Download Optimizing Transitions of Care: Redesigning nursing roles

Optimizing Transitions of Care:
Redesigning Nursing Roles to Improve
Quality and Reduce Cost
Suneela Nayak, MS, RN,
Clinical Quality Improvement Specialist,
Center for Quality and Safety
David Bachman, MD
Senior Medical Director, Clinical Integration
Learning Points
• Preventable Readmissions in the context
of Transitions of Care
• Why now? Where to Start?
• MaineHealth Transitions of Care Program
• Leading with Innovation: Redesigning
Roles, Competencies
Case Study : Mr. S
• 76 year old male, living independently,
limited social supports
• Past Medical History
– Congestive heart failure
– 6 routine medications including Coumadin
• Admitted for evaluation of syncopal
episode
Mr. S: Hospital Course
• Cardiac monitoring and diagnostic testing
• Developed urinary retention
– Urology consultation
– Urologic procedure performed
• Discharged on Coumadin, new antibiotic,
with urinary catheter
Mr. S: One week later
• Developed hematuria, urinary retention
• ED Visit
– Dramatic hematuria with catheter obstruction
– INR 9.6 (ideal range 2 –3)
– More urological intervention
• Readmitted
– Reversal of anticoagulation
• Transfused 6 units of blood
Questions to Consider
• Was this readmission predictable?
• Was this readmission preventable?
• What went wrong with the transitions of
care?
• How can we do better?
Why now?
2007 MedPac Report
• Medicare Payment Advisory Committee
• Readmissions
– “sometimes indicators of poor care or missed
opportunities to better coordinate care”
– 17.6% of Medicare patients readmitted within 30 days
– $15 billion in annual spending
– 76% of readmissions potentially avoidable
• Recommended public reporting, payment reform
Rates of Rehospitalization within 30 Days after Hospital Discharge
Jencks S et al. N Engl J Med 2009;360:1418-1428
Health Care Reform: Hospitals
• Reduce reimbursement for hospitals with high
risk-adjusted rates of readmission by 1% a year
beginning in 2012 (up to 5% total)
– 2012 : CHF, pneumonia, AMI
– 2013: Add COPD, CABG, PTCA, Other vascular
procedures, potentially global readmission rate
• Reduce reimbursement to SNF, Home Health
when patient under their care readmitted
Health Care Reform: Physicians
• Create new payment code for patient visit
within one week of discharge
• Apply payment reductions for physicians
who treat a patient during an admission
that results in a readmission
Payment Reform: MaineCare
• Reimburse for only one hospitalization
when MaineCare patient readmitted to
same hospital within 72 hours for the same
diagnosis.
Why Now?
•
•
•
•
Frequent & costly
Issue of quality of care and patient safety
Source of patient & provider dissatisfaction
Waste increasingly scarce clinical
resources such as nursing care
• Integral to movement towards Accountable
Care Organizations
Where to start?
Lots of Data and Tools
at your fingertips
MaineHealth: Efforts to Date
Transitions of Care Pilots
• Supported by funding from the Cardinal
Health Foundation
• Three pilot sites selected from
MaineHealth hospitals
Transitions of Care Pilots
Key Outcomes

MaineHealth Transition of Care Bundle

Implications for Role Redesign
MaineHealth
Transitions of Care Bundle
1. Risk stratification for readmission
2. Transition Checklist
3. Medication reconciliation
4. Patient/family health education
5. Timely communication among hospital
and post-hospital providers
6.Timely follow-up of patients
Leading with Innovation:
What are implications for
Redesigning
Nursing Roles and
Competencies?
National Summit of Advancing Health Through
Nursing..
Key Messages from Institute of Medicine and the
Robert Wood Johnson Foundation
 Nurses should practice to the full extent of their education
and training.
 Nurses should be full partners with physicians and other
professionals in redesigning health care
Washington DC, October 2010
Focus on Reduced Readmissions
Findings from MaineHealth Pilots:
1.
2.
3.
4.
Advocacy for patient’s agenda for care
Focus on safety, improved outcomes
Fully engage clinical skills, scope of practice
Develop ability to network across continuum
…Offers Abundant Opportunities for Clinicians,
Educators, & Leaders to Redesign Roles
and Competencies
Roles and Competencies
Key Roles
Clinicians
1. Advocacy for

patient’s
agenda for care
2. Focus on safety,
improved
outcomes

Skilled Patient
Centered Care
Practices
Skilled
Hand-Off
Communication
all levels of care
Educators
Leaders
Instill:
 Patient/ Family as
central members
of the care team
Innovate for
improved
outcomes and
reduced costs

Sustain an
environment of
knowledge sharing
(translate
knowledge from
individual to
system)
Comfort with
transparent
Communication
•Facilitate knowledge exchange between providers (Teach back)
•Sustain the gain through visible engaged leadership.
Roles and Competencies
Key Roles
3. Fully
engage
clinical
skills,
scope of
practice
Clinicians
Educators
Leaders

Assessment skills &
related actions
 Assessment &
related actions
Operationalize
roles to optimize
practice and scope

Develop comfort with
“Teach back”

Knowledge access :
-continuum networks
-electronic media
 Focus on what is
learned; skilled
use of “teach
back”
Sustain the gain
through visible and
engaged continuum
leadership.
 Refine
networking
skills
Facilitate
knowledge
exchange across
continuum

Quality through
measured outcomes
Roles and Competencies
Key Roles
4. Develop ability
to network
across
continuum
Clinicians

Establish
networks with
-continuum
-payers
-patient groups

Develop
transition plans
that ensure right
care, at the right
level.

“Admit to home”
Educators
Leaders
Instill
Shape pressing
 Continuum
agenda of
Navigation skills reimbursement
reform
 Optimal use of
EMR to enhance -Lead early ACO
hand-offs
work
-Build and sustain
networks to
reduce
downstream
spending
Mr. S, revisited
Admitted for syncopal episode
Hospital Course:
- Cardiac evaluation
-
urologic procedure
Discharged on Coumadin, new antibiotic, with catheter
One week later:
- ED Visit - Dramatic hematuria, obstruction
- INR = 9.6
- Readmitted
- Reversal of anticoagulation
- 6 units of blood transfused
Mr S: Risk for Readmission (8P‘s)
• Prior hospitalization: in last 6 months
Problem medications: anticoagulants
Polypharmacy: > 5 routine medications
Principal diagnosis: heart failure
• Psychological: PHQ2 screen
• Poor health literacy: unable to Teach Back
Patient support: lives alone
• Palliative care: advanced illness
Case Study:
The New Post Hospital Scenario
• Home support services
– Monitoring of
anticoagulant status
* No ED visit
* No readmission
• Follow-up phone call
* Decreased morbidity
• Office visit within 5 to 7
days
* Decreased cost
* Increased patient
satisfaction
Summary
Focus on Reduced Readmissions offers Abundant
Opportunities for Nurse Educators, Clinicians
and Leaders
Innovative redesign of roles, competencies to
- Improve clinical outcomes, quality,
satisfaction
- reduce cost
Questions?
Thank-you!