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

Transcription

1 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 Describe four strategies for clinical staff that help reduce or avoid unnecessary hospitalizations Identify two strategies to make transitions to other care areas successful 2 Background Information Section 3025 of the Affordable Care Act Hospital Readmission Reduction Program Reduction of payments for excess readmissions Readmission = admission of an individual to the same or another hospital within 30 days for an applicable condition Heart failure, acute myocardial infarction, pneumonia Acute exacerbation of COPD & elective total hip/knee arthroplasty 1

2 The Problem 30-67% of all hospital readmissions can be prevented Beneficiaries in LTC facilities account for only 3% of the Medicare population but 5% of total Medicare spending Medicare spending for each LTC beneficiary was $14,538 39% was spent on inpatient hospital stays 38% of beneficiaries living in a LTC facility were admitted to the hospital 41% of those beneficiaries had two or more hospital admissions 24% of all hospitalizations were for ambulatory care sensitive conditions Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Homes and Other Long-Term Care Facilities. The Henry J. Kaiser Family Foundation 4 Most Frequent Causes for Re-hospitalizations Medical Conditions Heart failure Acute myocardial infarction Pneumonia Chronic obstructive pulmonary disease Psychosis Gastrointestinal problems Electrolyte imbalance Sepsis Surgical Conditions Cardiac stent placement Percutaneous transluminal coronary angioplasty Coronary artery bypass graft Major hip or knee surgery Vascular surgery Major bowel surgery Other hip or femur surgery OIG Work Plan Hospitalizations of nursing home residents for manageable and preventable conditions Will determine the extent to which Medicare beneficiaries are hospitalized as a result of conditions thought to be manageable or preventable May indicate quality of care problems U.S. Department of Health and Human Services; Office of Inspector General; Work Plan for Fiscal Year

3 Why Should We Care? Medicare savings Reducing readmissions by 25% could save an estimated $2.1 billion Relationships with hospitals Decreased referrals Reduction of SNF payments 3% for facilities with high rates of care-sensitive, preventable hospital readmissions Better care for our residents Acute care costly and dangerous 7 Consider this 68% of residents have some degree of impaired cognition Your facility is a familiar surrounding their home Relocation stress syndrome increased dependence, anger, depression, withdrawal, feelings of insecurity Reduced anxiety Staff is familiar with the resident 8 Medicare Reimbursement Policies Concerns about Legal Liability and Regulatory Sanctions Resident and Family Preferences HOSPITALIZATION Availability of Diagnostic and Pharmacy Services Availability of Advance Care Plans and Orders for Palliative or Hospice Care Availability of Trained MDs, NPs, PA, RNs, and Personal Care Assistants 3

4 Medicare Reimbursement Policies Concerns about Legal Liability and Regulatory Sanctions Patient and Family Preferences HOSPITALIZATION Availability of Diagnostic and Pharmacy Services in Home and LTC settings Availability of Advance Care Plans and Orders for Palliative or Hospice Care Availability of Trained MDs, NPs, PA, RNs, and Personal Care Assistance Factors to Consider - Systemic Sufficient Personnel Good Communication and Collaboration Monitoring and Assessment Diagnostic Tests Physician or NP IV or advanced clinical services Factors to Consider - Clinical Co-Morbidity or Underlying Disease Physician Confidence Presence of Complications Risk of Complications Clinical Stability Level of Function 12 4

5 Factors to Consider Resident and Family Risk vs. Benefit of Hospital Transfer Lack of Understanding of Advance Directives Personal Preferences Provision of Palliative Care Provision or Use of Hospice Confidence in Facility 13 Let s Start From the Beginning 14 Hot Spots Admission process At risk population Nurses knowledge Medication management Communication with on-call physicians Consistent assignments Nurse practitioner presence 15 5

6 Admission Process Thorough admission assessment All body systems What is baseline? Identify risk factors Put a plan in place Communicate the plan Highest potential include: History of repeat hospital admissions Dementia Recent hospital discharges Multiple co-morbidities 16 Elderly (65 or over) Male African-American Cognitive impairment Rural or low income area Newly admitted to facility Non-English speaking At Risk - Social Ending Hospital Readmissions: A Blueprint for SNFs, Barbara Acello, MS, RN 17 At Risk - Clinical Acute Conditions Dehydration UTI Bacterial pneumonia Chronic Conditions Diabetes Respiratory conditions Circulatory conditions Dementia and behavior problems Ending Hospital Readmissions: A Blueprint for SNFs, Barbara Acello, MS, RN 18 6

7 Identify At Risk Population Identify residents at risk Based on risk factors Initiate care plan Communicate to nursing assistants Who needs additional monitoring Why What to look for 19 How Do You Know What Your Nurses Know? Are they up for the challenge? How well do they know the residents? Do they know the pathophysiology of disease processes? How do your nurses keep their skills sharp? Skills testing What type of ongoing education do they get on disease processes and clinical skills? 20 Staff Education Program Staff should Understand the why, what, and how Identify and address early changes Orientation programs Understand the problem and facility systems Problem-solving exercises Case studies What could we have done differently? Role-playing exercises Act out My part in keeping residents in our facility is. 21 7

8 Clinical Pathways Standardize care to assure all relevant nursing steps are taken to treat a resident Fever, dehydration, electrolyte imbalance, sepsis, urinary tract infections, congestive heart failure, pneumonia, GI distress, and acute change in mental status Shouldn t override common sense one pathway can t address every situation Appropriate to the level of care your facility can provide Highly visible, easily accessible, user friendly 22 Medication Management Medication review Purpose, similar drugs, dosages Review new orders for possible interactions Do your nurses know the hot medications that cause interactions? Warfarin NSAIDs, sulfonamides, macrolides, fluoroquinolones, Dilantin ACE inhibitors potassium supplements, NSAIDs Digoxin Nexium, Lipitor Theophylline Dilantin, Cognex, Cipro American Geriatric Society Beers Criteria Potentially inappropriate medications for use in the elderly Medication reconciliation Identify and clarify any discrepancies Monitoring lab values 23 Communication with the Doc Unfamiliar with the resident Reluctant to write orders Communication between the nurse and physician Clear and concise Be prepared SBAR S situation B background A assessment R recommendation 24 8

9 Staff to Staff Communication 24 hour report Walking rounds between nurses Walking rounds between nurses and aides When aides report something what is done? Do nurses look into it? Do they follow up with the aide? 25 Consistent Assignments When staff know resident, they recognize when things aren t right Subtle changes in mental, physical, or psychosocial ability Focus on excellence Good communication between nursing assistants and nurses Staff to acuity 26 Nurse Practitioner Availability reduces avoidable hospitalizations Leads to shorter times to get treatment ordered and residents seen Better quality of care Responsibilities of NP Coordinate care Perform assessments Manage medications Collaborate with attending physicians and specialists 27 9

10 Transferring Between Care Areas 28 Transitions of Care Transition of care = movement between healthcare locations, providers, or levels of care Within settings Between settings Across healthcare states Between providers Risk factors for poor transitions Multiple medical problems Cognitive deficits Depression or other mental health problems Isolated seniors Non-native English speakers Immigrants and refugees Those with few financial assets Transitions of Care in the Long-Term Care Continuum. AMDA 29 Root Causes of Ineffective Transitions of Care Communication breakdowns Education breakdowns Accountability breakdowns 30 10

11 A Closer Look Communication Breakdown Culture does not promote communication Lack of teamwork and respect Inadequate amount of time provided for communication to occur Lack of standardized procedures SBAR I PASS the BATON 31 Senders and Receivers Expectations out of balance Sender gives critical information to receiver in a timely manner Disconnect between what is actually received and what is actually needed to provide care Receiver responsibility to verify that the information needed was received and responsibility has been assumed Not a HIPAA violation 32 Senders vs. Receivers Receivers say No handoff occurred Incomplete information No opportunity to discuss hand-off with sender Senders say Too many delays Receiver did not call back Receiver too busy to take report 33 11

12 A Closer Look Education Breakdowns Conflicting recommendations, confusing medication regimens, and unclear instructions regarding follow-up care Excluded from planning process Lack an understanding of their medical condition or plan of care 34 A Closer Look Accountability Breakdowns Sending care setting does not take responsibility to ensure coordination happens Failure to coordinate care and communicate Steps are taken to assure that sufficient knowledge and resources will be available Transition coach 35 If Not Done Well Leads to Unneccessary hospitalizations Increased healthcare costs Stress for caregivers, families, and residents Compromised safety 36 12

13 Make it Smooth Start discharge planning on admission Identify risk factors for re-hospitalization If going home, what does the family need to know If going to another facility, provide comprehensive documentation Communicate, communicate, communicate Home visits by therapy and nursing 37 Care Transitions Resources Care Transition Project Community-wide approach to improve transitions from the hospital Project BOOST Assessment of the resident s readiness for discharge Medication reconciliation Medication use taught to resident and family with return demonstration Ability to state diagnosis, follow-up needs, and symptoms Telephone contact arranged for 3 days after discharge 38 Re-hospitalization and QAPI Data analysis Chart review on all hospitalizations QAPI Assess systems and resident data for potential causes Determine which resident conditions can be managed at the facility Develop systems, protocols, and pathways to aid in decision-making Identify training needs 39 13

14 Honey-Do List Staff education Online training Congestive Heart Failure (CHF) Management Chronic Obstructive Pulmonary Disease (COPD) Management Assessing Breath Sounds Components of a Respiratory Assessment Skills fair Refresher Resident and family education Meet with physicians and hospitals 40 Resources CMS Readmissions Reduction Program OIG 2014 Work Plan Clinical Pathways AGS Updated Beers Criteria Society of Hospital Medicine Project Boost 41 Contact Information Jennifer Moore jmoore@reliaslearning.com 14

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