quality Model  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 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 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 15  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 16 Liability Outcomes OtherGAA requests0 requests requests4 requests requests0 requests Totals:254

17 17 GAA Quality Model Outcomes at 14 Facilities Benchmarking Provider Care

18 18 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS 9 + MEDS

19 19 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS COGNITIVE IMPAIRMENT

20 20 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS NO TOILET PLAN

21 21 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS CATHETERS

22 22 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS UTI

23 23 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS TUBE FEEDING

24 24 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Range Of Motion

25 25 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS NO ACTIVITY

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

27 27 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS Pressure Ulcer Low Risk

28 28 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIPSYCHOTICS Low Risk

29 29 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIANXIETY

30 30 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS BLADDER Low Risk

31 31 Privileged and Confidential - Proprietary Information ALL GAA Quality Models HOUSTON/CENTRAL TEXAS RESTRAINTS

32 32  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 33  yInits/Downloads/NHQIQMUsersManual.pdf yInits/Downloads/NHQIQMUsersManual.pdf  yInits/10_NHQIQualityMeasures.asp yInits/10_NHQIQualityMeasures.asp  Google “Quality Measures Nursing Homes”

34 34 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 Improving Nursing Facility Care by Reducing Avoidable Acute Care Hospitalizations 34

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

36 36 Background  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 Hospitalization of Nursing Home Residents 36

37 37  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 Background 37

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

39 39  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 Expert Opinion Avoiding Hospitalizations 39

40 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

41 41 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 Care Paths Communication Tools Advance Care Planning Tools %2FParentShellTemplate&parentName=Topic&c=MQParents 41

42 42 Communication Tools Keeping it Simple 42

43 43 Target AudienceTools 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 o Acute mental status change o Fever o Pneumonia/Lower Respiratory Illness o Dehydration o UTI o 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  Communicating acute changes in status – file cards by the telephone Emergency room and acute care hospital staff  Transfer checklist Administrative nurses, medical director  Unplanned acute care transfer review Communication Tools *Situation, Background, Assessment, Recommendation 43

44 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? Yes? Adapted from Boockvar, Kenneth et all, JAGS 48: ,2000. TELL A NURSE 44

45 45 Associated with Hospitalizations 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

46 46 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 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 Change in Condition 46

47 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

48 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 48

49 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 49

50 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 *Suspect sepsis if there are two or more signs from red bolded parameters 50

51 51 SBAR: Situation, Background, Assessment, Recommendation 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] 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] 51

52 52 Care Paths Quality Improvement Measures 52

53 53

54 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 ◦ Respiratory rate more than 25/minute 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 54

55 55  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 Minimum Facility Monitoring 55

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

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

58 58  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 QM: Retrospective Chart Review 58

59 59  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?” Case Study 59

60 60  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? Case Study 1 60

61 61  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. Case Study 2 61

62 62  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 99.9 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. Case Study 2 62


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