Download Agnesian HealthCare

Transforming the Delivery of Care:
Using Patient Navigators in the Inpatient
Health Care Setting
Agnesian HealthCare
Non-profit, Catholic based healthcare system established in 1896
Fond Du Lac / Dodge County
160 Bed Hospital – Fond Du Lac, WI
25 Bed Critical Access Hospital – Ripon, WI
25 Bed Critical Access Hospital – Waupun, WI
Regional Clinics
Pharmacies
Home Health / Hospice
SNF / Assisted Living
HME
1
The Present State of Health Care
Silos of care with lack of coordination
Conflicting Recommendations
Confusing medication regimens
Incorrect medication lists
Lack of follow up care
Inadequate patient/caregiver preparation
Increased use of hospital and ED services
The Future State of Health Care
Accountable Care Organizations
Bundled payment structure
Increasing risk for readmission penalty
Consumer demand / expectations
2
Organizational Evaluation
Determined present gaps in transition
Completed SWOT analysis of care transition
Identified foundational model of program
Determined budgetary guidelines
Linked with strategic plan
The Focus of Care Transitions
Increase patient participation in health care
Improve medication self-management
Create a patient-centered record
Ensure primary / specialty care follow-up
Ensure understanding of disease management
Based on TCM (Transitional Care Model) - Coleman
3
Expected Outcomes
Decrease in rehospitalization
Decrease in ED use
Decreased length of stay
Improved utilization of resources
Improved quality of life
Improved patient satisfaction
Improved engagement
Focus Populations
Pneumonia
Heart Failure /
Cardiac
COPD
Cancer
Polypharmacy
Socioeconomic
4
Care Transitions Structure
ED
Navigator
Palliative
Navigator
Oncology
Navigator
General
Navigator
Cardiac
Navigator
Navigator Role
Reviews chart and interacts with multidisciplinary team
Completes initial assessment
Confers with physician
Develops goals
Develops plan of care including planned encounters
In-hospital encounters dependent on LOS and level of
need
Continues relationship post-discharge
5
Navigator Role - Continued
Post-Discharge Interaction
Target First Interaction within 48 hours discharge
More rapid response based on risk
Potentially time consuming – largely based on medications
95% interactions are by phone
Establish frequency based on need
Refer in additional resources as needed
Navigator Relationships
Community
Resources
Nursing
Home
Hospice /
Palliative
Clinic
Navigator
Program
Home
Care
ED
Hospital
6
Referral Process
Cerner Referral
Phone / Fax Referral
Direct Referral
No order required at present – referrals are
encouraged from various disciplines
Outcomes
Utilization
Readmission
Impact on Patient
Quality Improvement
7
Outcomes
Utilization
Capture
of 70% cardiac and respiratory admissions
Improved collaboration with care management, home
health, palliative
Establishment of 100% referral for lung cancer
Significant utilization within ED environment
Outcomes
Readmission
Readmit Rate – MDC 4
30.0%
25.0%
20.0%
15.0%
10.0%
Readmit Rate
Linear (Readmit Rate)
5.0%
0.0%
8
Outcomes
Readmission
5 South Reutilization
25%
20%
15%
Inpatient 30 Day %
OM 30 day %
10%
5%
ED 30 Day %
Linear (OM 30 day %)
Linear (ED 30 Day %)
0%
Outcomes
Impact on Patient
A patient with fragile state HF had 3 hospital stays within a 40 day period.
Care navigator involvement resulted in improved adherence to medication
and diet
Noted significant improvement in patient insight into disease process and
how his actions affected his health state.
Patient had no subsequent readmissions within a two month period.
He failed in his adherence regimen over Thanksgiving but demonstrated
greater insight into self-management by quickly obtaining medical services
based on symptoms rather than waiting as he had done previously. This
change in behavior resulted in a short ED visit rather than an outpatient or
inpatient hospital stay.
9
Outcomes
Impact on Patient
Patient with fractured upper humerus.
First call made after hospitalization found patient to be in pain and having
difficulty with ADL’s.
Daughter-in-law verbalized feeling stressed assisting her and unable to
leave patient alone.
Home care services initiated.
Homecare informed Care Navigator at time of their discharge.
Subsequent phone calls to patient to assess and assisted her with finding
resources for in-home housekeeping services.
Patient verbalized appreciation for follow-up.
Outcomes
Impact on Patient
Elderly male patient (very grumpy and resistant) with dx small bowel
obstruction with hx of diabetes, COPD stage 3, HTN, CHF, obesity.
He is on 18 scheduled medications. Agreed to reconciling meds with
navigator over phone.
Carvedilol was on his discharge list as a “medication with no changes” and
he was receiving it while in the hospital.
He stated he did not have this med & didn’t know anything about it. MD
note from almost 2 months ago stated he started pt. on this med.
Navigator contacted MD office and ensured patient received medication
10
Outcomes
Impact on Patient
49 y/o male with history of alcoholism.
- 19 ED visits, 11 Observation bed stays, 6 IP admissions – including
several ICU admissions.
Private Pay. No treatment options. Labeled as untreatable.
ED Navigator became involved this fall. Kept him out of the ED for 42 days,
then cut through barriers to get vivitrol ordered. Patient restarted day
treatment.
Subsequent failure resulted in increased use of ED and one inpatient stay.
POC developed to limit treatment, treat in ED only, and prescribe no pain
medications.
Has been seen once in the ED in the past three months.
Outcomes
Quality Improvement
Navigators generate significant volume of event reports
Close interaction with Peer Review arm of QI
Identify trending barriers impacting discharge
Findings used to educate nursing regarding discharge planning
and education
Role model for goal setting within home health
11
Expansion
Focus referrals with cardiac / respiratory dx.
Work closely with care management at Critical
Access facilities to identify risk patients
Increased access of ED navigator to Critical
Access through phone consultation
Future State
CPT code reimbursement for TCM services
Requires
close interaction and supervision by
provider
Requirements for interaction timeline, components
reviewed, and patient complexity
Community coalition involvement
Metastar
supported initiative
Involvement of community providers
12
Essential Components
Complete needs assessment
Determine population target
Identify AIM statement / milestones
Identify model
Determine resources available / needed
Implement pilot
Questions?
13