1. REDUCING HOSPITAL READMISSIONS: KEYS TO QUALITY CARE Casey King, LNHA Dana Andrews, MD MHSA Tammy Mejia, RN DON CWCA Winchester Terrace Skilled Nursing and Rehabilitation Center

2. Speaker Disclosures: Dr. Dana Andrews, Casey King, BA,BS,MA,LNHA and Tammy Mejia, RN, DON, CWCA have disclosed that they have no relevant financial relationship(s).

3. Learning Objectives: By the end of the session, participants will be able to: Understand the impact hospital readmissions have on the referring hospital, long-term care facility and the patient Identify the tools and methods necessary to implement a program to reduce rehospitalizations Implement a process that will:  Maintain continuity of care during acute illnesses  Deliver quality care within the skilled nursing facility  Reduce hospital readmissions from skilled nursing facility

4. Did You Know ????? 1  One in four Medicare patients are readmitted to hospital from skilled nursing facility within 30 days  Up to 2/3 of hospital transfers are avoidable  Medicare is planning financial incentives to reduce potentially avoidable hospital transfers through  pay for performance  bundled payments  1 Information provided by INTERACT II

5. Hospitals will face penalties for patients who are readmitted for : acute myocardial infarction, heart failure pneumonia starting in the fiscal year 2013 and the list will be expanded in 2015 CMS to Enforce PenaltiesCMS to Enforce Penalties

6. Rehospitalizations Negative Impact Nursing Facilities Loss of continuity of care for resident Loss in revenue to facility Ultimate loss in referral source if readmission rate unacceptably high Loss of confidence by residents, families and physicians

7. Data Comparison and BenchmarkingData Comparison and Benchmarking National Average for hospital readmissions 19.8% National Averages for readmission on CMS targeted diagnoses  CHF 24.8%  Pneumonia 18.4%  Acute myocardial infarction 19.8%

8. Facility GoalFacility Goal Reduce rehospitalizations of skilled residents from current 2009 rate of 30.5 % to less than 15% Improve relationships with local hospital Increase communication between nurse and physician Facilitate customer satisfaction

9. Causal Factors IdentifiedCausal Factors Identified Inadequate nursing assessments Poor communication skills between nurse and physician Lack of physician confidence in staff providing care/treatment within the facility

10. Keys for Process Improvement Keys for Process Improvement Development of a program that would provide nursing with an easy to use system that flows from one process to the next with focus on:  Nursing Assessment  Early identification of acute changes in condition  Communication of acute changes by staff to nursing  Effective communication of clinical picture to physician

11. Research and ResourcesResearch and Resources INTERACT II http://interact2.net http://interact2.net Provides tools useful in management of acute changes in resident conditions The SBAR communication tool Clinical Care Paths Acute Care Transfer Log Quality Improvement tool for review of acute care transfers

12. Research and ResourcesResearch and Resources  AMDA http://www.amda.com/http://www.amda.com/ Protocols for Physician Notification- Assessing and Collecting Data on Nursing Facility Patients Clinical Practice Guidelines  Heart Failure  Common Infections in Long-Term Care setting  Acute Change of Condition in Long-Term Care setting

13. The SBAR Cues the nurse to evaluate body systems, symptoms and collecting data physician needs when ordering treatment plan. Enhances confidence in nurse/physician relationship Used each time a condition change recognized Guides the implementation of appropriate care path Assists nurse in making requests of physician for additional testing/medication changes Streamlines documentation-serves as nursing documentation and physician/family notification

15. Clinical Care Paths Development of care path topics were based on:  Those conditions that were identified as significant reasons for readmission to hospital  Those conditions CMS would target for rehospitalization penalty

16. Clinical Care Paths Improves nurses’ capability to assess signs and symptoms Prompts the actions to take related to clinical data collected Denotes problem, interventions and goal- serving as an episodic plan of care for nursing

17. Clinical Care Paths Urinary Tract Infection Congestive Heart Failure Respiratory Infection Altered Mental Status Fever Dehydration-potential

19. Education and TrainingEducation and Training Emphasized the effect the process will have on quality care and customer satisfaction How and when to use the SBAR Implementation and use of care paths Scenario training and case reviews of SBAR and care paths

20. Unlocking the Success Unlocking the Success 2009 - 30.5 % of skilled residents were readmitted to the hospital within 30 days of admission 2010 - 13.48% of skilled residents were readmitted to hospital within 30 days of admission 2011- 10.6% of skilled residents were readmitted to hospital within 30 days of admission

21. Unlocking the Success Unlocking the Success

22. Conclusions Maintained continuity of care during acute illness episodes Delivery of quality care to our residents Solidified relationships with attending physicians Gave nurses tools/methods to confidently care for our residents Reduction of hospital readmissions to less than 11% for skilled residents

23. Questions??? Casey@leveringmanagement.com Tammy@leveringmanagement.com Winchester Terrace Skilled Nursing and Rehabilitation Center 70 Winchester Rd Mansfield Ohio 44907 419-756-4747