Southeast Michigan See You in 7 Hospital Collaborative: Session 2 Webinar. Tuesday, June 19 at 8 am

Transcription

1 Southeast Michigan See You in 7 Hospital Collaborative: Session 2 Webinar Tuesday, June 19 at 8 am

2 Agenda Administrative Buy-In & Getting Projects Off the Ground - Maureen Bowman, R.N., Vice President and Chief Nursing Officer Beaumont, Royal Oak - Nancy Mesiha, MD, FACC, FAAC & Anne Marie Kaminski, Administrative Director Cardiovascular Services St. John Hospital and Medical Center & St. John Macomb-Oakland Hospital Selection of Process Measures - Nancy Mesiha, MD, FACC, FAAC & Anne Marie Kaminski, Administrative Director Cardiovascular Services St. John Hospital and Medical Center & St. John Macomb-Oakland Hospital - Lorie Liegghio, Director, Cardiopulmonary & Neurology Services Garden City Hospital Closing - Next Assignment: Gap Analysis due July 6 - Multiple Choice Questions

3 Administrative Buy-in & Getting Heart Failure Project off the Ground Maureen Bowman, MA, BSN, RN Vice President & Chief Nurse Officer June 19, 2012

4 Getting Started Began with core measures o Considered best practice o Right thing to do o Tied to reimbursement Nurse Clinician service developed o Goal: Identify and swat all primary and secondary HF patients to ensure core measures met Established clinic at Beaumont, Troy 4

5 Heart Failure (HF) Readmissions Transition of Care Committee (developed Dec 2010) o Partnered with Beaumont Home Health discharge bundle Follow-up appointment Follow-up phone call Medication reconciliation Patient education o Efforts on alerting staff when HF readmit within 30 days Identify if needs readmission or observation Interview patient / family on why they returned to hospital Using interview tool for process improvements 5

6 HF Readmissions Participating in BCBSM PGIP MI transition of care collaborative with our physician organization Beaumont, Troy involved in community program with CMS and Area Agency on Aging health coach concept Participating in Partnership in Patients initiative with University Health Consortium (UHC) Working with physician group on 3-year demonstration project to decrease readmissions using Geisinger training module o Hospital will coordinate with PGIPs complex care managers on complex cases 6

7 Administrative Buy-in Business Case o Financial reasons Cost to organization Tied to reimbursement Moral imperative o Right thing to do For patient For the institution 7

8 Evidence To date, it appears that nothing in peer review literature has shown success In fact, recent literature has shown patients with lower readmission rates have a higher mortality rate More evidence and research to come 8

9 Lessons Learned Tried and piloted (kaizen process) various initiatives No magic bullet Try it Measure it Move on and try something else Learn quickly what works and what does not Appears it may be various initiatives that are the answer to decreasing HF readmissions 9

10 Questions 10

11 Heart Failure Care Continuum Program at SJPHS

12 Clinical Decision Unit (CDU Pilot) Multidisciplinary rounds Patients with multiple readmissions for Heart Failure Patients discharged from the hospital with known appointments IT involvement relative to Ejection Fraction (EF) IT involvement for Discharge Medications and Hard stops example: Why the patient is not discharged on an ACE/ARB? Need documentation of reason prior to moving forward with the discharge process.

13 Administrative Buy In Development of Co Management for Cardiovascular Services Utilization of our call center to make follow up appointments for the coordination of the care continuum 13

14 Thank you Questions for Nancy Mesiha, MD or Anne Marie Kaminski Administrative Director Cardiovascular Services

15 See You in 7 Selected Process Measures Process Measure Identifying heart failure patients prior to discharge Hospitals Focusing on Process Measure St. Joseph Mercy Oakland; McLaren-Macomb; Henry Ford Macomb; VA Ann Arbor Scheduling and documenting a follow-up visit with a cardiologist or primary care practitioner that takes place within 7 days after discharge St. Joseph Mercy Oakland; St. John Providence; St. John Macomb- Oakland & St. John Hospital; Garden City Hospital; McLaren-Macomb; VA Ann Arbor; St. Joseph Mercy Livingston Providing the patient with documentation of the scheduled appointment St. Joseph Mercy Oakland; Garden City Hospital; McLaren-Macomb; VA Ann Arbor; St. Joseph Mercy Livingston Identifying and addressing barriers to keeping the appointment St. Joseph Mercy Oakland; St. John Providence; Crittenton; Henry Ford Macomb; VA Ann Arbor Working to ensure that the patient arrives at the appointment within 7 days of discharge St. Joseph Mercy Oakland; Crittenton; VA Ann Arbor; St. Joseph Mercy Livingston Making the discharge summary available to the follow-up health care provider John Macomb-Oakland & St. John Hospital; Crittenton; VA Ann Arbor; St. Joseph Mercy Livingston All Slides to be posted on in provider resources Section of mycarecompare.org

16 Process Measures Selected and Barriers I. Scheduling and documenting a follow-up visit with a cardiologist or primary care practitioner that takes place within 7 days after discharge II. Making the discharge summary available to the follow-up health care provider We are currently working on scheduling and documenting follow up visits. Patients inconsistently make hospital follow-up appointments. Discharge summaries are not always dictated in a timely manner. The physician may not have seen the patient in the hospital

17 SY7 Process Measures Lorie Liegghio Director Cardiopulmonary & Neurology Services

18 Follow-up Appointment Scheduling and documenting a follow-up visit with a cardiologist or primary care practitioner that takes place within 7 days after discharge. Currently, we tell the patient/family to schedule an appointment when they get home. We are looking to put a process in place that is consistent in the organization and is compliant with the HFAP accreditation standards. This standard states the patient must know date and time of appointment for follow up. 18 Good Health. Generation to Generation.

19 Documentation Follow-up Appointment Providing the patient with documentation of the scheduled appointment. Currently, the patient receives a form of discharge instructions that includes follow up information. Appointments should be made before the patient leaves the hospital, and details should be reviewed with the patient prior to discharge. Putting this process in place can help us be successful with our HFAP accreditation standards for discharge and follow up care. 19 Good Health. Generation to Generation.

20 Planning Phase Ownership and collaboration between the hospital and physicians. Team selection Administrative Leadership (CNO) Cardiology Pharmacy Physician Champions (Cardiologist & Primary Care) Nursing Director Clinical Transitions Quality 20 Good Health. Generation to Generation.

21 Identifying Barriers Understand the needs of our patients and their families. Understand the needs of the multi-disciplined team. Understand the impacts on cardiologists and physicians. Evaluation of technology available and use it to its fullest potential. 21 Good Health. Generation to Generation.

22 Challenges Identification, documentation, and communication of barriers and risks. Problems to be solved by the team. Team updates on progress. Step back and re-evaluate processes that are problematic. Work to eliminate all barrier and risks 22 Good Health. Generation to Generation.

23 Teamwork Support Nursing adoption of the new process measures and change of workflow. Ancillary adoption of new work flow. Physician engagement and willingness to partner with hospital. Education and Competencies Support - Executive Team 23 Good Health. Generation to Generation.

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25 Thank you! Next Session: Session 3 Webinar Tuesday, July 17 at 8:30 am Gap Analysis Due July 6