IHI Expedition. Reducing Readmissions by Improving Care Transitions Session 2. Expedition Coordinator

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1 Thursday, June 20, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 2 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator 2 Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI s efforts for Medicare-Medicaid enrollees. Kayla leads IHI s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration. 1

2 WebEx Quick Reference 3 Welcome to today s session! Please use chat to All Participants for questions For technology issues only, please chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text When Chatting 4 Please send your message to All Participants 2

3 Expedition Director 5. Saranya Loehrer, MD, MPH, Director, Institute for Healthcare Improvement (IHI), aligns care transitions related programming within IHI and provides coaching and facilitation to teams within the STAAR initiative. She also contributes to IHI s efforts to adapt promising practices to better care for Medicare- Medicaid beneficiaries and serves as one of IHI s content curators to ensure IHI s publications and resources are reflective of the most recent innovations and best practices in the field. Saranya received her medical degree from Loyola University Chicago s Stritch School of Medicine and her Master of Public Health degree from the Harvard School of Public Health, where she served as a Zuckerman Fellow. Today s Agenda 6 Action Period Report Out Content: Capturing the Patient Story Content In Action St. Luke s Hospital UCSF Medical Center Action Period Assignment 3

4 Overall Program Aim 7 The aim of this Expedition is to share strategies for hospitals and their cross-continuum partners to co-design care processes to improve the transition of patients from the hospitals to the next care setting. Expedition Objectives 8 At the end of the Expedition each participant will be able to: Assess current challenges in reducing avoidable rehospitalizations and identify opportunities for improvement Explain how to build an effective improvement team including patients and families as well as acute, post-acute and community care providers Describe how to use the patient story to build an individualized plan of care. Use appreciative inquiry and Teach Back to better understand a patient s post-acute care needs and capabilities Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during patient transitions 4

5 Schedule of Calls 9 Session 1 Building the Team You Need to Reduce Readmissions Date: Thursday, June 6, 12:00-1:30 PM ET Session 2 Capturing the Patient Story Date: Thursday, June 20, 12:00-1:00 PM ET Session 3 Assess for Success: Appropriate Post-Acute Follow-up Date: Thursday, July 11, 12:00-1:00 PM ET Session 4 Passing the Baton: The Handover of Critical Information Date: Thursday, July 25, 12:00-1:00 PM ET Session 5 Putting it All Together: Orchestrated Testing and Implementation Date: Thursday, August 8, 12:00-1:30 PM ET Faculty 10 Peg M. Bradke, RN, MA, is Director of Heart Care Services at St. Luke s Hospital in Cedar Rapids, Iowa. She received her Bachelor s Degree in Nursing from Mount Mercy College and her Master s Degree in Nursing Administration from the University of Iowa, College of Nursing. In her 25- year career, she has had various administrative roles in the cardiac care areas. She currently coordinates the Heart and Vascular Service line which includes two intensive care units, two step-down telemetry units, the Cardiac Cath Lab, Electrophysiology Lab, Diagnostic Cardiology, Vascular and Interventional Lab, Respiratory Care, Cardiopulmonary Rehabilitation and Heart Failure and Coumadin Clinics. In addition, Peg is serving as faculty with the Institute for Healthcare Improvement (IHI) on the Transforming Care At the Bedside (TCAB) Initiative and STAAR (STate Action on Avoidable Rehospitalizations Initiative). 5

6 Action Period Report Out Reach out to 2 potential CCT partners to assess the current process for transfer of information Call 2 patients or caregivers hours after they have returned home to learn what went well and identify opportunities for improvement Some questions to consider: What has been your greatest concern since you went home? Did we miss anything in your discharge instructions? Were you confused by any of the instructions you were given? Now that you are home, what would you tell us is the most important thing we could have done for you to prepare you for your care at home? Action Period Report Out Continued What did you do? What surprised you? What will you do next as a result? 6

7 13 Capturing the Patient Story Peg Bradke, RN, MA Capturing the Patient Story Involve the patient, family caregiver(s), and community provider(s) as full partners in identifying the patient s home going needs. 7

8 Partner with Patient and Family to Determine Post-Hospital Needs Typical Failures Excluding the patient and family caregivers in assessing needs, identifying resources, and planning for discharge, leading to poor understanding of the patient s capacity to function in the home environment Lack of probing around unrealistic patient and family caregivers optimism to manage at home Lack of understanding of the patient s functional ability, ability to Teach Back, physical and cognitive health status, and social and financial concerns, which results in transfer to a care setting that does not meet the patient s needs 8

9 Partner with Patient and Family to Determine Post-Hospital Needs Typical Failures (cont.): Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression, social needs, etc.) Not addressing palliative care or end-of-life issues, including advance directives or planning beyond Do Not Resuscitate (DNR) status Medication errors, polypharmacy, and incomplete medication reconciliation Labeling the patient as noncompliant and not recognizing the care team s responsibility for facilitating self-care management Ongoing Assessment of Post-Hospital Needs Transformational Change Ideas: Take 5 establish a relationship and build trust Nurses and members of the care team take a stance of appreciative inquiry or as an investigative reporter - Ask the 5 Whys 9

10 5 Whys Root Cause Analysis 5 Whys Root Cause Analysis no $ for meds no insurance unintended consequences of receiving Medicaid no application/medicaid needs helps with application 10

11 Open Ended Questions to Ask the Patient and Family Caregivers How do you think you became sick enough to come into the hospital? How do you take your medicines at home? Any problems? Any side effects? Describe your typical meals at home or at a restaurant. When did you last talk with your doctor or nurse? What did you talk about? What, if anything, worried you before you came to the hospital? Expanding the Focus of Daily Patient Care Rounds Develop one comprehensive assessment of patients postacute care needs that integrates input from all members of the care team Make sure each member of the care team is clear about what information they must bring to rounds each day Change the focus on daily patient care rounds to include a dual focus of optimizing care in the hospital and decreasing the length of stay while simultaneously planning to meet the post-discharge care needs of patients 11

12 Proposed Agenda for Patient Care Rounds What are the goals/reasons for this admission? Are the health care teams goals and the patient s and family caregiver s goals in sync? What needs to happen during this hospitalization? What are the criteria for discharge readiness? What post-acute care plan should be put in place to meet the patients (or family caregivers) level of activation and comprehensive of the discharge plans? Routinely ask the question what is the likelihood that this patient will be readmitted in the next 30 days? If the likelihood is high, why? What services can be put in place to mitigate potential problems? Example: Additional Information that Bedside RNs Should Bring to Daily Patient Care Rounds Ongoing assessment of comprehensive discharge needs (not solely on admission) Assessment of patients and/or family caregivers understanding of the post-discharge plans and selfcare (using Teach Back) Answers from patient and family caregiver to the following question What concerns or worries you the most about going home or to the next care setting? 12

13 What Are We Learning About Capturing the Patient Story? Initial assessment should be completed upon admission, but ongoing assessment of homegoing needs should be ongoing over time Most teams think that they are already doing the assessment -- but have gained new insights from completing the diagnostic reviews Teams should consider embedding questions from the diagnostic review into the admission assessment for patients What Are We Learning About Capturing the Patient Story? Family caregivers and community providers are a vitally important source of information about home-going needs of patients There is often a discrepancy between the patient s, the family caregiver s, and provider s perception of the patient s needs and capabilities Completing a comprehensive admission assessment requires additional time; roles and responsibilities need to be designated and standard work processes need to be developed Multidisciplinary rounds are important to build the patientand-family-centered story and establish a comprehensive post-hospital plan of care 13

14 Aimee Traugh & Diane Pfeiler 28 Content in Action: St. Luke s Hospital Aimee Traugh Diane Pfeiler 14

15 ST. LUKE S HOSPITAL MEMBER, UNITYPOINT HEALTH SYSTEM Private hospital Cedar Rapids, Iowa Affiliate of UnityPoint Health System Licensed for 500 Beds with more than 17,000 admissions Truven Top 100 Hospital 5 years (2013); Heart Hospital 3 years (2012) Iowa Recognition for Performance Excellence Gold Award 2010 Magnet Designation 2009 Joint Commission Disease Specific Certification in Advanced Heart Failure, Stroke, Palliative Care and Total Joint. Society of Chest Pain Center Chest Pain Certification Gold Award from Get with Guidelines for Heart Failure UNITY POINT-ST LUKE S 3 CENTER BEDSIDE HUDDLES Putting patients at the center of all we do! 15

16 HUDDLES AS WE KNEW THEM Primary nurse, charge nurse, care coordinator Occurred at the nurse s station Multiple interruptions Noisy, noisy, noisy! Something was missing oh yeah, the patient! STAFF ENGAGEMENT Discussed at Unit Planning Committee Jan 2013 Decision made by frontline staff Dissemination of plan through weekly newsletter Focus on patient-centered care Manager support during implementation phase starting February 4 th

17 HUDDLES AS WE KNOW THEM NOW Occurs at patient s bedside with patient/family input Charge nurse guides intent daily goals, discharge goal, fall risk, skin integrity risk, Primary nurse daily goals to white board, barriers to discharge identified Care Coordinator opportunity to lay eyes on every patient, learn barriers, discuss discharge plan Documentation specialist listener, captures undocumented severity of illness, risk of mortality Maureen Carroll, RN, CHFN 34 Maureen Carroll, RN, CHFN, has been a clinical nurse on the cardiovascular unit at the University of California San Francisco since While working at UCSF she became a Geriatric Resource nurse, certified through the American Association of Heart Failure Nurses, and is currently working on a Master s degree at Regis University. Maureen has been the Heart Failure Program Coordinator at UCSF since October Maureen has developed and led the multidisciplinary Heart Failure team, the Readmissions Task Force at UCSF, and achieved the goal of reducing readmissions for heart failure patients by 30%. Maureen has presented at the Institute for Healthcare Improvement Annual Forum in 2010 and 2011, the University Health Care Consortium, and for the American College of Cardiovascular Administrators. She has consulted with many hospitals while working with the Avoiding Readmissions Through Collaboration (ARC) group and continues to work full time as the Heart Failure Program Coordinator at UCSF as well as faculty with the Institute of Healthcare Improvement. 17

18 35 Content in Action: UCSF Medical Center Maureen Carroll RN, CHFN UCSF Multidisciplinary Rounds Maureen Carroll RN, CHFN Heart Failure Program Coordinator 18

19 Background on MDR The evolution of MDR on one Cardiovascular unit What led to recent changes? Challenges Many Four cardiology teams, CT Surgery, & Vascular teams that we need to get report from daily New Residents every month Getting the entire team together at one time Getting the patient s story into rounds Busy and loud Nurse s station where rounds were held Not enough room for everyone Could not hear Privacy issues 19

20 Multidisciplinary Rounds -- Before What Changes Were Needed for Improvement? New location -Quiet, large enough for large Multidisciplinary Team, privacy Ongoing communication to new Residents each month Leadership approval Continuity Patients stories retrieved and communicated 20

21 MDR- What is the Goal? Addressing each patient s situation and communicating the needs and the plan between all disciplines involved What is the overall clinical picture of the patient and what will be needed for an optimal discharge? What are the psycho-social needs and /or concerns of this patient? (i.e. cognitive deficits, low health literacy, illiterate, support needs, financial concerns, etc.) What is the patient story? Is this patient considered at high risk for readmission? (Response to clinical condition, number of readmissions in past year, ability to manage chronic condition, ability to Teach Back, history that may affect outcomes, adherence to medication regimen, etc.) MDR - Goals What consults will benefit this patient on this admission? (dietary, spiritual, pharmacist, social worker, etc.) What are the appropriate support options for this patient? (RN/OT/PT Home care services, specialty clinic appointments, MD home visits, serial follow up calls, etc.) 21

22 The Patient Story Bedside nurse brings patient story to the Charge Nurse who attends MDR daily PM Charge Nurse communicates with AM Charge Nurse Case Manager meets with patients and families with any potential needs Chaplain meets all patients and families - attends rounds Heart failure coordinators meet with HF patients and families Residents add clinical story and needs Social worker meets patients and families with identified needs RESULTS= The Story is pieced together as a Team Multidisciplinary Rounds -- After Quiet, private area Comprehensive team addressing patient s needs Next steps in care Readmission risk Next goal: Include the Pharmacist 22

23 Action Period Assignment Observe rounds/huddles where patient transitions are discussed and think about the following: Who attends them? How are the patient s post-discharge needs surfaced and discussed? How are the perspectives of the clinical team solicited and incorporated? How are the patient s post-discharge needs addressed? Based on what you learned, what might you test to improve your process? Chat Time! 46 Chat in one thing you learned during today s session

24 Expedition Communications 47 Listserv for session communications: To add colleagues, us at Pose questions, share resources, discuss barriers or successes Next Session 48 Thursday, July 11, 12:00 PM 1:00 PM ET Session 3 Assess for Success: Appropriate Post- Acute Follow-up 24

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