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Heart Failure Order Sets Standardizing Care for the Heart Failure Patient 2012 Objectives: Standardize care for all heart failure patients in Legacy Base Practice on American Heart Association Guidelines and Best Practice Improve the Continuum of Care for CHF patients Decrease length of stay and readmissions associated with HF March 19, 2013 LEGACY HEALTH 2 Co-Management Agreement Focus Areas Legacy Cardiovascular Service Line across system Designate “Pillars” of cardiac care: Heart Failure, Rhythms, Coronary Disease, and “General” Cardiology for initial agreement Heart Failure Pillar mandate crosses through all aspects of Legacy care > > > > ED Hospital Course Discharge Outpatient What is Wrong With the Status Quo For CHF in-patients: > 29% readmission rate within 30 days For CHF out-patients: > Inadequate dosing of life saving drugs ACE Inhibitors Beta Blockers Why CHF Pillar Heart failure is the most common hospital admission diagnosis in patients age 65 or older Accounts for more than 700,000 hospitalizations among Medicare beneficiaries every year Associated with severe functional impairments and high rates of mortality and morbidity CMS target for quality initiatives and Core Measures Legacy Medicare Vulnerability/Opportunity FY10 EMC $51,401,110 FY11 EMC $54,988,087 FY10 GS $70,777,895 FY11 GS $70,521,181 FY10 MP $33,419,171 FY11 MP $34,779,386 FY10 MH $17,775,619 FY11 MH $17,574,637 FY10 SC $39,315,706 FY11 SC $40,494,024 FY10 Total $212,689,501 FY11 Total $218,357,315 $2,000,000-$6,000,000 Vulnerability plus Opportunity for Bonus From CHF readmissions Why do CHF Programs work? They rescue the most vulnerable > recently hospitalized patients > Chronic NYHA Class 4 patients They titrate life saving drugs to full doses > Some CHF patients are not on life prolonging drugs at all > Of those who are, most are not on doses shown to provide the life saving benefit Heart Failure Pillar Performance Measures • Heart Failure Readmission Rate • Heart Failure Appropriate Care Score • Development of and Compliance with System-wide, Quality-driven Multidisciplinary Pathway “Intake” Scope • Determine disposition • Medication List • Medication Reconciliation • Collection of baseline data • Risk stratification / Risk assessment • Initiate HF education process “Hospital Stay” Scope • Multidisciplinary Rounds • Medication reconciliation • Continuing education • Discharge planning / organization of post d/c services • Accurate documentation / core measures • HF treatment per pathway • Cardiac rehab referral • Treatment goals per HFSA/ACC/AHA guideline • Evaluate specialist consultation/ referral “Discharge” Scope • Discharge Criteria per HFSA/ACC/AHA guideline / readiness for discharge • Medication reconciliation • HF discharge instructions w pt and family/ teach-back • Documented d/c summary • Ensure follow up scheduled within 7 days • Discharge checklist / Risk Assessment • Scale, blood pressure machine, etc. • PASS • Provider notification of d/c “Post-D/C” Scope • Follow-up phone call • Home visit • PCP/Cardiologist/HF Clinic visit • Home tele-monitoring • SNF/Home Health coordination • Disease Mgt / Case Management • Communication/Tracking/ Analysis of re-admissions Team Members Team Members Team Members Team Members • Cardiologist • Cardiologist • Cardiologist • Cardiologist • ED physician • Hospitalist • Hospitalist • Primary Care • Hospitalist • Inpatient Nurse / Nurse Mgr • Inpatient Nurse / Nurse Mgr • ED Nurse • Cardiac Rehab Nurse • Cardiac Rehab Nurse • Nurse / HF Coordinator/ Home Health/ Hospice • ED Manager • Care Management • Care Management • Inpatient Nurse • Quality / Documentation Specialist •Pharmacy • Care Management • Care Management/quality metrics management •IT input •Pharmacy •Pharmacy ED Visit Admission Who? Ownership & Accountability Hospital Stay Discharge What? Ambulatory F/U; Post-discharge Process, not people LEGACY HEALTH Identifying Patients early in the ED If ED RNs note signs and symptoms of dyspnea, orthopnea, edema, weight gain, or history of HF an advisory will alert the use of the “ED Protocol for Heart Failure” with a decision tree 3/19/2013 LEGACY HEALTH 11 HF patients who are discharged from the ED Standard HF teaching instructions are given and reinforced. HF Education from Exit Care 3/19/2013 LEGACY HEALTH 12 Proper Identification if Heart Failure Patients HF Nurses/Case Mangers will run a workbench report each day for “HF Admitted Patients” 3/19/2013 LEGACY HEALTH 13 Order Set In Epic The “IP adult Heart Failure Order Sets” are in Epic and are based on AHA guidelines and best practice. Use of these order sets are essential to the success of the pathway 3/19/2013 LEGACY HEALTH 14 LEGACY HEALTH Multidisciplinary Rounds Multidisciplinary Rounds is alive at most sites and on the units where HF patients are concentrated HF Nurses/Case managers will identify high risk patients during rounds and actively work with the team to develop discharge plan including: > > > > 3/19/2013 discharge medications transportation home follow up clinic appointments (coag clinic, PCP) Teaching including documentation LEGACY HEALTH 16 Daily Weights Standardize process for daily weights Document time, charting location Incorporate and document teach back Utilize “Daily Weight Diary” with patient involved in an active roll in daily weight management 3/19/2013 LEGACY HEALTH 17 Discharge Instructions with Teach Back Standardization still in process System-wide form utilization will be based on community standard and reviewed by health literacy experts 3/19/2013 LEGACY HEALTH 18 Teach-back Prompts I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine? We covered a lot today about your heart failure and I want to make sure that I explained things clearly. What are three things you can do that will help you control your heart failure? What are you going to do when you get home? I shared a lot of information today. Could you share with me what you heard? Can you show me how you are going to weigh yourself when you get home? What questions do you have? LEGACY HEALTH HF Basic Teach Back Questions What food are you to avoid? Name some salty foods you should not eat? How often should you weigh yourself? What time of day are you going to weight? What weight gain will your report to your care provider? How are you going to remember to take your medications? What pill/pills are you taking for your heart? What warning sign would prompt (cause) you to call the care provider? Which provider would you call? LEGACY HEALTH Core Measure Documentation Physicians will use the IP Medicine Discharge summary template the core measure check list is embedded in that template and must be used to ensure 100% compliance with core measure documentation 3/19/2013 LEGACY HEALTH 21 Heart Failure Discharge Guidelines-WORK IN PROGRESS (post Epic Upgrade) Discharge expected today if clinically stable last 24 hours Labs: Discharge BNP is less than admit BNP (BNP decrease of at least 30%) BUN/CR trending down Electrolytes stable or improved Respiratory status O2 sat > 92% or baseline. > Home oxygen therapy arranged as needed. Activity tolerance- documented O2 saturation with activity. > Activity level back to baseline Ambulation prior to discharge to assess functional capacity Optimal Fluid status achieved > Below baseline weight, if known. Aim net negative volume status if admission for volume overload. > Discharge weight less than admit weight. Pharmaceutical therapy near optimal> On oral medications for 24 hours; and stable for 24 hours. > No IV vasodilators or inotropes for 24 hours VS stable T< 99.4 po ( 37.4 C ) > absence of orthostatic hypotension Heart rate 50-100/min or baseline Reminder: patient may meet these criteria but have different major diagnosis supporting continued IP stay. 3/19/2013 LEGACY HEALTH 22 Post Discharge Follow-Up Appointments All High Risk HF patients will have follow-up appointments made before discharge Each site will identify the appropriate person and work flow. 3/19/2013 LEGACY HEALTH 23 Follow up phone calls-post discharge A follow up phone call will be made within 7 days post discharge. Documentation will be in a common place under ”doc flow sheets, Heart Failure Follow up” This will allow all clinicians, both out patient and inpatient to see note. 3/19/2013 LEGACY HEALTH 24 Alert to Epic in-box for HF readmissions When patients are re-admitted with Heart Failure diagnosis an alert will be sent to the Epic in-box of designated case managers/HF Nurse Coordinator All patients with readmission alerts will be seen by case managers/HF patients with in 24 hours of alert and discharge plan reviewed for possible “misses” Care conferences will be planned for patient who have been readmitted 3/19/2013 LEGACY HEALTH 25 Readmission chart review Each readmission “fall out” will be reviewed by the respective hospital committee A common process will be used and opportunities for improvement will be identified (form to be developed) HF Pillar Medical Director will follow up on care issues 3/19/2013 LEGACY HEALTH 26 HF Nurses at each site EH-Laura Wheeler, Lynn Holter GS-Robin Klotz SC-Sue Frederick MP-Sue Willeson MH-Jill Sager, Bernadette Hoover and Brenda Grossnickle 3/19/2013 LEGACY HEALTH 27 HF Volumes ‐ 12 month rolling averages 1050 1053 1079 1021 1014 1074 1036 1077 1144 1140 1097 1135 1208 1171 1168 LEH LGS LMP LMH Au g‐ 1 2 ‐1 2 J ul ‐1 2 J un 2 y ‐1 r ‐1 2 Ma Ma Ap r‐ 1 2 2 b‐ 1 Fe ‐1 2 J an De c ‐1 1 1 No v ‐1 1 t ‐1 Oc Se p‐ 1 1 1 g‐ 1 Au ‐1 1 J ul ‐1 1 J un Ma y ‐1 1 1200 1000 800 600 400 200 0 LSC LEGACY HEALTH HF Compliance, all measures/all sites 100 90 94 93 92 92 99 98 98 97 97 95 94 99 99 99 100! 97 99 98 99 80 70 Feb‐11 Apr‐11 Jun‐11 Aug‐11 Oct‐11 Dec‐11 Feb‐12 Apr‐12 Jun‐12 Aug‐12 LEGACY HEALTH HF Inpatient Measure Compliance, August 2012 Top 10% US Avg LH comp num den EH GS MP MH SC DC Instructions 100 93 96 80 83 100 98 94 93 100 LVF Assessment 100 98 100 95 95 100 100 100 100 100 ACE/ARB for LVSD 100 95 100 25 25 100 100 100 100 100 99 200 203 100 100 100 100 100 n= 39 52 44 15 53 Total fallouts 0 1 1 1 0 ACS (target 96.5) 100 96 96 86 100 n= 18 23 22 7 25 Overall compliance LEGACY HEALTH Legacy HF Pillar Dashboard US Avg readmit rate for Medicare pt population = 24.8% LEGACY HEALTH HF 30 Day Observed/Expected Readmission Rate ‐ Medicare Pts 1.40 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Aug‐11 Sep‐11 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 EH GS MP MH SC LH Linear (LH) LEGACY HEALTH 1.40 HF 30 Day Observed/Expected Readmission Rate ‐ All Pts 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Aug‐11 Sep‐11 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 EH GS MP MH SC LH Linear (LH) LEGACY HEALTH 10 HF Mortality: All patient populations EH N u m b e r o f H F D e at h s 9 8 GS 7 6 MP 5 MH 4 SC 3 LH 2 1 0 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 LEGACY HEALTH Next Steps Medical Executive Committee Approval JUNE/JULY Quality Council Approval/Presentation JUNE/JULY Nurse Exec Committee Approval of Education Plan JUNE/JULY Education plan for Physicians roll out AUG/SEPT Education plan for nursing staff roll out AUG/SEPT Epic Projects testing completed and Operational SEPT/OCT Baseline data for HF order set compliance-Clarity report SEPT Audit for HF order set compliance OCT/NOV Tracking Implementation % Utilization of Heart Failure Admission Order Set % Utilization of Heart Failure Discharge Order Set 30-day Readmission Rate If Order Sets Followed, 100% Core Measurements Will Be Reached Summary Physician and Nurse Education is planned for fall All Epic pieces to be complete by fall Heart Failure Pillar will continue to adjust pathway to meet American Heart Association guidelines as they are updated HF Nurses at each site will meet monthly for continuous process improvement Heart Failure Joint Commission Accreditation in 2013! 3/19/2013 LEGACY HEALTH 37 Any Questions? Lynn Pappas, Cardiovascular Service Line Director > 503-415-5715 Dr. Sandy Lewis, HF Pillar Medical Director > 503-229-7559 Desi Shubin, RN Manager > 503-413-7299 Mark Roady, CNS > 503-413-3345 LEGACY HEALTH LEGACY HEALTH Questions? LEGACY HEALTH LEGACY HEALTH LEGACY HEALTH