Reducing Hospital Readmissions: Home Care as the Solution

Transcription

1 Reducing Hospital Readmissions: Home Care as the Solution Kathy Duckett RN, BSN Sutter Center for Integrated Care

2 Learning Objectives 1 Review the 3 principles of Integrated Care Management (ICM) 22 Define key ICM Transitions of Care practices in the hospital and home 3 Discuss home care s unique value as a transitions of care partner 2

3 Facts About Who We Serve Sutter Care at Home 28 Locations 11 Home Health 7 Hospices 2 Infusion 2 HME 1 Private Duty & Geriatric Care Management 1,800 Employees 770 Volunteers 18,000 Average Daily Census Sutter Center for Integrated Care Sutter Health: Transitions of Care, PCMH, Case Management 5900 Providers outside of SCAH/SH 48 States 3 Countries: US, Canada & Singapore

4 Integrated Care Management (ICM): Where it Started Journey Towards Excellence In Homecare: Improving Outcomes of Care 4

5 The Right Thing to Do: IOM Quality Chasm Report Current healthcare systems cannot do the job Trying harder will not work Changing care systems will work Make the right thing to do the easy thing to do 5

6 The Right Thing to Do: IOM Quality Chasm Report ALL health care providers should pursue six major aims: 1) Safe 2) Effective 3) Patient Centered 4) Timely 5) Efficient 6) Equitable Providing care that is respectful of and responsive to individual patient preferences, needs, & values & ensuring patient values guide all clinical decisions. A New Health System for the 21 st Century (IOM, 2001) 6

7 Integrated Care Management (ICM) Model What is It? A care delivery model Based on Wagner s Care Model (aka Chronic Care Model) Integrated Health Literate Care All patients across continuum Defines key best practices & competencies for all providers across settings 7

8 Integrated Care Management (ICM): A Care Delivery Model for Improved Outcomes Person Centered - Care with dignity and respect - Goals drive care - Patient as partner Evidence-Based - Clinical best practices - Patient Engagement: Self-management support Health literate care Coordinated Care - Seamless transitions across providers, settings, and time - Meaningful and timely information exchange Improved outcomes leading to better health, better care and lower cost

9 Patient Goals BEFORE: Patient will Wellness At Risk Chronic Conditions Complex Conditions Advanced Illness Receive flu and pneumonia vaccine according to guideline level care. Remain free of signs and symptoms of infection at surgical site. Reach control of diabetes with BS levels of and daily control of diabetes as evidenced by HgA1C of less than 7. Be able to walk 100 feet unassisted. Be at acceptable pain level while remaining as alert as possible. 9

10 ICM Person-Centered: Patients Goals Drive Care Wellness At Risk Chronic Conditions Complex Conditions Advanced Illness Return to weekly bridge game without undo fatigue. Remain in home without going to ER or Hospital in order to participate in all of grandchildren s school and ballet activities. Be able to safely drive again. Walk on my own to the activity center without assistance. Able to join ROMEO (Retired Old Men Eating Out) group for lunch once a week. 10

11 Stoplight: Supports Patient & Family Engagement First person Patient daily assessment drives navigation Font, layout, graphics consistent with health literacy and plain language principles Supports patient and caregiver engagement Supports teach back with content ready for chunk and check

12 ICM Evidence-Based: Patient Engagement Where we tend to focus: Adherence to clinical guidelines Patient education Directing Where new focus is needed: Clear communication Comfortable with questions Choices provided, not just advice Confidence building focus

13 Health Literate Stoplight Tools In Action One Patient s view on the Stoplight tool 13

14 Care Transitions Definition Care transitions refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Eric A. Coleman, MD, MPH Care Transitions Program SM 14

15 ICM: Coordinated Across Providers, Settings, & Time 15

16 Transitions Can Be Tricky Hospital Home 16

17 Stats and Facts Medicare pts 1 in 5 patients discharged from hospital readmitted within 30 days Readmissions often a sign of inadequate discharge planning, poor care coordination between hospital and community clinicians, and the lack of effective longitudinal community-based care. The additional hospital stays imply that many patients are getting sicker, not better, after their initial discharge. Other patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care. These readmissions lead to more tests and treatments, more time away from home and family, and higher health care costs. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries September 28, 2011

18 WHAT Literature Review of Care Transitions Best Practices Across Providers & Settings Hospital Programs Ambulatory Care Programs Home/Community Programs Accrediting Organization Programs

19 ICM TOC Aligns with The Joint Commission 7 Foundations For Safe Transitions 1. Patient/family action/ engagement 2. Early identification for at risk patients 3. Transitions planning 4. Medication management 5. Multidisciplinary collaboration 6. Transfer of information 7. Leadership support Source: Hot Topics in Healthcare, Issue # 2, Transitions of Care: The need for collaboration across the healthcare continuum. The Joint Commission, February,

20 Home Care's Unique Role in Transitions Comprehensive assessments including risk assessments Focus on medication reconciliation, signs & symptoms, MD Follow - up appointments Case management & care coordination ICM Training: Skills for effective health coaching in self management support & evidence-based guideline care

21 ICM Transition of Care Objectives Expand the role of home health professionals Provide transition of care services in the hospital and home settings Restructure in-home care processes to optimally support transitioning patients Provide systematic approach for care of home health high-risk patients discharged from the hospital

22 ICM Transitions of Care (TOC) Compared to Other TOC Models INTERVENTION Coleman CTI Naylor TCM Project BOOST Reengineered Dis-Charge RED Risk Assessment Medication Reconciliation Red Flags & Follow-up 24/7 on call response Hospital Visit Physician F/U Home Visit post discharge Remote Monitoring Active engagement of pts PHR (Patient Health Record) ICM 22

23 ICM Unique TOC Interventions INTERVENTION Coleman CTI Naylor TCM Project BOOST Reengineered Dis- charge RED Health Literacy Screen Depression Screen Personal concerns/goals Med Management Pt friendly med list Health Literate stoplights Case conf High Risk pts Family Caregiver Assessment ICM 23

24 How Is This Model Different? Care transition support begins in the hospital and continues in the home by same healthcare sector home health The fewer the transitions the less the risk No one size fits all Patients have fewer layers of care providers Clinicians are trained to identify patients common barriers for self-care Clinicians provide care based on patient goals and aspirations

25 ICM Transitions of Care: Hospital & HH Partnership In Hospital Process Multidisciplinary Rounds Transitions Care Planned by Team Hospital Secures Pt Choice Admission Attendees: MDs, Case Management, Nursing, Social Work, Pharmacists Risk Assessment Appropriate for Homecare MD writes order Hospital Case Manager meets with patient and secures Pt Choice Notify SCAH if selected to provide Home Care services HCC Accesses Patient Data HCC Initial Bedside Visit HCC Second Bedside Visit Family/caregiver conference may be held to determine appropriate level of care: HH, AIM, Hospice Chart Review Reviews with RN Case Manager Initiates Referral Intake (RI)Note Explains program and inquires about patient s concerns Pt Assessments: Risk for readmission Begins Stoplight teaching Continues assessment and stoplight teaching Builds rapport Updates RI note Discharge HCC notifies branch of discharge 25

26 Risk Stratification: Institute for Health Improvement High-Risk Pts Moderate Risk Pts a. Patient has been admitted two or more times in the past year b. Patient failed teach back, or the patient or family caregiver has a low degree of confidence to carry out self-care at home a. Patient has been admitted once in the past year b. Patient or family caregiver has moderate degree of confidence to carry out self-care at home 26

27 Person-Centered Starting in Hospital I have four areas we need to focus on to help prepare you and your family for discharge, but before we start on my list can you tell me what you are the most concerned about when you leave here and go home? Then transitions of care focus areas. 1. Medication Management Post-Discharge 2. Early Follow-up 3. Symptom Management 4. Personal Health record 27

28 Patient Facing Tools: Consistency Across Providers & Settings 14 Topics available: 1. Heart failure 2. COPD 3. Diabetes 4. Depression 5. Pneumonia 6. Falls 7. Wounds 8. Pain 9. Constipation 10. Nausea 11. Anxiety 12. Stroke 13. Shortness of breath 14.High risk medication stoplights (Coumadin, Lovenox & anticoagulants, Plavix & antiplatelets, Tamoxifen, Methotrexate) Coming soon: Skin care Aspiration Insulin/oral hypoglycemics Weight gain/edema Provider specific instruction determined here: Call your nurse Call your doctor Call HH/hospice Call Case Manager 28

29 ICM Transitions of Care: Home Health Touch-Points Pre-discharge Home visits Remote monitoring Week 1 Home Care Coordinator inhospital pt visit Pt Assessments: Risk for readmission Pt Concerns & Stoplight teaching 1st visit w/in 24 hrs of dc 2nd visit w/in 72hrs by same clinician 3rd visit same week Focus on med rec, signs & symptoms, MD f/u, personal health record Remote monitoring to detect signs of exacerbation Week 2 3 home visits Focus on patient engagement, med management, barriers and confidence-building Remote monitoring Remote monitoring with focus on health coaching Additional interventions Case conference Pt friendly med list Medication Management SBAR communication Home visits continue based on need 29

30 Health Coach in the Home: Medication Management Emphasis on med reconciliation and adherence Med brown bag bring all meds out Include all meds taken before hospitalization Ask: - What concerns do you have about your medications? - Do you take any herbs and over the counter meds? - Teach back: Show me which meds you take when NOTE: Ongoing Reconciliation: Any new or changed meds since my last visit? 30

31 Client Friendly Medicine List Medication and Route Dose Frequency Reason Instructions Font size increased to 14 pt 31

32 SBAR Application Transitions of Care Notes EMR Documentation New or change order requests of MD Personal Health Record Case Conferences/ Huddles Eliciting information from patients/families/caregivers 32

33 MY Personal Health Record (PHR) Record belongs to patient and they are asked to be responsible for maintaining it Helps them take a more active role in care and empowers them 33

34 SBAR for Patients in PHR 34

35 Technology in Transitions Theory-Based Telehealth Utilized for early identification of exacerbation Demonstrate cause and effect relationships Coaching for symptom reporting Postive reinforcement/ confidence building

36 ICM Transitions Of Care: Provider, Payor, Healthcare System Decrease in 30-Day Readmission Rates After Implementing ICM Transitions Of Care 40% 20% 0% Sutter-Santa Rosa -20% -40% -60% -40% -47% -38% White County Med Ctr (AR) -80% -100% First Health (NC) Our care transitions partnership with Sutter Santa Rosa resulted in a 40% decrease in 30-day rehospitalization rates from Q to Q

37 ICM Transitions Of Care: Outcome Measure from Patients Perspective Percentage of "always" responses 100.0% 95.0% 90.0% 85.0% n= % n= % 70.0% 65.0% 60.0% Did your clinician listen carefully to you? n=200 n=24 n=13 n=20 n=28 n=18 n=26 n=188 n=252 n=157 n=196 n=184 n=188 n=19 n=212 n=20 n=226 n=21 n=19 n=188 n=179 n=26 n=200 n=19 n = 21 n=211 n=13 n=204 n=182 n = 12 n = 154 n = 11 n = 9 n = % 50.0% Mar 2012 Apr 2012 May 2012 Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Santa Rosa HH 89.5% 75.0% 87.5% 84.6% 89.3% 94.4% 88.5% 68.4% 85.0% 81.0% 89.5% 76.9% 78.9% 95.2% 84.6% 91.7% 88.9% 100.0% All SCAH HH 81.7% 86.5% 81.3% 82.8% 85.6% 82.1% 84.7% 83.0% 86.8% 83.2% 83.2% 80.3% 85.0% 84.8% 78.9% 83.5% 87.7% 84.9% Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 2013 Apr 2013 May 2013 Jun 2013 Jul 2013 Aug

38 ICM: Tools, Practices, and Competencies Across the Health Care System Patient- Centered Medical Home Practices Person-Centered Patient as partner Dignity and respect Goals drive care Home & Community Services Providers Hospital Staff: Coordinators Transitions Coach Evidence-Based Patient engagement Clinical best practices Self-management support Behavior change Disease/ Population Management Case Managers Coordinated Care Meaningful and timely information exchange Across settings, providers and time 38

39 ICM Transitions of Care: Hospital staff perspective I just wanted to take the opportunity to let you know how much we appreciate the Sutter Home Health hospital liaisons. We have had several cases lately that required an enormous amount of post discharge follow up and their follow through has been amazing. Just wanted you to know! Thank you! Susan Case Management Sutter Medical Center, Santa Rosa 39

40 What patients should expect from their health care team: Cooperation: Those who provide care will cooperate and coordinate their work fully with each other and with you. The walls between professionals and institutions will crumble, so that what you experience becomes seamless. You will never feel lost. Crossing the Quality Chasm: A new Health System for the 2st Century, (IOM, 2001) 10 rules to redesign and improve care 40

41 Thank You What questions do you have? Kathy Duckett RN, BSN Director of Training and Development