1. A Facility Approach to Reducing Hospitalizations from the SNF to Acute Care Hospitals
September 12, 2019

2. Objectives Understand the impact of rehospitalizations.
Understand the Centers for Medicare & Medicaid's Services (CMS) Triple Aim.
Discuss how to target high risk patients.
Explore ways to reduce rehospitalizations in the Skilled Nursing Facility.
September 12, 2019

3. The Impact of Rehospitalization
Historically, one fifth of Medicare beneficiaries are rehospitalized within 30 days of discharge.
It is estimated that unplanned rehospitalizations in 2004 was $17.4 billion.
Avoidable hospital transfers/unnecessary hospitalizations
Cost
Disruptive and disorientating
Increase risk of medication errors
Increase risk of hospital acquired infections
September 12, 2019

4. IHI: Triple AIM
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.
CMS: Hospital Readmission Reduction Program
Affordable Care Act
Bundle Program
September 12, 2019

5. CMS: Guidelines to Improve Care
“Make communication and care coordination efforts better.”
“Work better with patients and caregivers on post-discharge planning.”
September 12, 2019

6. High Risk Diagnoses: CHF (HF is often not the readmission diagnosis)
COPD
PNA
Advanced stage chronic disease (CA, ESRD, ESLD, etc.)
Sepsis
Dementia
September 12, 2019

7. Reducing Rehospitalizations
Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations.
3 Strategies found to be important for the reduction of hospital transfers
Training licensed nurses in structured evaluation, documentation and communication strategies.
Telehealth.
Evidence based, expert consensus derived order sets that address the most common symptoms associated with re-hospitalization.
The top 3 Clinical factors with associated s/s found to be related to hospitalization were:
Abnormal vital signs
Altered mental status
Shortness of Breath
The top 3 clinical factors related to hospitalization with no reported symptoms were:
Pulse oximetry
Low hemoglobin
X-ray
The Journal of the American Medical Directors Association
September 12, 2019

8. Reducing hospitalization
Successfully Reducing Hospitalizations of Nursing Home Residents:
Results of the Missouri Quality Initiative
Found a 30% reduction in all cause hospitalization when an APRN was imbedded in the facility to provide direct care, mentor, role model and educate regarding recognition of early s/s of illness, assessment and management of common illnesses.
Use of interact tools (Stop and Watch/SBAR) were critical elements of the intervention.
APRN completed RCA of hospitalizations.
Proactive ACP was a critical component of reduction of hospitalization as well
September 12, 2019

9. Genesis HealthCare
Facility: PowerBack Willow Grove Goal for 30 day rehospitalization: 9.9%
14.1% in 2017
September 12, 2019

10. Approach to Reducing Rehospitalizations
Target acuity
Identify declines or changes in condition
Increase communication
Collaboration of care
Include the interprofessional team on all shifts
September 12, 2019

11. Targeting Acuity Completion of readmission tool High risk
First 72 hours
Change in status
History of recurrent hospitalizations
Daily rounding
Timely follow ups & frequent visits
Use of facilities capabilities
“High Risk Huddle” or high risk rounds
LACE, Genesis high risk tool
September 12, 2019

12. Identifying Declines or Changes in Conditions
Stop and Watch
Interact Tool
SBAR
September 12, 2019

13. Stop and Watch Seems different than usual Talks/communicates less
Overall needs more help
Pain – new/worsening; Participates less in activities
Ate less
No bowel movement in 3 days or diarrhea
Drank less
Weight change
Agitated or nervous more than usual
Tired, weak, confused, drowsy
Change in skin color or condition
Help with walking, transferring, toileting more than usual
September 12, 2019

14. SBAR
Situation
Background
Assessment
Request
September 12, 2019

15. Increasing Communication, Collaboration of Care, & Interprofessional Team Inclusion
Increase communication with family
Plan of care
Facility capabilities
Frequent updates
Advance Care Planning
Code Status/POLST
Goals of care
Hospice
Communication of treatment plan to nursing/walking rounds
Sign off to on-call
Family – discuss current condition, prognosis, expected response, complications
Send nursing home capabilities & stop sign tool
September 12, 2019

16. Increasing Communication, Collaboration of Care, & Interprofessional Team Inclusion
72 hour meeting to discuss goals, introduction of provider staff & roles.
Provider/nursing staff communication with specialists, CADs, navigation team.
Communication with medical team and ED staff if transfer occurs.
Transition team follow up for discharged patients.
Communication with PCP.
September 12, 2019

17. Analyzing 30 day Rehospitalizations
Monthly reports – 30 day rehospitalization
Weekly meetings to discuss cases.
Avoidable or unavoidable
What can we learn?
Quality Assurance & Performance Improvement (QAPI)
“Hindsight is one of our best tools for improvement.”
September 12, 2019

18. 30 Day Rehospitalizations as a % of Total Admits from Hospitals
Year
1stQ
2ndQ
3rdQ
4thQ
Final
2017
18.5%
12.3%
15.7%
10.9%
14.4%
2018
14.5%
12.6%
5.6%
24% reduction from 2017 to 2018

19. QUESTIONS?
September 12, 2019

20. References: Centers for Medicare & Medicaid Services
Jencks, S, Williams, M, & Coleman, E. (2009) Rehospitalizations among Patients in the Medicare Fee-for-Service Program. Retrieved from
Successfully Reducing Hospitalizations of Nursing Home Residents: Results of the Missouri Quality Initiative. JAMDA 18 (2017)
Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Educing Unnecessary Hospitalizations. JAMDA 17 (2016)
September 12, 2019