Hospital to Home to Primary Care Provider/Community Care: Achieving Effective Transitions through the New CCAC Rapid Response Nursing Program

Transcription

1 Hospital to Home to Primary Care Provider/Community Care: Achieving Effective Transitions through the New CCAC Rapid Response Nursing Program Janet McMullan, RN, BScN, MN, Client Services Specialist, Project Lead RRNP, OACCAC Dilys Haughton, RN(EC), BScN, PHC NP, GNC(C), MHSc, CHE Director, Client Services Operations, HNHB CCAC Outstanding care every person, every day OACCAC, June 21, 2013

2 Objective Agenda Learn about the new CCAC Rapid Response Nurse Program, designed to facilitate safe transitions for patients from acute care in the hospital to their homes and/or primary care provider and community supports. Agenda 1. Review Project Background and Evidence 2. Provide an Overview of Rapid Response Nurse Program 3. Consider Lessons Learned & Preliminary Performance Measurement from one CCAC 4. Highlight Key Learnings 2

3 Background Effective transitions between hospital and home are recognized as critical to achieving better patient outcomes and avoiding rehospitalisation. Many patients have sub-optimal experiences in care transition between hospital and home/community care. Problems include: Medication discrepancies Confusion about post discharge care plans Hospital readmission rates for COPD / HF ~30% Risk of readmission is significantly lower when: 1 st home care visit take place within 24 hours of discharge Primary care visit occurs within 7 days of discharge 1 Nurses in CCACs: Providing Care and Creating Connections Across Sectors, P. 4 3

4 Governance Structure Provincial Client Service Committee Provincial RRNP Working Group RRNP Work Stream 1 Roles & Responsibilities RRNP Work Stream 2 Communication 4

5 Evidence: Effective Transitions Research for care transitions in specific diagnoses has been ongoing for decades! Common elements from the literature include: In-home follow-up care (24-72 hours) Care coordination across transitions Medication management/reconciliation Patient education/empowerment (Coleman) or care management (Naylor) Patient-centered care Patient enabled with personal health record Follow-up with primary care provider (Rich et al, 1995; Naylor et al., 1995; Coleman et al., 2006) 5

6 Program Goals Reduce rehospitalization and avoidable emergency department visits by improving the quality of transition from acute care to home care for two population groups: Frail adults and seniors who are medically complex or have chronic diseases that tend towards frequent hospitalization, unstable health and costly treatments. Medically complex/vulnerable children, and their families 6

7 Rapid Response Nurses Care Coordinator Rapid Response Nurse 24 hours 7 days Primary Care Hospital Home Home/Community Care 7

8 Referral Source Emergency Dept. Hospital Care Coordinators Intake by Hospital CC -Case finding -Screening for eligibility -Identify RRN involvement Pre D/C -Collection of D/C information -Overall Service Planning -Service Ordering of RRN Integrated Care Discharge from Hospital 24 Hours RRN Visit -Consent for Tx -Problem-based assessment using common tool -Teach back approach to education -Medication Reconciliation -Confirm medical tests -Update In-Home Health Record -Linking with PCP Follow-up Care 7 Days - Ongoing problem- based assessment to ensure client stable & safe -Address ongoing medication issues -Linking with PCP -Contribute to Service Planning -Joint visit/phone with CC and SP to transition care LOS 2-3 weeks Model of Care Transition to PCP/SP/Community CC - -Arrange PCP appointment if needed -Update PCP about acute care event/ post D/C plan -Share contact information -Share problem based assessment & medication reconciliation -Discharge from RRN Program Transitioning from Hospital to PCP/Community Providers Target Population - Complex and Chronic Using CCM: * Medically complex/vulnerable children, and their families * Frail adults and seniors that are medically complex or have chronic diseases that tend towards frequent hospitalization, unstable health and costly treatments, including: CHF, COPD, Diabetes, Other Ambulatory Sensitive Conditions 8

9 Key Performance Indicators Client Information Number / % of patients served (by type/profile children, adults, seniors; by ambulatory sensitive condition*) Access # of visits; average number of visits per patient Average Length of Stay Number / % of in-home visits within 24 hours of hospital discharge* Reason for not receiving service Health System Impact / Cost Effectiveness Number / % of emergency visits within 30 days* Number / % of hospital re-admissions in 30 days* Number / % of primary care appointments within 1 week of hospital discharge* Quality Measures Patient / informal caregiver experience & Provider Experience overall satisfied with transition care, perception of care connections and integration(tbd)* Health System Outcomes Measure of physician engagement - contacts between RRN and PCP* 9

10 Learnings from Local Implementation

11 HNHB CCAC Implementation January to March 2012: April to June 2012: July to September 2012: HNHB LHIN funding (to reduce ALC) Design and implementation in 2 branches (Hamilton and Burlington) Implemented a consultant pharmacy programme Spread programme across the LHIN (Haldimand Norfolk, Brant and Niagara) October to December 2012: Full implementation of Adult Rapid Response Programme Consolidated clinical programme infrastructure (e.g. P and Ps) January 2013 ongoing: Partnered with hospital Bundled Transitions Project test of change Developing Paediatric focus of intervention Knowledge transfer Service provided 6 days / week 11

12 Improving the Transition to Primary Care Mr. J. was in hospital for 9 months following a stoke and was discharged home. He requiring total care and was awaiting a move into Long Term Care. PMHx: Longstanding epilepsy, osteoarthritis, osteoporosis - experiencing fracture of the hip and wrist, depression, non insulin dependent diabetes, indwelling by catheter. Recent UTI x 3 with the onset of delirium. No primary care provider visits in the last 6 years. Issue: Patient is sleeping 23 hours / day. Why: Drug toxicity? Infection? Blood sugars? Pneumonia? UTI? Narcotic influence? Depression? Key success factors: Access to hospital information (clinical connect); collaboration with primary care (blood work / CXR); consultation with pharmacist Outcome: The patient woke up! Up in the chair 5 6 hours / day. Socializing with others. Avoid hospital readmission. Able to moving successfully to Long Term Care. 12

13 Patient Characteristics: Diagnoses ~25% HF / heart related disorders ~25% COPD ~25% geriatric giants (e.g. pain, cognition, continence, mobility, falls) Unique features at HNHB CCAC Support transition of high risk patients awaiting LTC (Home First) Support complex community patients at risk of ED visits / hospitalization Clinical pharmacy programme Most patients have multiple conditions, and multiple physicians involved 13

14 Rapid Response Referrals 80 Number of Weekly Referrals (N=2,177) (May 28, 2012 June 15, 2013)

15 Patient Characteristics: Care Requirements MAPLe Score by Age Group MAPLe measures ability to care for self / care requirements MAPLe 1 MAPLe 2 MAPLe 3 MAPLe 4 MAPLe % patients are > age 75 47% patients could move into LTC (MAPLe 4, 5) Another 35% are at the tipping point (MAPLe 3) 18% of RRTT patients have an active placement file 15

16 Patient Characteristics: Medical Complexity Patients by CHESS Score (N=1315) CHESS, a subscale of the RAI HC instrument, measures medical frailty Higher CHESS, lower life expectancy 66% patients have CHESS > CHESS 0 CHESS 1 CHESS 2 CHESS 3 CHESS 4 CHESS % patients >3 16

17 Clinical Pharmacy Consultations 17

18 Performance Metrics Performance Output Indicator ( ) # of new hospital patients discharged home to CCAC RRTT program # of existing CCAC patients referred to CCAC RRTT program % of high risk patients from hospital that require readmission within 7 days of discharge (81 of 911 patients) Actuals 911 (60.9%) 584 (39.1%)

19 Time to First Visit Data for May 2013 Excludes Sundays visits Includes referrals from community care coordinators (standard < 72 hours) # of Referrals (May 2013) Total First Visit < 24 Hours First Visit < 48 Hours First Visits < 72 Hours Visits within 72 hours Visits > 72 hours No contact Total N = % 8.99 % 7.91 % 65.8 % % % 19

20 % Readmission Hospital Readmissions 0.16 RRTT 7 Day Readmission Rate May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Avg hospital readmission rate 8.9% 20

21 Hospital Readmissions Hospital readmissions within 7 days Patients Readmitted to Hospital by Age (N=81) Patients discharged from hospital and readmitted N = 81 (8.9%) 82% > age 70 63% patients have CHESS >2 72% patients have MAPLe > < >100 21

22 Key Learnings Bridging the patient to home is an effective strategy to reduce hospital readmission rate Programme supports integration of patient care across sectors (hospital / home care / primary care) Identification / hospital screening for risk is important: need appropriate hospital risk screening process All medical patients at risk of readmission using LACE screening tool. Hospitals across the LHIN will implement a Bundled Transitions Project using teach back techniques to further screen patients Hospital engagement is required at the front line, middle and upper management levels Timely transfer of accurate information such as medication lists and in-hospital record of care is important 22

23 Key Learnings Medication reconciliation is a key strategy Focus on specific populations helps concentrate efforts and help reduce hospital readmission (e.g. HF) About half of all patients have diagnosis of COPD or HF Many patients have multiple diagnoses and multiple physicians involved who is the lead? Patients often become disconnected from their primary care physicians: making the connection with PCP is important but can be challenging (physicians away, may not know the patients well). However, the number of orphaned patients is small. Data collection across sectors is important to determine impact of programme on readmission rate 23

24 Outstanding care every person, every day