PRISM Understanding risk and aligning resources to improve outcomes

PRISM Understanding risk and aligning resources to improve outcomes
September 2017

Overview for today Background on PRISM
PRISM bundles: risk based interventions Impact of PRISM bundles Where are we going with all this? ©2014 Trinity Health - Livonia, MI

Recap – today’s challenges
Health care is complex, fragmented, expensive Hand-offs, communication failures Inpatient: Change in units, shifts, rotations Across sites of care: outpatient, inpatient, SNF Discharge summaries, referral letters Mass General survey – 59% housestaff reported patient harm due to suboptimal handoffs (Kitch Jt Comm J Qual Pat Saf 2008) Only modest level of agreement of the patient’s clinical risk between check-out physicians and incoming physicians Kappa (Brannen J Patient Safety 2009) ICC (Ratelle J Gen Intern Med 2014) HCAHPS doctor communication scores worse for high risk patients Failure to recognize, rescue Delays, gaps in care Clinician alert fatigue ©2014 Trinity Health - Livonia, MI

Recap – today’s challenges
Imbalance between needs and type of care provided for patients with multiple, chronic conditions Clinical practice guidelines may conflict with each or not pertain to patients with multiple conditions (Boyd JAMA 2005, Lugtenberg PLoS One 2011) Patients admitted for one condition often readmitted for a different condition (Jencks NEJM 2009) 25 – 33% patients die with pain, shortness of breath, emotional needs (Teno JAMA 2004) Cancer screening performed for 31 – 55% of those at high risk of dying (Royce JAMA Int Med 2014) ICU ventilator use for advanced dementia patients doubled from – 2013 (Teno 2016) Health care resources are finite Nurses, hospitalists, ICU beds, transition coaches, time for patient teaching (inhaler technique – 2 minutes versus 6 minutes for teach back Press J Gen Int Med 2012) ©2014 Trinity Health - Livonia, MI

Look to make complex simple Look for patterns Look for common denominator

Pareto Principal: 30 % of patients > 80% deaths
> 40% readmissions PRISM 1 and 2 patients will likely need more than “usual care” ©2014 Trinity Health - Livonia, MI

PRISM is a counter influence
Simple construct – pay extra attention to high risk subgroup Pareto principle – small proportion of patients (inpatients AND outpatients) have disproportionate number of adverse events High risk patients need higher nursing staffing levels High risk patients may have golden hour - physicians should see early and often High risk patients have needs anticipated by other team members (eg. Rapid response team, nutrition, pharmacy, palliative care, etc) Understand explicit risk of dying – Which goals are most important to the patient right now? (Fried Arch Int Med 2011, Tinetti JAMA Cardiology April 2016) aggressive life-saving efforts right now? Living longer at all costs? Time spent living independently? Control bothersome symptoms (pain, SOB, anxiety, depression) irrespective of survival time? Use remaining time to repair personal relationships? Creates common clinical language for hand-offs and communication Knowing a patient is PRISM 1 provides an immediate array of information Framework transportable to home care and local SNFs to initiate risk-based interventions Outpatient version - No longer “inpatient silo” versus “outpatient silo” ©2014 Trinity Health - Livonia, MI

AROC 30-day mortality (0.88) 180-day mortality (0.89) Palliative status (0.89) Unplanned Transfer (0.74) 30-day readmission (0.69) What is PRISM? Prediction rule that generates a probability of a patient’s risk of dying (mortality risk) within the first 30 days of admission based on information known at the time of admission Probabilities are distilled into a single score ranging 1-5 PRISM 1 – Highest Risk PRISM 5 – Lowest Risk Informs initial placement into the appropriate nursing unit, timeliness of initiating treatment, surveillance and response activities of the clinical team, and transitions of care ©2014 Trinity Health - Livonia, MI

Obtained Electronically
PRISM Risk Factors Provided by Clinician Obtained Electronically Current or past history of: Cognitive Defect Other Neurological Atrial Fibrillation Cancer Metastatic Cancer Leukemia Currently have: Respiratory failure Injury Heart Failure Sepsis Medical vs Surgical Admission Age Gender BUN WBC Platelet Count Lactate Hemoglobin Albumin Arterial pH Arterial pO2 Troponin Hospitalized at SJMHS within past year Emergent Admission ©2014 Trinity Health - Livonia, MI

30-day Outcomes by PRISM Strata SJMAA Adult Inpatients, CY2015

Need to institute treatment early
Need to institute life-saving measures quickly Need to account for persistent level of risk after discharge ©2014 Trinity Health - Livonia, MI

Disposition and PRISM:
Informs Work of Case Managers, Social Workers

PRISM 1 patients sent home experience a similar
level of events as their counterparts in SNF, home care ©2014 Trinity Health - Livonia, MI

PRISM 1 and 2 patients provide lower scores for Doctor Communication and Staff Responsiveness
(adjusted for age, gender, language, self-reported health, educational level and service) More Favorable Responses Less Favorable Journal of Hospital Medicine, September 2016 15 15 ©2014 Trinity Health - Livonia, MI

Look for common patterns in our daily work
Some root causes (To Err Is Human): Delay in diagnosis, treatment Failure to respond Failure to prevent Failure of communication Some remedies: Care within “Golden hour” Nurse staffing Team work Communication Standard work ©2014 Trinity Health - Livonia, MI

PRISM Score 1 PRISM Score 2 PRISM Score 3 PRISM Score 4/5
PRISM Across the Continuum: Standardized Process & Expectations Identify Vital Few Items to Customize Level of Intensity, and Support Appropriate for Risk Level Assign PRISM Score and Pre-Admit Work Identify Appropriate setting for care, Initiate Care and Bundles Transition & Discharge Post Discharge Follow up PRISM Score 1 PRISM Score 2 PRISM Score 3 PRISM Score 4/5 Placement & Admission Admit & Placement Guidelines include risk and acuity Prioritize order entry and initiation for high risk patients Heightened vigilance for high risk patients in first 24 hrs Reducing Mortality Reducing Complication Improving Evidence Based Care and Patient Experience Reducing Readmissions, ED Utilization Early Screening of high risk patients for Case Management, Palliative Care and Nutrition Addressing Advance Directive and Goals of Care proactively for high risk patients Appropriate frequency of nursing assessments for low risk pts Progressing Care How do we think about PRISM across the continuum? Starting at the top left blue box, patients are assigned a PRISM score and pre admit work up is complete. Once the score is given, an appropriate unit is selected for placement and admission. While progressing through care, other disciplines get involved as appropriate (SW, case management, palliative care, etc). Then the patient arrives at the point where they ready to transition to another facility or discharge home. Throughout this whole process we hope to reduce mortality, complications, and readmissions, improve evidence based care, and finally improve the patient experience Scheduling of follow up appointments for high risk patients Differentiated Handoffs by risk/complexity level Standardized, Minimum Home Care support for high risk patients Discharge med rec, education/support Discharge & Transition Copyright©Saint Joseph Mercy Health System, Ann Arbor Michigan

Palliative Care, Case Management and Social Work
Example how concurrent processes of care can be launched (PRISM 1 Acute Care Bundle) Physicians ED Provider generates PRISM Score prior to bed assignment Verbal ED to Inpatient Physician communication Inpatient Provider: begins assessment and initial inpatient care orders prior to floor arrival evaluates status changes in person during acute stay Nursing ED Nurse repeats vitals within 1 hr prior to transport to bed or calling report Verbal ED to Inpatient Nurse handoff Inpatient RN: greets patients (within 1 hr) upon arrival to floor (beginning work on PRISM 1 admit checklist) notifies physician of change in status, VS q30min x 4, q1hr x 2, q2hr x 4, then q4hr until stable Rapid Response Team rounds daily PRM Ensures score is available for placement decisions and documented in Cerner Places PRISM 1 patients in Intermediate Care at a minimum, ICU if aberrant vitals in ED Palliative Care, Case Management and Social Work Case Management completes initial assessment within 24 hrs (M-F) Palliative Care team addresses Goals of Care, Advance Care Planning Social Work supports Advance Care Planning needs Nutrition Completes screen within 48 hrs of admission Healthy snacks for PRISM 1 patients proactively supplementing meals 18 18 18 18 ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI

PRISM Bundle: Interventions for Care Coordination and Transitions
PRISM Score Select Interventions PRISM 1 Palliative Care Consult for goals of care and symptom management Verbal IP to PCP provider handoff attempted Discharges to Home include Home Care at minimum HomeCare Bundle inplace, includes first visit within hrs Discharges to ECF targeted to occur prior to 1pm ECF Bundle, includes all assessment completed within hrs and HomeCare and PCP appointment when d/c from ECF PRISM 1 & 2 Pharmacy provides medication review and counseling (while admitted or with post discharge phone call) PRISM 1, 2 & 3 Schedule follow-up appointment for within days after discharge to home/homecare (PRISM 1 & 2 attempt closer to 3 days)

Primary Bundle Elements - Assessment for Regional Standardization in Progress July 2017
©2014 Trinity Health - Livonia, MI

Higher nursing staffing levels (not GMB)
PRISM 1 Patients: Higher nursing staffing levels (not GMB) Start treatment quickly (“golden hour”) Respond quickly, bedside evaluation if new symptoms because mortality risk increases greatly Include PRISM score with handoffs Palliative Consult – goals of care, symptom control Home care (if PRISM 1, non-SNF) Attempt communication with PCP (or SNF doc) at discharge ©2014 Trinity Health - Livonia, MI

PRISM 1 ECF Bundle (Each team member plays a role) regional collaborative
Discharging Hospital and ECF Admitting Team Includes PRISM Score on referral to initiate bundle Targets transfer to occur prior to 1pm SNF Nurse Sees patient within 1 hr of arrival Completes Med Rec within 2 hrs of arrival Discusses condition changes and alerting physician with charge nurse (low threshold for alerting physician) SNF Physician Sees patient same day of admit or next morning, completes assessment within hrs Request Home Care for discharge Working on expanding to include interventions for PRISM 2 & # SNF Ancillary Social Work, Therapy, Nutrition consults complete within 24 to 36 hours Screen for Palliative Care (Review handoff from IP Palliative Care) Patient/Family Participates in 48/72 hour Care Conference PCP & Home Care PCP sees patient for follow up after discharge from SNF Home Care participates in last care conference 23 23 ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI

PRISM 1 Home Care Bundle: Ann Arbor Example
Liaison & Health Coaches Reviews PRISM Score on standard referral Triages for admission to Home Care same day or within 24 hrs of discharge from hospital Health Coaches & Office Staff RN completes welcome call on day of hospital discharge to assess status and schedule visit Makes High-Risk calls on Thursday/Friday to assess need for weekend visit Completes post-homecare follow-up contact and coaching Home Care Nurse Completes initial visit within 24 to 36 hours Includes health coaching principles in all care plans Screens for Palliative Care and reviews handoff from IP Palliative Care team Interdisciplinary Team Reviews Patient at each standard IDT Care Conference Completes Case Manager and Clinical Supervisor pre-discharge conference PCP Arranges to follow patient for orders and oversight prior to hospital discharge Sees patient for follow up appointment with within 3-7 days of discharge 24 ©2014 Trinity Health - Livonia, MI

Process Metrics and Outcomes
©2017 Trinity Health

30 Day Mortality Actual # Deaths / Expected # Deaths
26 ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI

30 Day Readmissions (Actual / Expected)
30 Day Readmissions (Actual / Expected). Reflects statistically significant decreases in Pneumonia, most Medical Discharges, however, trends for HF, COPD, AMI, Stroke, Surgery were non-significant with this particular risk-adjustment method 27 ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI

75th percentile - Time from order placement to Nurse Review (hours)
Numerator Denominator Time from diet order placement by physician to RN review (dietorderrnreview_hr) - 75th percentile (in hours) Scored in ED

Associations with Early Assessment and Inpatient Care Orders*
Length of Stay PRISM 1: (vte advisor) Shorter average LOS by 0.37 days (p = .003) PRISM 2: (vte advisor) Shorter average LOS by 0.16 days (p = .01) 30 day mortality PRISM 1: 18% fewer deaths (vte advisor or diet order), p = .03 PRISM 2 : 13% fewer deaths (vte advisor or diet order), p =.07 CHF patients 30 day mortality borderline lower (vte or diet order) 19.8% versus 31.7% (p = .05) Severe infections (sepsis) 30 day mortality lower (vte or diet order) 39.1% versus 47.0% (p = ) Unplanned transfers to ICU in first 24 hours PRISM 1: 46% fewer unplanned transfers if diet order or vte advisor completed within 75 minutes (p = .03) Top 3 clinical conditions having unplanned transfer regardless of PRISM score: Serious infection (33% of transfers), Pneumonia (9.8% transfers), Alcohol-related (6.1%) *As measured by launching VTE advisor (or diet order if noted) within 75 minutes of floor arrival in non-surgical cases (cannot determine causal relationships) …mortalitysite 8/1/13 – 3/31/16 30 30 30 ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI

Nutrition Screen for PRISM 1, non-ICU
Discharge Month Measure 201611 201612 201701 201702 Target Pop: PRISM 1, admit unit Not ICU 86 95 93 97 Any Intervention Criteria Met - Count 69 74 70 77 Any Intervention Criteria Met - % Target Pop 80% 78% 75% 79% Individual Intervention Criteria - Count: Nutrition Consult Order entered w/i 48 20 19 Nutrition Note entered w/I 48 hrs 63 68 62 Review in TeamFlow w/I 48 hrs 24 27 30 Prospective PRISM scored, disch as IP or TC

PRISM Bundle and HCAHPS Dashboard for Prospective PRISM Scores
PRISM 1 PRISM 2 PRISM 3 PRISM 1 & PRISM 2

PRISM 1 Follow Up Appointments Kept (IHA)

Current state All 5 SE Michigan Trinity hospitals + Grand Rapids St. Mary are generating inpatient scores (see next slides for details) CNOs working across the region to standardize PRISM-related care bundles Outpatient PRISM scores generated and delivered to IHA practices monthly (more detail at a later time) “Check-in PRISM” launched. Before the ED evaluation takes place, an initial PRISM score is calculated at the time of ED registration [NEW] There is now a separate prediction rule in place in all EDs to identify patients at high risk for repeated future ED visits ©2014 Trinity Health - Livonia, MI

[NEW] Prediction Rule to Identify Those at Risk for Frequent ED utilization
Prediction rule for determining patients likely to return to the ED 2 or more times in the 30 – 120 days following the index visit developed Allows 30 days for interventions to be put in place 3 Risk Categories (high, medium, low) for returning to the ED Implemented in 6 Trinity Hospital Emergency Departments Scores visible in the ED PRISM web application No standard bundles yet Permits control charts to evaluate effectiveness of interventions (observed / expected) ©2014 Trinity Health - Livonia, MI

Other new uses of inpatient PRISM scores
Ann Arbor Pastoral Care visiting PRISM 1 patients in the Emergency Department Working on a patient pathway for PRISM 1 patients ©2014 Trinity Health - Livonia, MI

Your Care Path starts as soon as you arrive at St
Your Care Path starts as soon as you arrive at St. Joe’s and continues beyond…. Patient Pathway Draft (pg 1) When you arrive to your in-patient room During your stay As you prepare to leave The nursing team will greet you when you arrive in your room and will make you comfortable. They will assess your immediate needs. Your Hospitalist doctor will see you within 1 hour and develop with you the right treatment plan to get you better. The nursing team will make sure the tests, medications and plan are carried out and will inform you and your family of next steps. Your “My Important Papers” folder is where all your new information will be kept. Your team will review the material often with you. Good nutrition is important for healing, so healthy meals and snacks will be provided. We begin planning for your discharge from the hospital the day after you are admitted since a safe transition takes time to put into place. The Care Coordination Team will work with you and any family to determine the type of support you will need once you leave the hospital. Sitting in your bedside chair and walking a few times a day are important steps to get you better. We will always assist each time to keep you safe. Nursing team will check on you every hour. Your doctors will see you once or twice a day and review your care plan with you. Sometimes it can be difficult to manage troubling symptoms, like pain or fatigue; while at home and in the hospital. Our Palliative Care staff are part of the team that help you learn how to better cope with your illness and its impact on your daily life. Your active participation in all discussions and decisions are so important. We will help you make the plan that is right for you, and respect your wishes. Other physician consultants and therapists might also be involved in your care, but your Hospitalist is the one in charge. Ask any one of your healthcare team when you have questions or need help. Your care team will ensure you have the support necessary for a safe transition from the hospital: We will help you schedule a follow up appointment with your own doctor, if you are going home. Your hospital physician will update your primary care physician with a summary of your hospital stay. If you have a family member or support person, it is best to include them in all of your health teaching ,or as often as they can visit you while you are at St. Joe’s, since sometimes it is hard to remember once you get home. Home Talk with your team about what to expect when you go home A nurse or pharmacist will review your medications with you before you leave the hospital. When arrive home, a Home Care nurse will call to schedule a home visit 2 – 3 days after discharge, a pharmacist will call you to answer any question you may have about your medications. Skilled Nursing Facility Our goal is to have you transferred earlier in the day and once your arrive, you will be seen by the nurse within 1 hour. The physician as well as members of the social work, therapy and nutrition teams will meet to discuss your plan of care by the second day. When you are ready to go home, your skilled nursing facility team will : Schedule a follow up appointment with your Primary Care physician Plan for Home Care to follow up with you after you leave

Your Care Path: After the Hospital
Patient Pathway Draft (pg 2) What to Expect if you are going Home In the Hospital We will help you schedule follow-up appointments A nurse or pharmacist will review your medications with you before At Home Home Care nurse will call to schedule a home visit A Pharmacist will call you 2-3 days after discharge to answer any question you may have about your medications. Before I Leave the Hospital Do I: Understand the purpose and the common side effects of my medications Have all the medications I need Have all the equipment I need Feel comfortable getting up and moving around What else do I need to know or learn What other questions do I have? What to Expect if you are going to a Skilled Nursing Facility In the Hospital Our goal is to have you transferred earlier in the day When you arrive at the Facility A nurse will see you within 1 hour The physician as well as members of the social work, therapy and nutrition teams will meet to discuss your plan of care by the second day When you are ready to go home, your skilled nursing facility team will : Schedule a follow up appointment with your Primary Care physician Plan for Home Care to follow up with you after you leave

If your patient asks about PRISM
health.org/clinical/prism/docs/Infosheet_Talking_ab out_PRISM_with_Patients.pdf ©2014 Trinity Health - Livonia, MI

We are Building Coordinated, Risk-based Care Across the Continuum

Every patient in our population will have a PRISM score
Our Vision: Every patient will get timely, anticipatory, appropriate care based on the level of risk/need Every patient will received better-coordinated care wherever they are (home, physician office, hospital, emergency department, skilled nursing facility or other) because all care providers communicate the level of risk (“handoffs”) using the same language Every patient in our population will have a PRISM score 41 41 ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI ©2014 Trinity Health - Livonia, MI

PRISM Understanding risk and aligning resources to improve outcomes

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