Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
REDUCING READMISSIONS St. Luke’s Hospital Case Study Cedar Rapids, IA IHI National Forum Orlando Florida December 9, 2013 ST. LUKE’S HOSPITAL MEMBER, UNITYPOINT HEALTH Private hospital – Cedar Rapids, Iowa Affiliate in the UnityPoint Health system Licensed for 500 Beds with more than 17,000 admissions Truven Top 100 Hospital – 5 years (2013); Heart Hospital 3 years (2012) Iowa Recognition for Performance Excellence Gold Award - 2010 Magnet Designation – 2009 The Joint Commission DiseaseSpecific Certification in Advanced Heart Failure, Stroke, Palliative Care and Total Joint. Society of Chest Pain Center – Chest Pain Certification Gold Award from Get with Guidelines for Heart Failure 2010-2013 WHY IS REDUCING AVOIDABLE REHOSPITALIZATIONS STRATEGIC FOR ST. LUKE’S HOSPITAL? It is part of our mission: “To give the healthcare we’d like our loved ones to receive” It represents goals that are aligned with healthcare reform: providing better value for decreased costs. Learning has been incorporated into our present work with development of population management and ACO work TRANSITION TO HOME TEAM MEMBERS CHAIR: Peg Bradke, VP-Post-Acute Care Sherrie Justice, Dir-PI Robinn Bardell, Mgr-Case Mgmt Carmen Kinrade, VP-Nursing Excellence Sarah Baumert, Mgr-5E Patty Koelker, PCC-5E Diane Pfeiler, PCC-3C Jennifer Mahoney, UPH Clinic - Northridge Alexis Benion, Living Center West Shirley McCloy, Resp Ther Dean Bleadorn, Mgr-RT Sandi McIntosh, Dir-ED Myrt Bowers, Assoc Exec Dir-Witwer Center Jennifer Owens, Med Soc Svcs Shelley Cahalan, Gen Mgr-VNA Julie Peterson, Mgr-Card Rehab Christy Charkowski, STL Hospitalists Karen Pierce, Data Analyst, PI Sara Claeys, Dietary Svcs Amrita Samra, MD - CRMEF Christina Djerf, Prog Coord-Lifeline Brandi Simmons, Living Center West Elizabeth Eichhorn, ARNP-Living Center West Amy Schweer, STL HF Clinic Marilinne Staub, UM Spec. Krissy Elder, PCC-5C Aimee Traugh, Mgr-3C Karen Forster, Pharm Sheila Tumility, Reg PI Proj Mgr Terri Grantham, APN-Card Outcomes Brook Van Dee, ARNP-OP Pall. Care Renee Grummer-Miller, OP Pall. Care Jean Westerbeck, Living Center West Barb Haeder, APN-Card Outcomes Pam Williams, JRMC Resp Care Sue Halter, ARNP-STL HF Clinic Sharon Zimmerman, Resp Care Signe Henderson, Coord-Home Care Amrita Samra, MD, CRMEF Dr. Todd Langager, Cardiology Medical Director VOICE OF THE CUSTOMER Feedback from Chronic Disease Management class Patient and family members on our PatientFamily Advisory Council Feedback from follow-up phone calls Feedback from Cardiopulmonary Rehab participants Feedback from High-Risk Clinic Patients CROSS-CONTINUUM TEAM Meets monthly Reviews readmissions for each month related to core diagnosis to assess causes and opportunities for improvement Reviews process and outcome measures Continually testing and improving, aggregating the experiences of patients, families and caregivers Each facility reports in testing occurring in their area SEVERAL SUBGROUPS REPORT INTO THE LARGER TRANSITION TO HOME TEAM Data Management Patient Education processes Home Care SNF/Nursing Facilities work processes Physician Clinic processes Case Management/Social Work/Care Coordination Several members of the Transition to Home team are members of the hospital ACO and Population Health Management work. Information is bidirectional between these teams. Continuum of Care Process Standardized care through order sets. Use of the clinical indicator sheet as a checklist for evidence-based care being met. Report developed to identified key core measure patients – (e.g. BNP, Troponin etc) Teaching: • Utilizing Universal Health Literacy Concepts • Enhanced teaching materials • Teach back Utilization of whiteboard to individualize patient’s plan of care and communicate to team. Continuum of Care (2) Bedside report to involve patient and family caregivers as partners in care. Daily huddles are facilitated with the patient care nurse, charge nurse, and care coordinator. Daily goals are reviewed providing opportunity to review plan for the day, available support for patient, discharge goals, and determine what it will take to get the patient home safely. Assessment of palliative care referral is part of discussion. Standardized Disease specific on-line discharge instructions. Continuum of Care (3) Touch points post discharge: Home Care - care coordination visit 24 to 48 hours post discharge on high risk patients Physician Clinic follow up appointment made prior to discharge for 3-7 days after returning home Follow-up phone call set up based on post discharge needs at 5-9 days Standardized tool for transfer of information to nursing facilities for next level of care . Telehealth monitor available through Home Care Chronic Disease Management Program for patients In addition staff participate in Integrated Chronic Disease Management class ENHANCED ADMISSION ASSESSMENT During Admission Assessment, the patient and family are asked, “Who would you like to have present when we provide your discharge information?” Information added to the whiteboard RN and physician do medication reconciliation Concentrated effort for Admission. Dedicated Admission Center RN’s complete home medication list and prepare an appropriate list for physician to address. At times, the pharmacy or physician offices need to be called to get additional information. If the patient is a home care patient, the home care agency is called to get the current list of medications ENHANCED ADMISSION ASSESSMENT (2) Referral to Palliative Care for patient with advanced stages of disease - the referrals have consistently increased. Team rounds daily on units Bedside report to involve the patient and family caregivers as partners in their care. Daily discharge huddle is facilitated daily with the RN caring for the patient, the charge nurse, and unit-based case manager Take 5 completed on patient at start of shift. Daily goals are reviewed and written on the whiteboards in each room, providing the opportunity to review the plan for the day, anticipate discharge needs, and determine what it will take to get the patient home safely Interview Questions For patients that are readmitted within 30 days of last admission: Can you tell me in your own words why you think you ended up sick enough to be readmitted again? Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night? Have you seen your doctor since you were discharged from the hospital? Do you have all of your medications? How do you set up your pills every day? Were there any appointments that kept you from taking any of your pills? PARADIGM SHIFT “The patient is noncompliant.” vs. Asking, “What is our responsibility as the sender of the information?” ENHANCED TEACHING AND LEARNING The patient education materials facilitate the use of Teach Back, and the same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinic. Short, succinct material developed for each Core Measure DRG. Teach Back question part of packet for staff and patient reference. Patient teaching flowsheets set up to address Teach Back and assure the documentation and use of Teachback. TEACH BACK WITH DISCHARGE INSTRUCTIONS Can you show me on these instructions: How you find your doctors’ office appointment? What other tests you have scheduled and when? Is there anything on these instructions that could be difficult for you to do? Have we missed anything? Who will you call if you have questions? ENHANCE TEACHING AND FACILITATE LEARNING Use Teach Back: In the hospital During home visits and follow-up phone calls To assess the patient’s and family caregiver’s understanding of discharge instructions and ability to do self-care Building Teach Back into our work Session in Nursing Orientation Session in Nursing Residency Program Net Learning module, competency validation, and in-house prepared instructional DVD with Teach Back demonstration Closing staff meetings, walking the talk Staffs participate in Chronic Disease Management HEART FAILURE MAGNET LOW SODIUM EATING PLAN BROCHURE Cover page Back page LOW SODIUM EATING PLAN BROCHURE LOW SODIUM EATING PLAN BROCHURE LOW SODIUM EATING PLAN BROCHURE Heart Failure Workshop Saturdays 9:00 a.m. to Noon St. Luke’s Hospital Nassif Heart Center Third Floor This workshop is taught by a registered nurse and registered dietitian. You will learn about: ♥ Causes of heart failure ♥ Activity and exercise ♥ Low Sodium eating plan ♥ Guidelines for dining out ♥ Reading food labels ♥ Medications ♥ Living with heart failure There will be displays of health information to look at and a packet of heart failure information for you to take home. This is an excellent program for people who have had heart failure or have a heart problem that puts you at risk for heart failure. Learning more about your heart failure is essential in controlling your heart failure symptoms and preventing problems. Family members and caregivers are encouraged to attend also. This program is FREE No registration necessary Walk-ins welcome! To learn more, call St. Luke’s Heart Care Services (319) 369-7736 28 Where To Start? Go to the Unresolved Education Tab Select the topic you educated on Begin charting on the right side of the screen What you taught on Additional comments DISCHARGE ASSESSMENT - SMART TEXT POST-ACUTE CARE FOLLOW-UP Home Care Visit set up for 24-48 hours after discharge. Home Care liaison in-house. Teach Back questions part of visit . Partnership with physicians’ offices resulted in redesign of scheduling follow-7p visits to allow office visits within seven days for patients. Appointments are scheduled prior to discharge and noted on discharge instructions. Advanced Medical Team Pilot in Pulmonology Clinic with High Risk/High Resource patients. Consistent Care Plan Program in Emergency Dept. 3W TEST OF CHANGE EMERGENCY DEPARTMENT CONSISTENT CARE PLAN Consistent Care Program (EDCCP) for patients who had visited the ED 12 or more times in the previous 12 months. 103 Care Plans were developed, mailed, and implemented. Care Plans are a communication tool that provide data specific to that patient’s medical history and current medical needs, along with Goals of Care for when patients present in the Emergency Dept. Using care plans and with intervention by a social work case manager, there has been a reduction in patient’s Emergency Department use. CONSISTENT CARE PROGRAM REAL-TIME HANDOVER COMMUNICATIONS Medication Reconciliation is a joint physician and nurse accountability. Patients going home are offered a care coordination visit with Home Care in the first 24-48 hours after discharge. The home care does a certified content visit including medication reconciliation and determines eligibility. St. Luke’s partnered with the hospital’s home care agency (VNA) and two long-term care facilities to standardize and enhance the quality of the handoff communication process. A new interagency transfer form is now used. Warm handover with those patients with complex issues. Provided education for home care and long-term and skilled care RNs and CNAs on HF, MI and Pneumonia and continuity processes. Base Event Discharge Disposition Housewide Acute Inpatient Readmissions wi 30 Days Jul 2012 - Jun 2013 Psych Hospital, 26, 2.1% Other Institution, 2, 0.2% LTAC, 6, 0.5% Home, 718, 58.6% Rehab, 20, 1.6% MC Swing , 12, 1.0% Hospice Facility, 8, 0.7% Hospice Home, 11, 0.9% Court, 1, 0.1% Home Care, 200, 16.3% ICF, 27, 2.2% SNF, 195, 15.9% Readmit Admit Source Housewide Acute Inpatient Readmissions wi 30 Days Jul 2012- Jun 2013 One Distinct Unit to Another, 30, 2.4% Hospice Facility, 5, 0.4% SLH, 0, 0.0% Court/Law, 6, 0.5% Non-Acute Health Care Facility, 0, 0.0% Skilled/ICF, 72, 5.9% Different Hospital, 23, 1.9% Home & Clinic, 1,092, 88.9% Histogram of Days Between Admissions (with Outlier removed) Normal Mean 10.36 StDev 8.389 N 56 12 Frequency 10 8 6 4 2 0 -6 -3 0 3 6 9 12 15 18 21 24 Number of Days Between Admissions 27 30 Histogram of Days between Initial Discharge Date and Readmission Date Heart Failure as Initial Admission • Incomplete medical management • Wrong site of post- acute care • Socio-economic factors • Physician follow-up • Med problems 7 • Patient compliance with regime • Disease trajectory 14 30 Mean StDev N 12 11 10 Frequency 9 8 7 6 5 4 3 2 1 0 -6 0 6 12 18 Days between 24 30 36 15.10 8.773 49 HCAHPS RESULTS DISCHARGE INFORMATION (% YES) 90 89 88 87 84 82 88 87 86 84 82 GOOD 84 82 80 78 2009 2010 St. Luke's 2011 Jan-Sep 2012 National The following questions make up this composite measure: #19 – During hospital stay, did doctors, nurses or other hospital staff talk about whether you would have the help you needed when you left the hospital? #20 - During hospital stay, did you get the information in writing about what symptoms or health problems to look out for after you left the hospital? Prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI) http://www.mitre.org/work/health/news/bundled_payments/St_Lukes_Case_Study.pd CRITICAL CAPABILITIES FOR CARE REDESIGN INCLUDE: Cross-continuum participation and alignment The development and use of standardized tools and compatible information infrastructure Horizontal leaderships and executive sponsorship and engaged physicians Effective external and internal learning 47 LESSONS LEARNED Importance of engaged executive leaders and physicians. Patients and families help transform care in profound ways. The patient and family home environment must be understood. Involving front-line staff in the changes helps them understand why they are important and grows ownership by engaging them in redesign. The power of relationship building and collaboration of the cross-continuum team builds new ideas to work and removes many of the “silos’ in the care. LESSONS LEARNED (CONT) The role of Information Technology in the process should be addressed simultaneously with the work. Ongoing monitoring of Process and Outcome Measures is important to hardwiring best practices. Using patient stories unleashes energy and participation that becomes evident in process and outcome results. QUESTIONS: Peg Bradke RN, MA Vice President, Post Acute Care Services UnityPoint Health St. Luke’s Cedar Rapids, IA [email protected]