Multidisciplinary PAC Collaborative: Slowing the Revolving Door of Unplanned Readmission

Transcription

1 Multidisciplinary PAC Collaborative: Slowing the Revolving Door of Unplanned Readmission Joy LaGuardia MSN, CCM Manager Post-Acute Services Dept. of Care Coordination & Clinical Social Work 1

2 Learning Objectives 1. Demonstrate how UCLA Health work collaboratively with Post-Acute Care Facilities in re-evaluating transitional care practices to ensure a safe transition of patients. 2. Identify strategies with post-acute providers to reduce readmissions. 3. Illustrate key education components for hospital and nursing home staff to minimize the post-acute bounce back effect. 2

3 TOCC A. What? Transition of Care Collaborative B. Who? Partnership between UCLA Health and PAC Facilities C. Why? For continuous improvement on transitional care best practices D. Quarterly meetings with PAC facilities E. Accomplishments: Identified opportunities with bi-directional feedback & in real-time readmitted cases Review of readmitted cases from SNF and with HHA disposition on DC Warm Hand off UCLA continues to provide educational courses such as: PICC Line care, post- VAD HHC care, G-tube, vascular access, Pleurex drain, suprapubic catheter, pending completion of schedule within service departments Process and Outcome dashboard by PAC facilities 3

4 EHH 7 touch points audit tool Pt name MRN Hospital Payor Hospital DC date Risk for readmission Warm hand-off prior to DC? 1st tuck-in call? 2nd tuck-in call? Test RR XYZ 12/8/2017 Low Risk Not required Yes Test RR ABC 11/1/2017 Moderate Risk Yes Yes Yes Date of first visit # of days to 1st visit PCP name AVS available? Pt lives alones? Family support available? Taking meds? Attended F/U appts? Pt education provided? Esc. Protocol followed Pt readmitted? Readmisison date # of days to re-admission 12/10/ MD Yes Yes Yes Yes 12/10/ /1/ MD No Yes Yes No Yes Yes Yes 12/15/ JL

5 Strategies 1. Standardization of Transition of Care Processes Integration of LACE+ to Transition of Care Forms 8Ps / Project BOOST Input from HH care and Social Work (in progress) Case reviews with HHA, SNF, ARU. 2. Deliver enhanced services based on readmission risk (LACE+) and patient needs (BOOST) Implementation of the Enhanced Home Health 7 minimum touch points Review readmissions occurring within seven days HH Onsite hospital visit required in meeting patient/family if LACE +score > 58 Integration of the Social Work input based on 8Ps Education schedule requested by EHH providers 3. Post-acute care SNF strategy SNF Education on LACE+, 8PS and BOOST during TOCC Monthly meetings with SNF Administrators to review the implementation of the SNF 2.0 INTERACT Interventions to Avoid Emergency Transfers to Acute Setting 4. Post-acute care ARU strategy Monthly review of CRI re-admissions Conduct RCA, and identify opportunities 5SW

6 The P What it means What can the Home Health Agency do to address this? Problems with medications Patients with polypharmacy i.e. >10 routine medications or who are on high-risk medications including anticoagulants (e.g. warfarin, heparin, Factor Xa or thrombin inhibitors), antiplatelet agents in combination (e.g. aspirin and clopidogrel), insulin, oral hypoglycemic agents, digoxin, and narcotics. RN med rec at SOC, include over the counter meds/supplements (ask: what do you take for heartburn..? Ask about patients medication access/refill processes. Compare what s in the home (assess home environment including kitchen, bedroom, bathroom) with the Discharge Summary (AVS) and calling MD immediately for discrepancies. Being mindful of Beers list and communicate alerts to the PCP. Take a bag into the home that says discontinued meds and put the meds in a bag for the patient (separate active meds from discontinued meds). Look for a system of medication organization in home. Follow-up visit/call within 72 hours by RN for med-compliance and use teach back. Tuck in calls on Fridays. Psychological Principal diagnosis Physical limitations Poor health literacy Poor social support Prior hospitalization Palliative Care Patients who screen positive for depression/anxiety or who have a history of depression/anxiety. Patients with a principal diagnosis or reason for hospitalization related to cancer, stroke, diabetic complications, COPD, or heart failure. Patients with frailty, deconditioning, or other physical limitations that impair or limit their ability to significantly participate in their own care (e.g. perform activities of daily living, medication administration, and participation in posthospital care). Patients who are unable to demonstrate adequate understanding of their care plan as demonstrated by their inability to complete Teach Back successfully The absence of a reliable caregiver to assist with the discharge process and to assist with care after the patient is discharged. This P also captures the concept of social isolation. Unplanned hospitalization in the six months prior to this hospitalization? When thinking about this patient, would you be surprised if the patient died within a year? Does this patient have an advanced or progressive serious illness? This risk factor would be triggered if you answered no to the first or yes to the second question. Send social worker for evaluation (request as a part of the standard order) and assess for coping skills, resources in community. Review social work consult notes in Care Everywhere. Assess how long patient has been on anti-psychotic/anti-depressant. Patients on antidepressants for a long time or no follow-up after start of new psych medication contact the PCP and request that patient be re-evaluated for efficacy/medication adjustment. Use pathways for high risk conditions. Use teach-back at every visit related to condition signs, symptoms, promote early action. Provide outpatient resources for education. Assess need for assistive devices, need for caregiving support. Recommend PT, OT, Speech and nutrition. Assess for language barrier, ask patient to repeat back information, use interpreter services. Give instructions to caregiver. Frontload visits. Assign social worker to evaluate for internal/personal and community resources. Reach out to family members. Review social work consult notes in Care Everywhere. Assess cognitive/competence level of caregiver and their capacity to care (ideally takes place at the hospital at bedside). Allow caregiver to do teachback as well. Identify what were the root cause of prior hospitalizations? Why ED vs. PCP visit? Use it as an opportunity to educate patients and help identify an emergency plan. Provide patients with information on UCLA urgent care. Having one place the patient can go to for information on who to contact for what, including symptoms to look out for (ex: magnet on refrigerator for PCP s phone number, HH RN s number, and place the document of what symptoms to look for on the frig) or help them program important phone numbers into cell phone. Check if patient was seen by Palliative Care in hospital through Care Everywhere. Assess need for palliative care and symptoms. Identify services to patient. 6

7 Contact: 7