Using Patient Care Conferences to Avoid Readmissions and Resolve Delays

Transcription

1 Using Patient Care Conferences to Avoid Readmissions and Resolve Delays Colleen Booz Dittrich, LMSW, CCM, ACM Manager, Care Transitions The University of Kansas Hospital Kansas City, KS Sandy McFolling, RN, MS, ACM Senior Clinical Advisor ACMA Chicago, IL April 27, 2015

2 Objectives Increase awareness of national trends and impact on therapeutic communication Examine impact of patient/family related barriers to discharge and risks for readmission Recognize patient/family triggers and apply methods to facilitate effective communication Provide a toolkit for leading a successful patient care conference

3 National Trends: Aggression within the Workplace

4 Trends: Worker Type Figure 2.

5 Trends: Employee Response

6 Healthcare Risk Factors (OSHA) Free movement of public in healthcare settings Low staffing levels Isolated work with clients Use of hospitals by criminal justice system Lack of community based care for mentally ill Long waits for services Distraught family members and patients

7 At-Risk Situations in Healthcare Care/treatment delays Patient refusal of necessary care Patient environment/discomfort (pain, equipment, mobility, wound care, medication) Medication effects Existing mental health disorder Confusion or cognitive impairment Family perception that a vulnerable pt. is not receiving needed care (Lennaco, 2013)

8 ACMA Compare TM National Trends in Avoidable Delays Delay Root Cause Avg delays per month 550 bed hosp* Avg days per delay** Projected avg cost per delay*** Precert or preauth delay $1,579 Family / Patient related delays $1,654 SNF Placement Delays $917 Incorrect level of care at beginning of stay NA Inappropriate continued stay (end of stay) $705 Physician plan of care / coordination $1,206 Procedure / testing delays $1,141 Data above based on benchmarking information from ACMA Compare benchmarking. *Approximate patient volume = 2,200 discharges per month. ** Average number of additional overnights added to LOS due to the delay. *** Based on average cost per day of $450 for days at end of stay, $800 for other days.

9 CM Involvement: Avoidable Delay Trends Delay Root Cause Avg delays per month 550 bed hosp* Avg days per delay** Projected avg cost per delay*** Lack of financial resources $6,927 Lack of community resources $975 Patient homelessness $2,196 Behavioral health needs $1,443 Complex care needs $3,041 Delays in tests / treatments $1,141 Missing or delayed physician plan of care $1,206 Data above based on benchmarking information from ACMA Compare benchmarking. *Approximate patient volume = 2,200 discharges per month. ** Average number of additional overnights added to LOS due to the delay. *** Based on average cost per day of $450 for days at end of stay, $800 for other days.

10 National Trends: Readmissions Readmission Root Cause Avg readmissions % of discharges Avg readmissions per month* Uncontrolled Advancement of Chronic Disease 3.18% 70 Unrelated Readmissions 1.99% 44 Medical Plan of Care Treatment or Complications 1.97% 43 Scheduled Readmission 1.80% 40 Patient / Caregiver Issues 0.29% 6 Medication Management 0.19% 4 Data above based on benchmarking information from ACMA Compare benchmarking. * For hospital of 550 beds with approximate patient volume = 2,200 discharges per month.

11 Developing Sustainable Plans: Patient Challenges Dealing with conflicts over can t or simply won t CM attempts to provide stability and structure perceived as attempts to control Patient realization CM is not omnipotent tyrant or fountain of unlimited support Street culture values=personal autonomy, self reliance, cautiousness and skepticism toward professional helpers

12 Homelessness and Engagement Common challenges: Suspicious of treatment providers Ambivalence toward treatment First time offers rejected, may accept later Ongoing residence moves not interpreted as rejection of services Commonly no income or disability funding, takes time to secure benefits

13 Medical Conditions Which Can Cause Aggression Pneumonia, worsening chronic airway disease Diabetes Malnourished alcoholic Neuro-Stroke, Tumor, Seizure Metabolic disturbance Liver or renal failure Sepsis, UTI

14 Understanding the Patient The Needs, Triggers and Methods for Supporting the Patient Experience

15 Patient Experience

16 Patient Experience Recognize patient experience is also their support person s experience Emotions affect ability to hear what care team is communicating to us Persons with h/o childhood trauma may act out as adult (self harming behaviors, abuse) Care/treatment can add to patient frustration

17 Comprehensive Assessment Helps to identify potential risks Key Components in the conversation - Getting to know you beyond clicking the boxes - Understand support system - Validate with family & identify disconnects - Further explore questions - Continually check-in with patient/family - Adapting plan to patients readiness

18 Recognizing Individual Perspective Medical and physical (medications, sensory impairment, substance abuse) Emotional factors (fear of the hospital, frustration with rules, feelings of loneliness or depression) Situational and Cultural (change in routine, lack of privacy, language barriers) Past history of bad experiences Liberty Mutual Group.com

19 Understanding Family Dynamics Deal with aggressive, assertive family members take over and maneuver themselves in to positions of power Withhold info from patient Utilize intimidation Establish position of power to control patient Expose Family secrets

20 De-escalation Approaches Use empathic non-confrontational approach while also setting boundaries Listen, avoid giving opinions on issues beyond your control Avoid excessive stimulation Avoid aggressive postures and prolonged eye contact Ask for help from care team as needed Check to be sure medical issues such as pain are addressed Determine what the patient wants and the level of urgency

21 Care Conferences The Who, What, When and How

22 Identifying the Need Significant amount of questions unanswered for the patient/family shared with care team Difficult decisions to consider regarding the care plan Multiple family members or support agencies involved in coordinating the patients care Advantage of having all the care team members in the same room to discuss a comprehensive update and plan for patient s care progression

23 Common Obstacles Participant is uninformed about current status or recommendations from the team Difference of opinions regarding next steps Denial or difficulty understanding the information Anxiety about making a decision or managing their care post discharge Mistrust with the healthcare team

24 Preparation is Key What are the issues? Can they be resolved without a conference? What do we hope to achieve? Who needs to attend? How do I need to prepare the team and the patient/family prior to the care conference?

25 Outlining a Plan Formal agendas are useful for complex cases General outlines and communication of the plan for the meeting should be discussed with the care team in advance Order of discussion Necessary items that need to be addressed Who will facilitate and guide the meeting

26 Preplanning with the Team Remember who the patient is beyond diagnoses Outline any known questions or concerns identified by the patient or support system Discuss realistic options for care and discharge Work through our issues and remove our biases Review expectations and plan for each team members participation Plan for the hard conversations

27 Preplanning with the Patient/Support Communicate the need for a meeting Outline what they can expect Encourage their participation Identify a day/time to have meeting Recognize and plan for the emotional response and prep necessary prior to a care conference

28 Vera s Story One patient s experience changes practice Questions provided for families and patients to consider discussing in the conference

29 Examples of the WHY Articulate why we are meeting as a team We want to have the opportunity to get on the same page regarding treatment planning, next steps and answer any questions you may have with your care plan. You and I have been talking about some of your questions and concerns. We want to have a care conference with you to allow us the opportunity to get together as a team to discuss these concerns and identify a plan for next steps.

30 Facilitating the Discussion Set the stage for the purpose of the meeting and plan Give idea of agenda and schedule Thank everyone in the room for attending and being an active participant in the discussion Allow for introductions Begin with medical overview and current status

31 Facilitating the Discussion Be ready to address derailments Re-cap what was discussed as a team Present next steps and follow-up items Seek validation from patient/family Summarize plan and timeline

32 Evaluating Effectiveness Patient/Family Follow-up with patient/family following the meeting to ensure the conference met their needs; address any pending questions Involve other key care team members Ensure timely follow through on action items

33 Evaluating Effectiveness Care Team What worked, what didn t How can we improve next time What support can we get from our team/dept Does there need to be an additional meeting Discuss any feedback from the patient/family

34 Next Steps Recognize this is one piece of managing delays and avoiding readmissions Key is to engage the patient/family as part of the care team to allow for ongoing communication and planning throughout the hospitalization Don t assume one care conference meeting solves all the needs for each patient

35 Next Steps (cont.) Manage patient/family expectations by staying in close communication Anticipate their needs and facilitate care conferences to help ensure clear goals and efficient planning Address questions/concerns timely and ensure a successful transition plan

36 Thank You! Questions?

37 Reference List Lennaco, J., Dixon, J., Whittemore, R., Bowers, L. (January 31, 2013). Measurement and Monitoring of Health Care Worker Aggression Exposure OJIN: The Online Journal of Issues in Nursing. Vol. 18,No.1, Manuscript 3. Kanter, J. Clinical Issues in the Case Management Relationship Clinical Case Management.com/uploads/ How to Manage Patient Aggression and Ensure Staff and Patient Safety. Case Management for the Mentally Ill Patients Harris.