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Improving the Transition from Tertiary Care Hospitals into Various Post Acute Environments Gerda Maissel, MD Medical Director, PAC Susana Hall, RN, BSN,

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Presentation on theme: "Improving the Transition from Tertiary Care Hospitals into Various Post Acute Environments Gerda Maissel, MD Medical Director, PAC Susana Hall, RN, BSN,"— Presentation transcript:

1 Improving the Transition from Tertiary Care Hospitals into Various Post Acute Environments Gerda Maissel, MD Medical Director, PAC Susana Hall, RN, BSN, MBA, ACM Clinical Business Consultant to PAC Baystate Health, Springfield, MA

2 Baystate Medical Center 3 Flagship of Baystate Health Flagship of Baystate Health 650+ beds 650+ beds Level 1 Trauma / Level 3 Nursery Level 1 Trauma / Level 3 Nursery Tufts Med School Teaching Facility Tufts Med School Teaching Facility 293 residents and fellows 293 residents and fellows 37,940 Discharges FY06 37,940 Discharges FY06 ED >105,000 per year ED >105,000 per year Solucient Top 100 Hospital Solucient Top 100 Hospital Magnet Hospital - Nursing Magnet Hospital - Nursing EMR CIS EMR CIS

3 Objectives Literature Review Literature Review Overview of Post Acute Levels of Care Overview of Post Acute Levels of Care Review of strategies, specific tactics & data Review of strategies, specific tactics & data Lessons Learned / Next Steps Lessons Learned / Next Steps

4 Literature Review – PAC Transition Issues Christopher L. Roy, MD et al., Patient Safety concerns Arising from Test Results that Return after Hospital Discharge, Ann Intern Med., 2005 Schoen C et al., Taking the Pulse of Health Care Systems: Experiences of Patients with Heart Problems in Six Countries. Commonwealth Fund, 2006 Naylor MD, McCauley KM, The effects of discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions, J Cardiovasc Nurs, 1999. Stewart, S. et al., Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths, J Am Geriartr Soc. 1998 Myer JS, et al., Are Discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program, Acad Med., 2006 OLeary,KJ, et al., Outpatient physicians satisfaction with discharge summaries and perceived need for an electronic discharge summary

5 Literature Review – PAC Transition Issues Kripalani S., et al., Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care, JAMA 2007 Foster DS, et al., Evaluation of immediate discharge documents – room for improvement, Scott Med J, 2002 Moore C., et al., Tying up Loose ends; discharging patients with unresolved medical issues, Arch Intern Med, 2007. van Walraven C, Rokosh E, What is necessary for a high-quality discharge summary Am J Med Qual, 1999 OLeary, KJ, et al., Outpatient physicians satisfaction with discharge summaries and perceived need for electronic discharge summaries, J Hosp Med, 2006 Williams, Mark, Hospital Patient Safe-D(ischarge): Discharge bundle for, Emory University, 2005

6 Post Acute Care Levels of Care ABCs In-patient settings : In-patient settings : LTAC: Long Term Acute Care LTAC: Long Term Acute Care IRF : Inpt Rehabilitation Facility IRF : Inpt Rehabilitation Facility Sub- Acute or Short Term or TCU Sub- Acute or Short Term or TCU SNF: Skilled Nursing Facility SNF: Skilled Nursing Facility LTC: Long Term Care LTC: Long Term Care Home Setting : Home Setting : VNA: Visiting Nurse Association VNA: Visiting Nurse Association Medical House Calls Medical House Calls Palliative Care Palliative Care Hospice Hospice

7 Initial PAC Strategy 1996 started with belief: BMC had a responsibility to ensure our patients had the highest quality of PAC that would provide the optimal potential for return to prior functional status.

8 Post Acute Strategies Overview Developed key relationships with each major type of post acute care Developed key relationships with each major type of post acute care Home Health - 1995Home Health - 1995 Sub Acute - 1996Sub Acute - 1996 LTAC - 2004LTAC - 2004 IRF - 2007IRF - 2007 Excluded PAC levels that had less impact on the hospital Excluded PAC levels that had less impact on the hospital Long Term Residential CareLong Term Residential Care Assisted LivingAssisted Living

9 Post Acute Strategies Mutual wins & goal setting Mutual wins & goal setting Collaborate, dont own Collaborate, dont own Collegial partnershipsCollegial partnerships Allows each to focus on their core businessAllows each to focus on their core business Imbed medical leadership Imbed medical leadership Ability to influence standards of careAbility to influence standards of care Clinical championsClinical champions Regular, formal and informal communication Regular, formal and informal communication Program based approach Program based approach Pull not push patients to post acute Pull not push patients to post acute Not financially based Not financially based

10 Post Acute Tactics Oversight committees Oversight committees Steering Steering Operations Operations Medical leadership positions Medical leadership positions Selected medical staffing Selected medical staffing Internal and External Education Internal and External Education PAC PI PAC PI

11 Key Success Factors Shared Goals Shared Goals Mission and Vision Mission and Vision Involved broad groups of staff, both sides Involved broad groups of staff, both sides Case managers, physicians, nursing, therapy, program mangers, administrators Case managers, physicians, nursing, therapy, program mangers, administrators Influential stakeholders Influential stakeholders Embraced quality and safety as core drivers Embraced quality and safety as core drivers Not heads in beds Not heads in beds Transparency Transparency Data sharing Data sharing Similar Cultural Values

12 Medicare Readmission Analysis Discharges with and w/o PAC FY06 Medicare PAC - Readmission Analysis Medicare Discharges WITH PAC No. of Cases % of Medicare Discharges FY06 FY06 Medicare Discharges 11661 Total Discharged With PAC Services 453438.88% Total Readmitted within 15 days 52011.47% Top 20 DRGs Readmits within 15 days 2051.76% Medicare Discharges WITHOUT PAC No. of Cases % of Medicare Discharges FY06 FY06 Medicare Discharges 11661 Total Discharged Without PAC Services 712761.12% Total Readmits w/in 15days 108215.18% Top 20 DRGs Readmits within 15 days 2482.13%

13 Post Acute Data Discharge patterns from Baystate by level of care and or diagnosis Discharge patterns from Baystate by level of care and or diagnosis Bounce back rates from post acute providers Bounce back rates from post acute providers Key quality & safety initiatives both organizations Key quality & safety initiatives both organizations Post acute program outcomes Post acute program outcomes Key staffing / leadership changes Key staffing / leadership changes Readmission rates Readmission rates

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15 PAC – Performance Improvement Team at Baystate Medical Center Subset of Medical Services Performance Improvement (MSPIT) Subset of Medical Services Performance Improvement (MSPIT) Multi Organizational Team, various backgrounds Multi Organizational Team, various backgrounds Program Directors Program Directors Physicians Physicians Nursing Nursing Therapy Therapy Case Management Case Management Risk Management (to assist in initial development) Risk Management (to assist in initial development)

16 PAC – PI Evolution Blinded shared case discussion (still on going) Blinded shared case discussion (still on going) Bounce backs, complaints, challenging patient care Bounce backs, complaints, challenging patient care Reduced noise Reduced noise Ideas for operational improvement Ideas for operational improvement Programs and Services Document Programs and Services Document Education to Baystate Audiences Education to Baystate Audiences Post acute levels of care specifics Post acute levels of care specifics Discharge summary importance and content Discharge summary importance and content Expectation management Expectation management Modification of Baystates discharge report Modification of Baystates discharge report Formally surveyed post acute providers Formally surveyed post acute providers Used feedback to change hospital process and DC summary organization and content Used feedback to change hospital process and DC summary organization and content Developing the Hand off of care for pts treated and returned from the ED Developing the Hand off of care for pts treated and returned from the ED

17 Electronic PAC Discharge Report Key Hand off information Current information Reason for acute admission Reason for acute admission Advanced Directive Advanced Directive Allergies Allergies Infection Control Concerns Infection Control Concerns Emergency contacts Emergency contacts Physician and Nursing Discharge Summary Physician and Nursing Discharge Summary Scheduled Meds at time of transition w/ time of next dose Scheduled Meds at time of transition w/ time of next dose Last 7 days Discontinued scheduled and PRN Meds w/ date/time of last dose Discontinued scheduled and PRN Meds w/ date/time of last dose Completed / Discontinued IV Infusions Completed / Discontinued IV Infusions History and Physical Clinical Summary of last 7 days Lab Lab Therapies Therapies Vaccines (pneumoncoccal / influenza) Vaccines (pneumoncoccal / influenza) Consult orders and dictations Consult orders and dictations Vitals for last 24 hrs Vitals for last 24 hrs Radiology Reports Radiology Reports Ancillary Assessments Ancillary Assessments Nutrition Therapies Case Management

18 Case Review <72 hour Re-Admits / Unplanned Transfer Protected by peer review laws Protected by peer review laws HIPPA – sharing of PHI by entities providing care to the patient HIPPA – sharing of PHI by entities providing care to the patient Medical Staff Bylaws Medical Staff Bylaws Baystate policies Baystate policies All corporate entities recognize process as peer review and abide by confidentiality status. All corporate entities recognize process as peer review and abide by confidentiality status.

19 Lessons Learned / Next Steps Patients who have some level of PAC are less likely to be readmitted. Patients who have some level of PAC are less likely to be readmitted. If readmitted the subsequent LOS is as much as 1 – 1.5 days longer than initial LOS If readmitted the subsequent LOS is as much as 1 – 1.5 days longer than initial LOS Raised awareness of the need for PACRaised awareness of the need for PAC Identification and screening of patients with risk factors for readmission if sent home.Identification and screening of patients with risk factors for readmission if sent home. End of week discharges have a slightly higher rate of return within 72 hours. End of week discharges have a slightly higher rate of return within 72 hours.

20 Lessons Learned / Next Steps High percentage of discharges to PAC occur between 3pm and 5pm. High percentage of discharges to PAC occur between 3pm and 5pm. Working to establish mid-level provider coverage in eveningsWorking to establish mid-level provider coverage in evenings Home healthcare readmissions - opportunity for greater understanding of readmissions within 72 hrs. Home healthcare readmissions - opportunity for greater understanding of readmissions within 72 hrs.

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