Preventing Unplanned Acute Care Admissions A Nursing Home Quality Initiative

Size: px
Start display at page:

Download "Preventing Unplanned Acute Care Admissions A Nursing Home Quality Initiative"

Transcription

1 Preventing Unplanned Acute Care Admissions A Nursing Home Quality Initiative UPMC Senior Communities Skilled Nursing Facilities UPMC Senior Communities: Who are We? 5 Skilled Nursing Facilities 5 Personal Care Facilities 6 Independent Living facilities 1 CCRC Expands through 5 Counties in Western Pa: Allegheny Butler Westmorland Venango Washington UPMC SRC Quality Approach to Unnecessary hospitalization Identified Unplanned Acute Care Admissions as a Quality Indicator for improvement in A CQI workgroup was initiated which consisted of representatives from each facility and included Medical Directors, DONs, and Administrators. Conducted review and evaluation of unplanned transfers. Determined adjustable actions and interventions most likely to improve rate of unplanned transfers. Initiated actions. 1

2 Blueprint : QI for unplanned acute care admissions 1. Assessment Collect data & Analyze admissions, discharges, and reasons for them. 2. Planning Develop a preliminary plan & Determine what resources are needed. 3. Implementation Keep objective records during the implementation. Do not be disappointed if the plan is not 100% effective. This is normal. Identifying and working through problems encourages growth. Set a target date for evaluating the plan. 3. Evaluation The frequency of admissions and discharges in your facility will help you determine the target date for evaluating the plan. Facilities with many admissions and discharges will be able to evaluate the plan more quickly than facilities with little resident turnover. When you have collected the necessary information, evaluate the effectiveness of the plan based on the information you have collected and comments from residents, families, and staff. Make modifications as needed and begin again until you have fine tuned your facility processes and the plan is as effective as it can be. INTERACT Four Components 1. Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents 2. Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition 3. Managing some conditions in the NH without transfer when this is feasible and safe 4. Communicating efficiently and effectively with the next care setting when appropriate TINTERACT program includes 3 types of tools: Advance Care Planning Tools Communication Tools Care Paths 2

3 Review and Evaluation of Unplanned Transfers occurring in SRC SNFs Facilities collected detailed data on unplanned transfers for 3-4 months in Data was reviewed to determine most frequent components related to unplanned transfer. FINDINGS: Diagnosis was the highest predictor/indicator for potential for unplanned transfer. This included all 3 diagnosis criteria: 1. Diagnosis on admission to facility: Renal Failure, Fractures, CHF, Pneumonia, COPD 2. Reason for Transfer: Fever, Respiratory problems, Change Mental status change 3. Hospital Diagnosis after Transfer Pneumonia, UTI, Dehydration, Mental Change Data Collection Tool UNPLANNED HOSPITAL DISCHARGES* MONTH/YEAR FACILITY: UNIT *This includes ALL RESIDENTS who are transferred out & admitted to the hospital unexpectedly (unplanned) whether there is a "Bed Hold" or not. IF DISCHARGING PHYSICIAN IS DIFFERENT THAN WAS MD DAY ATTENDING, WAS NOTIFIED OF LIST NAME DISCHARG WITHIN 48 DATE OF DATE WEEK REASON AND WITHIN 48 HRS. MOST RESIDENT ATTENDING DATE OF ADMITTIN OF of SHIFT of FOR HOSPITAL CIRCUMSTANCE HRS. OF PRIOR TO RECENT NAME PHYSICIAN ADMISSION DIAGNOSIS DISCHARGE DISCH DISCHAR DISCHARGE DIAGNOSIS (E.G. ON-CALL) ADMISSION DISCHAR MD VISIT COMMENTS Findings Prompted Training needs: Findings supported the need for increased skill to identify and manage clinical conditions: Fever, infection, UTI, pulmonary problems Dehydration Findings supported the need for increased skill to identify the atypical signs of illness in the elderly such as a change in mental status. 3

4 Nursing Education Implemented to increase skills: Preventing Dehydration Care of pneumonia in LTC UTI Prevention Peri Care & Catheter Care Respiratory Assessment Physical Assessment, Identifying Change in Condition Education conducted throughout 2008 & 2009 Nurse to Physician Communication Enhancement Nurse Education conducted: Communicating Change to physician Use Care Paths and Communication tools Education Focus Required repeated training and emphasis to hard wire into daily operations Ongoing Enhancement to Nursing Education 2010 Education added to annual Core Curriculum for nursing staff: Hydration & Preventing Dehydration Physical Assessment and Identification of Change in Condition Physician Notification & Communication Respiratory Assessment UTI Prevention Peri care Catheter Care 4

5 Initiative Expanded UPMC SRC Clinical Operations joins the Aging Institute, University of Pittsburgh Division of Geriatric Medicine and UPMC Health Plan to expand the efforts to reduce acute care re-admissions from post acute sites. Group focus on four main evidence based components: 1. Improve the use and adoption of POLST and other advance directives (e.g., Five Wishes). 2. Improve the identification and management of acute change of resident status. 3. Improve and standardize clinical management and inter-clinician communication. 4. Improve and standardize communication during transitional care from NH to ED/hospital. Enhancing Clinical Care Capabilities Consistent Assignment Definition: having 85% of residents have a maximum of 8 CNA caregivers over the course of one month (long stay residents) or 2 weeks (short stay residents) Increases staff familiarity with resident and ability to identify early change in condition. 1. STOP & WATCH Early Warning Tool Tool to assist CNA with identification of change; Provide method to communicate change effectively to nurse. Palliative Care and POLST 2011 Focus POLST Policy revised Palliative Care Initiative including Staff education Care Planning and Conversation Guides Goals of Care Care Plan for every resident Adopt 5 WISHES as preferred Advanced Directive Resident/family education/informational brochures on Advance Directives and 5 WISHES 5

6 Ongoing Enhancement to Nursing Education 2011 Education added to orientation for all clinical new hire employees: Senior Communities focus on reducing unnecessary/unplanned admissions to acute care Early Identification of Change in Condition Stop & Watch tool for CNAs Physical Assessment of change in condition Notification/communication with physician WHAT HAPPENED? 9 SRC Consolidated Unplanned Acute Care Admissions Rate per 1000 Resident Days 2008 to

7 Tips for success Determine baseline/extent of Acute Care Transfers. Identify unique specifics of facility/organization. Determine implementation activities according to available resources. Support tools implementation with both clinical content and process education. Track results and share with all staff on a regular basis. Sustainability depends on continued education and support of the process. 19 INTERACT TOOLS Available: INTERACT Website: interact2.net/ Paper Tools: Med Pass: E-tools: Point Click Care: 20 One must wait until evening to see how splendid the day has been. 7

CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Phase 2--Payment Model

CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Phase 2--Payment Model CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Phase 2--Payment Model The Revolving Door One fourth of all nursing home resident go the hospital each year - Some many

More information

Tools Use Suggested Formats. All facility staff Provides a visual depiction of INTERACT in daily practice

Tools Use Suggested Formats. All facility staff Provides a visual depiction of INTERACT in daily practice INTERACT Version 1.0 Tools This table outlines the INTERACT tools, and briefly describes their use, and suggests recommended formats for use. You may not want to use all of the tools. The core tools are

More information

Implementation Guide Version 4.0 Tools

Implementation Guide Version 4.0 Tools Implementation Guide Version 4.0 Tools Program Overview Purpose of the Guide This Guide is intended primarily for INTERACT champions and trained educators who are responsible for implementing and sustaining

More information

INTERACT 4 Patty Abele, FNP BC

INTERACT 4 Patty Abele, FNP BC INTERACT 4 Patty Abele, FNP BC (No relevant financial relationships to disclose) TODAY WE WILL Identify the risks and disadvantages associated with avoidable hospitalizations Identify the goals of the

More information

Reducing Avoidable Hospitalizations INTERACT, PACE, RA+IT

Reducing Avoidable Hospitalizations INTERACT, PACE, RA+IT Reducing Avoidable Hospitalizations INTERACT, PACE, RA+IT Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD Thomas Jefferson University Jefferson School of Population Health Chief Medical Officer The Access

More information

Beyond the Hospital Walls: Impact of a SNFist Practice Model

Beyond the Hospital Walls: Impact of a SNFist Practice Model Beyond the Hospital Walls: Impact of a SNFist Practice Model Aaron Snyder, MD Vice President, US Acute Care Solutions Kim Repac Chief Financial Officer, WMHS Aging Population 50 Million Distribution

More information

*Your Name *Nursing Facility. radiation therapy. SECTION 2: Acute Change in Condition and Factors that Contributed to the Transfer

*Your Name *Nursing Facility. radiation therapy. SECTION 2: Acute Change in Condition and Factors that Contributed to the Transfer Gaining information about resident transfers is an important goal of the OPTIMISTC project. CMS also requires us to report these data. This form is where data relating to long stay transfers are to be

More information

SKILLED NURSING FACILITY HOSPITAL COLLABORATION: ANTIOCH & LONE TREE CONVALESCENT

SKILLED NURSING FACILITY HOSPITAL COLLABORATION: ANTIOCH & LONE TREE CONVALESCENT 04/24/13 1 SKILLED NURSING FACILITY HOSPITAL COLLABORATION: ANTIOCH & LONE TREE CONVALESCENT Phylene Sunga, NHA Wednesday, April 24, 2013 Change is NOW and NOT Tomorrow "If I am interested in change I

More information

Florida Health Care Association 2013 Annual Conference

Florida Health Care Association 2013 Annual Conference Florida Health Care Association 2013 Annual Conference The Westin Diplomat Resort & Spa Session #53 Assess and Educate to Prevent Rehospitalizations Thursday, August 8 10:00 to 11:30 a.m. Regency 1 Upon

More information

3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information

3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking Jennifer Moore, RN Content Developer Objectives Describe two reasons why returns to the hospital are not desirable

More information

OPTIMISTIC 8/13/2014. Outline OBJECTIVES

OPTIMISTIC 8/13/2014. Outline OBJECTIVES OPTIMISTIC An Approach to Increasing Quality of Life for Long Term Care Residents Presented by Noadiah Malott RN,MSN,ACNP-BC Project NP School of Medicine Department of Medicine Division of General Internal

More information

Hospital Readmission Reduction: Not Just Nursing s Job

Hospital Readmission Reduction: Not Just Nursing s Job Hospital Readmission Reduction: Not Just Nursing s Job David Farrell, LNHA, MSW Affordable Care Act - Three Aims Better patient experience Better outcomes Lower costs 1 Linking Payments to Quality Outcomes

More information

Why try to reduce hospitalizations? How many are avoidable?

Why try to reduce hospitalizations? How many are avoidable? Joseph G. Ouslander, MD Professor of Clinical Biomedical Science Associate Dean for Geriatric Programs Charles E. Schmidt College of Biomedical Science Professor (Courtesy), Christine E. Lynn College of

More information

Readmissions Moving beyond blame to fill the patient needs. Jackie Conrad RN, MBA, RCC Cynosure Health

Readmissions Moving beyond blame to fill the patient needs. Jackie Conrad RN, MBA, RCC Cynosure Health Readmissions Moving beyond blame to fill the patient needs Jackie Conrad RN, MBA, RCC Cynosure Health jconrad@cynosurehealth.org 1 51 year old male with 3 acute care admissions and 2 ED visits in the past

More information

INTERACT for Assisted Living

INTERACT for Assisted Living INTERACT for Assisted Living Part 1 NYSHFA/NYSCAL 2014 Fall Conference & Trade Show LuAnne Leistner MS, RN, BC, NE, BC, CALN Director Clinical Services- Assisted Living/Brookdale November 20, 2014 1 Bio/Disclosures

More information

Spreading INTERACT Practices Across the Continuum Through Skilled Nursing, Assisted Living, Home Health and Homes With Services

Spreading INTERACT Practices Across the Continuum Through Skilled Nursing, Assisted Living, Home Health and Homes With Services Spreading INTERACT Practices Across the Continuum Through Skilled Nursing, Assisted Living, Home Health and Homes With Services Kevin W. O Neil MD, FACP, CMD Internal Medicine and Geriatrics Chief Medical

More information

Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents

Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents Joseph G. Ouslander, M.D. Professor of Clinical Biomedical Science Associate Dean for Geriatric Programs Charles E. Schmidt College of Biomedical Science Florida Atlantic University Assistant Dean for

More information

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. Payment Model

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. Payment Model Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Payment Model Payment Model Six Enhanced Care and Coordination Providers (ECCPs) entered into cooperative agreements with

More information

Session Objectives 10/27/2014. How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider? Kim Barrows RN BSN

Session Objectives 10/27/2014. How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider? Kim Barrows RN BSN How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider? Kim Barrows RN BSN Session Objectives At the end of the session the learner will be able to: 1. Discuss the history

More information

Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready. Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting

Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready. Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting OBJECTIVES Define Rehospitalization and discuss current statistics

More information

Creating Care Pathways Committees

Creating Care Pathways Committees Presentation Creating Care Title Pathways Committees December 12, 2012 December 12, 2012 Creating Care Pathways Committees LeadingAge Indiana Integrated Care & Payment Executive Series 1 2012 Health Dimensions

More information

Hospital Readmissions Survival Guide

Hospital Readmissions Survival Guide WHITE PAPER Hospital Readmissions Survival Guide The Long-Term Care Provider s Ultimate Survival Guide to Incorporating INTERACT into Health Information Technology (HIT) March 2017 In this survival guide,

More information

improvement program to Electronic Health variety of reasons, experts suggest that up to

improvement program to Electronic Health variety of reasons, experts suggest that up to Reducing Hospital Readmissions March/2017 The readmission rate for patients discharged to a skilled nursing facility is 25% within 30 days1. What can senior care providers do to reduce these hospital readmissions?

More information

Transfer Trauma: A Trip to the ER Can Put an Older Adult at Risk

Transfer Trauma: A Trip to the ER Can Put an Older Adult at Risk Transfer Trauma: A Trip to the ER Can Put an Older Adult at Risk Mukaila Raji, MD, MSC Professor and Director, Internal Medicine-Geriatrics Program Director, UTMB Geriatric Fellowship Department of Internal

More information

Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN

Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN Session Objectives At the end of the session the learner will be able to: 1. Discuss the history of hospital readmission

More information

Outcomes Reporting: Be Ready to Negotiate with a Hospital

Outcomes Reporting: Be Ready to Negotiate with a Hospital Outcomes Reporting: Be Ready to Negotiate with a Hospital Tanya Procell, RN ADN Director of Clinical Services Provider Professional Services Teresa Chase President & CEO American HealthTech July 24 th,

More information

POLST Discussions Doing it Better. Clinical Update in Geriatric Medicine. Judith S. Black, MD, MHA. POLST Overview. Faculty Disclosure PART I

POLST Discussions Doing it Better. Clinical Update in Geriatric Medicine. Judith S. Black, MD, MHA. POLST Overview. Faculty Disclosure PART I Faculty Disclosure POLST Discussions Doing it Better Clinical Update in Geriatric Medicine Dr. Black discloses that she is employed by Allegheny Health Network and is an executive committee member of the

More information

Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs)

Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs) Skilled Nursing Facility (SNF) Shared Best Practices to Reduce Potentially Preventable Readmissions (PPRs) Referral Review referrals to determine if care needs can be met in your facility by: Triaging

More information

February 27, Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models

February 27, Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models 1 February 27, 2014 Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models 2 Having Audio Issues? If you experience any disruptions or other issues

More information

Sepsis Screening Tools

Sepsis Screening Tools ICU Rounds Amanda Venable MSN, RN, CCRN Case Mr. H is a 67-year-old man status post hemicolectomy four days ago. He was transferred from the ICU to a medical-surgical floor at 1700 last night. Overnight

More information

EXECUTIVE SUMMARY: briefopinion: Hospital Readmissions Survey. Purpose & Methods. Results

EXECUTIVE SUMMARY: briefopinion: Hospital Readmissions Survey. Purpose & Methods. Results briefopinion: Hospital Readmissions Survey EXECUTIVE SUMMARY: Purpose & Methods The purpose of this survey was to collect information about hospital readmission rates and practices. The survey was available

More information

Reinventing the cottage hospital : Did implementation of municipal acute bed units reduce the demand for hospital admissions?

Reinventing the cottage hospital : Did implementation of municipal acute bed units reduce the demand for hospital admissions? Reinventing the cottage hospital : Did implementation of municipal acute bed units reduce the demand for hospital admissions? Terje P. Hagen and Jayson O. J. Swanson Department of Health Management and

More information

Agenda: Noon Overview of the regulatory sections affected by the Reform of RoP in Phase 2

Agenda: Noon Overview of the regulatory sections affected by the Reform of RoP in Phase 2 Webinar: Driving Five Star & RoP Implementation Through a QAPI Approach: Final Rule: Integrating Phase 2 New Requirements of Participation into Practice (Part 1) Presentation Date: 02/15/17 Live Webinar

More information

Nursing Home Pearls or

Nursing Home Pearls or Nursing Home Pearls or How to Enjoy Practicing in Skilled Nursing Facilities Lowell C. Dale, MD November 11, 2016 2016 MFMER slide-1 DISCLOSURE Relevant Financial Relationship Medical Director Golden Living

More information

The New Survey Process What To Expect Paula G. Sanders, Esq.

The New Survey Process What To Expect Paula G. Sanders, Esq. PHCA Webinar February 14, 2018 The New Survey Process What To Expect Paula G. Sanders, Esq. DEPARTMENT OF HEALTH ENFORCEMENT TRENDS How to Read State Tags DOH CMPs Per Year 2014-2017 2014 $79,250.00 2015

More information

Housekeeping. Harmony Healthcare International, Inc.

Housekeeping. Harmony Healthcare International, Inc. Tackling Avoidable Readmission through Care Transition: PART I HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Diane Buckley, BSN, RN, RAC-CT Director

More information

The Future of Post-Acute Care Under Value-Based Payment

The Future of Post-Acute Care Under Value-Based Payment The Future of Post-Acute Care Under Value-Based Payment Robert Mechanic, MBA Brandeis University Northeast Home Health Leadership Summit January 22, 2015 Medicare Margins for Freestanding Home Health Agencies

More information

Restorative Nursing Care Plan Template

Restorative Nursing Care Plan Template Care Plan Template Free PDF ebook Download: Template Download or Read Online ebook restorative nursing care plan template in PDF Format From The Best User Guide Database Discipline. Month and Year of Service.

More information

Root Cause and Data Analysis

Root Cause and Data Analysis Root Cause and Data Analysis Michelle Synakowski LeadingAge NY Policy Analyst/Consultant 2 1 3 Systemic Analysis and Action Systematic approach to problem analysis Thorough Highly organized Structured

More information

Hospital Readmissions

Hospital Readmissions Hospital Readmissions The Long-Term Care Provider s Ultimate Survival Guide to Incorporating INTERACT TM Into Health Information Technology (HIT) In this survival guide, we ll give you the tips you need

More information

Transitions of Care: From Hospital to Home

Transitions of Care: From Hospital to Home Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss

More information

Telehealth for Acute and Urgent Care

Telehealth for Acute and Urgent Care Telehealth for Acute and Urgent Care the Andrew Waring, Consultant, Serengeti Projects Ltd Agenda Individual and workshop introductions and objectives Benefits Chronic Telehealth Benefits Acute and Urgent

More information

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE Training Slides 061015 Why Take Action to Prevent Readmissions? Better patient care and patient experience Home

More information

Community Rapid Response Team (CRRT) Presenters: Dawn Gallant RN,BN, CCHN (C) Jennifer Williams BN,RN,BA, NP

Community Rapid Response Team (CRRT) Presenters: Dawn Gallant RN,BN, CCHN (C) Jennifer Williams BN,RN,BA, NP Community Rapid Response Team (CRRT) Presenters: Dawn Gallant RN,BN, CCHN (C) Jennifer Williams BN,RN,BA, NP Community Rapid Response Team (CRRT) A pilot program in partnership between: Department of Health

More information

NEW LONG TERM CARE SURVEY PROCESS PHASE 2 REQUIREMENTS OF PARTICIPATION AUGUST 23, 2017

NEW LONG TERM CARE SURVEY PROCESS PHASE 2 REQUIREMENTS OF PARTICIPATION AUGUST 23, 2017 NEW LONG TERM CARE SURVEY PROCESS PHASE 2 REQUIREMENTS OF PARTICIPATION AUGUST 23, 2017 Disclaimer: The information contained in this presentation is representative of the current information provided

More information

FOR LEADINGAGE POST-ACUTE AND LONG TERM SERVICES AND SUPPORTS

FOR LEADINGAGE POST-ACUTE AND LONG TERM SERVICES AND SUPPORTS December 2016 MODEL SCORE CARD ELEMENTS FOR LEADINGAGE POST-ACUTE AND LONG TERM SERVICES AND SUPPORTS BACKGROUND The purpose of this scorecard is threefold: 1. To help organize quality measures into internal

More information

UPMC & UPMC HEALTH PLAN. UPMC CENTER FOR WELLNESS For individuals with spina bifida and spinal cord injury

UPMC & UPMC HEALTH PLAN. UPMC CENTER FOR WELLNESS For individuals with spina bifida and spinal cord injury Thursday, August 16, 2012 3:00 PM-4:30 PM EDT UPMC & UPMC HEALTH PLAN Add your company logo here UPMC CENTER FOR WELLNESS For individuals with spina bifida and spinal cord injury Sponsored by AMGA and

More information

einteract User Guide July 07, 2017

einteract User Guide July 07, 2017 einteract User Guide July 07, 2017 This document covers the use of the einteract features in PointClickCare. Table of Contents einteract... 3 einteract Quick Reference Guide... 3 Overview of einteract...

More information

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/15/2016

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/15/2016 Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/15/2016 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop

More information

Reducing Readmission Case Stories Discussion of Successes

Reducing Readmission Case Stories Discussion of Successes Reducing Readmission Case Stories Discussion of Successes University of California, San Francisco Maureen Carroll RN, CHFN Transitional Care Manager Heart Failure Program Coordinator UnityPoint Cedar Rapids

More information

FIRE DEPARTMENT COMMUNITY ASSISTANCE, REFERRAL, & EDUCATION SERVICES

FIRE DEPARTMENT COMMUNITY ASSISTANCE, REFERRAL, & EDUCATION SERVICES FIRE DEPARTMENT COMMUNITY ASSISTANCE, REFERRAL, & EDUCATION SERVICES What is FDCARES? Fire Department Community Assistance Referral, and Education Services Proactive connection phone calls and home visits.

More information

Tool: Discharge Planning Process (c)(1)

Tool: Discharge Planning Process (c)(1) Purpose & Intent 483.21(c)(1): To develop a discharge plan to help as many residents who want to return back to the community, to be effectively discharged from the nursing center back to the community.

More information

Rehospitalizations: How Do You Measure Up?

Rehospitalizations: How Do You Measure Up? Rehospitalizations: How Do You Measure Up? National Nursing Home Quality Care Collaborative (NNHQCC) Health Services Advisory Group (HSAG) Today s Objectives Recognize the role skilled nursing facilities

More information

Acute Care for Older People from Residential Care Facilities (RACF)

Acute Care for Older People from Residential Care Facilities (RACF) Opportunities for Promoting Care in Appropriate Sites Suma Poojary Acute Care for Older People from Residential Care Facilities (RACF) Background Mobile Assessment and Treatment Service ( MATS) Barriers

More information

NoCVA Preventing Avoidable Readmissions. Moving Beyond the Basics March 27, 2014

NoCVA Preventing Avoidable Readmissions. Moving Beyond the Basics March 27, 2014 NoCVA Preventing Avoidable Readmissions Moving Beyond the Basics March 27, 2014 Dr. Amy Boutwell REDUCING READMISSIONS IN 2014 Using data to drive an expanded, multifaceted strategy Amy E. Boutwell, MD,

More information

Electronic Medication Reconciliation and Depart Process Overview Nursing Deck

Electronic Medication Reconciliation and Depart Process Overview Nursing Deck Electronic Medication Reconciliation and Depart Process Overview Nursing Deck Revised: 8/16/2011 1 Introduction To achieve the highest standard of care that our system aspires to, as well as to meet the

More information

Is It Really a UTI? Do You Know It When You See It?

Is It Really a UTI? Do You Know It When You See It? Is It Really a UTI? Do You Know It When You See It? Today s Objectives 1. Define Symptomatic UTI versus Asymptomatic Bacteriuria 2. Review RAI MDS Coding Manual Definition of UTI 3. Analyze UTI as a Quality

More information

Understand healthcare facilities and organizational structure with focus on LTC.

Understand healthcare facilities and organizational structure with focus on LTC. Unit A Nurse Aide Workplace Fundamentals Essential Standard 1.00 Understand the range of function, legal and ethical responsibilities of the nurse aide within the healthcare system. Indicator 1.01 Understand

More information

Home-Based and Long-Term Care Presentation to Health PEI Board of Directors November 6, 2012

Home-Based and Long-Term Care Presentation to Health PEI Board of Directors November 6, 2012 Home-Based and Long-Term Care Presentation to Health PEI Board of Directors November 6, 2012 Divisional Profile The Home-Based and Long-Term Care Division provides supportive services to people in need

More information

M2020 Accuracy in Patients in Assisted Living Facilities

M2020 Accuracy in Patients in Assisted Living Facilities This job aid provides guidance on answering M2020 (Management of Oral Medications) accurately for patients living in Assisted Living Facilities (ALF) or other situations where medications are routinely

More information

Thinking Differently about Hospital Readmissions

Thinking Differently about Hospital Readmissions Thinking Differently about Hospital Readmissions LaNita Knoke RN, BS, CMCN Healthcare Strategist Senior Care Continuum Each Home Instead Senior Care franchise office is independently owned and operated.

More information

IMPORTANT PROVIDER UPDATES

IMPORTANT PROVIDER UPDATES December 28, 2015 IMPORTANT PROVIDER UPDATES Dear Provider, Please find attached important updates, reminders and policy changes for Coordinated Care providers regarding: Page Title Number 2 Notice 1:

More information

Effective Tools to Prevent and Manage Adverse Events

Effective Tools to Prevent and Manage Adverse Events Effective Tools to Prevent and Manage Adverse Events Based on Office of Inspector General Adverse Events Report Diane C. Vaughn, RN, C-DONA/LTC; LNHA vaughndiane@hotmail.com Objectives Upon completion

More information

Documentation 101: CDI JULY 19, 2017

Documentation 101: CDI JULY 19, 2017 Documentation 101: CDI THE FIFTH NATIONAL PHYSICIAN ADVISOR AND UTILIZATION REVIEW BOOT CAMP JULY 19, 2017 Infirmary Health: About Us Infirmary Health is the largest non-governmental healthcare system

More information

HomeFirst. Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future.

HomeFirst. Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future. Most importantly, we patients prefer and hope to be at home not in hospital, so I think this service is the way of the future. HomeFirst I felt I was looked after at home much better than I would have

More information

Antimicrobial Stewardship in Continuing Care. Nursing Home Acquired Pneumonia Clinical Checklist

Antimicrobial Stewardship in Continuing Care. Nursing Home Acquired Pneumonia Clinical Checklist Antimicrobial Stewardship in Continuing Care Nursing Home Acquired Pneumonia Clinical Checklist March 2015 What is Antimicrobial Stewardship? Using the: right antimicrobial agent for a given diagnosis

More information

Guidelines for the appointment of. General Practitioners with Special Interests in the Delivery of Clinical Services. Respiratory Medicine

Guidelines for the appointment of. General Practitioners with Special Interests in the Delivery of Clinical Services. Respiratory Medicine Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical Services Respiratory Medicine April 2003 Respiratory Medicine This General Practitioner with a

More information

Transforming Health Care For Seniors in the Mississauga Halton LHIN Right care, right time, right setting, right cost

Transforming Health Care For Seniors in the Mississauga Halton LHIN Right care, right time, right setting, right cost Transforming Health Care For Seniors in the Mississauga Halton LHIN Right care, right time, right setting, right cost Narendra Shah COO MH LHIN September 29, 2010 1 Implications of Alternate Level of Care

More information

Home Health. Improving Patient Outcomes & Reducing Readmissions. Home Health: Improving Outcomes & Reducing Readmissions

Home Health. Improving Patient Outcomes & Reducing Readmissions. Home Health: Improving Outcomes & Reducing Readmissions Home Health Improving Patient Outcomes & Reducing Readmissions Home Health: Improving Outcomes & Reducing Readmissions Benefits of Home Health Care Scientific evidence proves people heal more quickly,

More information

Stopping the Chain of Infection: Strategies for Preventing Sepsis in Long Term Care September 20, 2016

Stopping the Chain of Infection: Strategies for Preventing Sepsis in Long Term Care September 20, 2016 Stopping the Chain of Infection: Strategies for Preventing Sepsis in Long Term Care September 20, 2016 VHQC 1. Private, nonprofit healthcare consulting firm 2. Virginia s QIO since 1984; now the Quality

More information

Data Entry for the Advancing Excellence Campaign What you need to know

Data Entry for the Advancing Excellence Campaign What you need to know Data Entry for the Advancing Excellence Campaign What you need to know An important step in quality improvement is to regularly review your facility s progress toward meeting its goals. In fact, this is

More information

REDUCING READMISSIONS FOR SNF PATIENTS

REDUCING READMISSIONS FOR SNF PATIENTS REDUCING READMISSIONS FOR SNF PATIENTS Amy E. Boutwell, MD, MPP President, Collaborative Healthcare Strategies New York State Partnership for Patients HIIN September 28, 2017 Objective Identify 3 practical

More information

CareTrek : Nebraska s Journey to Safe Care Transitions

CareTrek : Nebraska s Journey to Safe Care Transitions CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement

More information

OASIS ITEM ITEM INTENT

OASIS ITEM ITEM INTENT (M2400) Intervention Synopsis: (Check only one box in each row.) At the time of or at any time since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered

More information

Patient Interview/Readmission Chart Review. Hospital Review:

Patient Interview/Readmission Chart Review. Hospital Review: Appendix: Readmission Review Form Patient Interview/Readmission Chart Review Patient Name: Previous Hospital Admission Date Account Number Previous Hospital D/C Date: D/C MD: Previous Hospital Discharge

More information

Outcome Measures: Reform at the Core: Page 1. The Triple Aim Goals. Getting Down into the Weeds

Outcome Measures: Reform at the Core: Page 1. The Triple Aim Goals. Getting Down into the Weeds Outcome Measures: Getting Down into the Weeds LeadingAge Missouri Fall Conference 18 September 2013 Andy Edeburn, VP of Continuum Strategies 2 Reform at the Core: The Triple Aim Goals Better Care Improve/maintain

More information

Linking the LAS with Health & Social Care. 6 th December 2016

Linking the LAS with Health & Social Care. 6 th December 2016 Linking the LAS with Health & Social Care 6 th December 2016 Outline: About me.. LAS Context Integrating LAS with H&SC London Ambulance Service NHS Trust 2 LAS context London Ambulance Service NHS Trust

More information

4/13/2015. I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor for CMS.

4/13/2015. I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor for CMS. Alice Bonner, PhD, RN, FAAN Northeastern University April 30 th, 2015 Photo:Alex Tenappel I am the former Director of the CMS Division of Nursing Homes. I am not currently a CMS official; I work as a contractor

More information

Improving Resident Care: A look at CMS quality of care initiatives

Improving Resident Care: A look at CMS quality of care initiatives Improving Resident Care: A look at CMS quality of care initiatives W H I T E P A P E R by Diane L. Brown dbrown@hcpro.com What do reduction in rehospitalization, caring for dementia patients and preventing

More information

Sample Learning Care Plan For Nursing Students

Sample Learning Care Plan For Nursing Students Sample Care For Free PDF ebook Download: Sample Care For Download or Read Online ebook sample learning care plan for nursing students in PDF Format From The Best User Guide Database Blank Individualized

More information

Admissions and Transitions Optimization Program. Nursing Facility and Practitioner Billing

Admissions and Transitions Optimization Program. Nursing Facility and Practitioner Billing Admissions and Transitions Optimization Program Nursing Facility and Practitioner Billing November 2016 Contents Introduction... 4 Payment Reform... 5 Components... 5 Eligibility... 6 Long Term Care (LTC)

More information

Introduction to Population Health Healthcare Public Health

Introduction to Population Health Healthcare Public Health Introduction to Population Health Healthcare Public Health Dr Jason Horsley Senior Clinical Lecturer in Public Health, ScHARR Consultant in Public Health, Sheffield City Council j.horsley@sheffield.ac.uk

More information

Safe Transitions Best Practice Measures for

Safe Transitions Best Practice Measures for Safe Transitions Best Practice Measures for Nursing Homes Setting-specific process measures focused on cross-setting communication and patient activation, supporting safe patient care across the continuum

More information

Our Vision UPMC will lead the transformation of health care. The UPMC model will be nationally recognized for redefining health care by:

Our Vision UPMC will lead the transformation of health care. The UPMC model will be nationally recognized for redefining health care by: Performance Document - Annual Performance Review Self-Evaluation Donald Bucher, Supervisor, CRNP Annual Performance Review, 07/16/2013-07/15/2014 Author: Donald Bucher Role: Employee Status: Completed

More information

Mobilize Me : The Ready-Set-Go Approach to Mobilizing the Acute Elder Population

Mobilize Me : The Ready-Set-Go Approach to Mobilizing the Acute Elder Population Mobilize Me : The Ready-Set-Go Approach to Mobilizing the Acute Elder Population Lily Spanjevic, RN, MN & Amy dehueck, BScPT Advanced Practice Nurse Professional Practice Leader-Physiotherapy Geriatrics-Medicine

More information

The Urine Dipstick: A Quick Way To Over-Treat! Ann McFeeters, RN Infection Control Practitioner September 26, 2012

The Urine Dipstick: A Quick Way To Over-Treat! Ann McFeeters, RN Infection Control Practitioner September 26, 2012 The Urine Dipstick: A Quick Way To Over-Treat! Ann McFeeters, RN Infection Control Practitioner September 26, 2012 Objectives Discuss what is a Urinary Tract Infection (UTI) Reflect on current practices

More information

Transitions of Care. ACOI Clinical Challenges in Inpatient Care. March 31, 2016 John B. Bulger, DO, MBA

Transitions of Care. ACOI Clinical Challenges in Inpatient Care. March 31, 2016 John B. Bulger, DO, MBA Transitions of Care ACOI Clinical Challenges in Inpatient Care March 31, 2016 John B. Bulger, DO, MBA Disclosure I have not accepted any honoraria, additional payments of reimbursements related to the

More information

Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence

Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Risk Factor Analysis for Postoperative Unplanned Intubation and Ventilator Dependence Adam P. Johnson MD, MPH, Anisha Kshetrapal MD, Harold Hsu MD, Randi Altmark RN, BSN, Herbert E Cohn MD, FACS, Scott

More information

This is a high level overview report to update the Board on the Acute Adult Safety Programme consisting of the following sections:

This is a high level overview report to update the Board on the Acute Adult Safety Programme consisting of the following sections: Greater Glasgow and Clyde NHS Board Board Meeting June 2014 Board Paper No. 14/34 Board Medical Director Scottish Patient Safety Programme Update 1. Background The Scottish Patient Safety Programme (SPSP)

More information

2/18/2016 THE ROLE OF NURSE PRACTITIONERS IN LONG-TERM CARE DISCLOSURES OBJECTIVES

2/18/2016 THE ROLE OF NURSE PRACTITIONERS IN LONG-TERM CARE DISCLOSURES OBJECTIVES THE ROLE OF NURSE PRACTITIONERS IN LONG-TERM CARE Nanette Lavoie-Vaughan, DNP, ANP-C East Carolina University Tomika Williams, PhD (c), AGPCNP-C, RN-BC East Carolina University DISCLOSURES Nanette Lavoie-Vaughan

More information

QBPs: New Ways To Improve Patient Care

QBPs: New Ways To Improve Patient Care Module 1: QBPs: New Ways To Improve Patient Care Quality Based Procedures (QBPs) Pathway Improvement Program What are Quality Based Procedures (QBPs)? QBPs are groups of patients with similar diagnoses

More information

Why Every SNF Should Be Offering Telemedicine For Its Residents or Transforming SNF Care Through Telemedicine

Why Every SNF Should Be Offering Telemedicine For Its Residents or Transforming SNF Care Through Telemedicine PACAH 2018 Spring Conference John Whitman, MBA, NHA The Wharton School Tapestry TeleHealth The TRECS Institute Why Every SNF Should Be Offering Telemedicine For Its Residents or Transforming SNF Care Through

More information

Applicant Name: Survey Date: Reviewer Name: Class A Licensed-Only Home Care Pre-licensing Survey. Not Met. Notes. Met

Applicant Name: Survey Date: Reviewer Name: Class A Licensed-Only Home Care Pre-licensing Survey. Not Met. Notes. Met Class A Licensed-Only Home Care Pre-licensing Survey Applicant Name: Survey Date: Reviewer Name: Confirm information provided on application: Applicant name: Address: City, State: Phone number: Emergency

More information

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 3/16/2016 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop

More information

Acute kidney injury Keeping kidneys healthy: The AKI programme board. Dr Richard Fluck, National Clinical Director (Renal) NHS England

Acute kidney injury Keeping kidneys healthy: The AKI programme board. Dr Richard Fluck, National Clinical Director (Renal) NHS England Acute kidney injury Keeping kidneys healthy: The AKI programme board Dr Richard Fluck, National Clinical Director (Renal) NHS England NHS Outcomes Framework NHS Five Year Forward View A vision for the

More information

Dual-eligible SNPs should complete and submit Attachment A and, if serving beneficiaries with end-stage renal disease (ESRD), Attachment D.

Dual-eligible SNPs should complete and submit Attachment A and, if serving beneficiaries with end-stage renal disease (ESRD), Attachment D. Attachment A: Model of Care for Dual-eligible SNPs MA Contract Name: Geisinger Health Plan MA Contract Number: H3954-097 Type of Dual-eligible SNP: Full The model of care describes the MAO's approach to

More information

Review Process. Introduction. InterQual Level of Care Criteria Long-Term Acute Care Criteria

Review Process. Introduction. InterQual Level of Care Criteria Long-Term Acute Care Criteria InterQual Level of Care Criteria Long-Term Acute Care Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of Long-Term Acute Care (LTAC) admission,

More information

Improving Nursing Home Compare for Consumers. Five-Star Quality Rating System

Improving Nursing Home Compare for Consumers. Five-Star Quality Rating System Improving Nursing Home Compare for Consumers Five-Star Quality Rating System Improving Nursing Home Compare Major Revision to Nursing Home Compare Mid-December Improved Navigation - Similar to Hospital

More information

CareTrek : Nebraska s Journey to Safe Care Transitions

CareTrek : Nebraska s Journey to Safe Care Transitions CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement

More information

Leveraging Your Facility s 5 Star Analysis to Improve Quality

Leveraging Your Facility s 5 Star Analysis to Improve Quality Leveraging Your Facility s 5 Star Analysis to Improve Quality DNS/DSW Conference November, 2016 Presented by: Kathy Pellatt, Senior Quality Improvement Analyst, LeadingAge NY Susan Chenail, Senior Quality

More information