Transitional Care and Ventilator Program Benefits and Scope of Program

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3 Transitional Care and Ventilator Program Benefits and Scope of Program Purpose: Understand the gaps in quality and patient safety that exists in post-acute care literature and essential components of Transitional Care Program that attempts to address these gaps and promote high quality, patient centered cost-effective care that incorporates the latest medical knowledge, evidence based guidelines, best practices in communication, collaboration, and care coordination through highly functioning well trained teams. In addition, it is important to understand how these programs will also positively impact the disparity of healthcare that exists in rural communities and skilled nursing facilities. Objectives: Understand some of the key factors that are associated with poor post-acute care clinical outcomes and excessive hospitals costs Understand the factors that influence staff and patient satisfaction and relationship to clinical outcomes and patient safety Understand how Transitional Care Program utilizes swing beds in critical access hospitals and positively impacts: o Clinical outcomes and patient satisfaction o Revenues and resources for transitional care patients, inpatients and outpatients o Long term viability of these facilities o Jobs and access to healthcare. Understand the essential clinical components of Transitional Care Program and impact of effective communication, collaboration and care coordination on the following: o Patient and staff satisfaction o Hospital readmissions o Financial impact Background and Medical Literature Excessive Acute Care Hospital Costs Healthcare expenditures in the United States in 2009 was 2.49 Trillion dollars o Hospital costs accounted for approximately 30% of total expenditures o Hospital costs in 2009 was 759 billion dollars There is an approximate $80 billion cost shift from Medicare and Medicaid to commercial payers (Fox) 1

4 o Many of these patients require post-acute services and inadequate pathways to meet demands impacts excessive acute care hospitals costs that are not reimbursed by Medicare and Medicaid o In addition, perceived and real drop off in quality of care in post-acute care settings by patients, families, and providers results in significant obstacles to timely acute care hospital discharge and contributes to long lengths of stay and uncompensated care o Small percent of patients account for a high percent of bed days and resources Weissman reported that patients who stayed for more than 14 days in a medical surgical ICU accounted for 7.3% of admissions but 40% of total patient days Patients on mechanical ventilation may account for less than 10% of admissions to intensive care units but account for over 30% of bed days and resources o Patients with chronic disease contribute to growing hospital costs, readmissions and patients requiring post-acute care. o Ability to establish high quality post-acute care pathways, promote a seamless continuum of care is an essential strategy to maximize the cost avoidance opportunity for acute care hospitals and healthcare systems and reduce overall cost of care Hospital Readmissions The costs and clinical consequences of hospital readmissions is staggering o Nearly one in five Medicare patients are readmitted to acute care hospitals o Associated costs are around $ 15 billion. Friedman reported on rate and cost of preventable readmissions o Included residents in New York, Wisconsin, Pennsylvania, and Tennessee over a 6 month period in 1999 o Estimated hospital cost of preventable readmission was over $700 million during the 6 month period Skilled Nursing Facility Outcomes Garibaldi reported that poor clinical outcomes that include urinary and lower respiratory tract infections, decubitus ulcers and other poor outcomes can be attributed to high staff turnover, lack of attention to infection control practices and other factors 2

5 Cook reported that 45% of patients discharged from a Surgical ICU to an extended care facility died within two years Carey reported that over 13% of coronary artery bypass patients transferred to other healthcare facilities died Ankrom reported from a nursing home ventilator program that 15% of patients were liberated from the ventilator and 19% of patients were alive at one year Staffing Levels Staffing levels was one of the three top priority areas for improvement identified from AHRQ 2012 Data Base o Only 56% of respondents reported a positive response to the following: there are enough staff to handle the workload and work hours are appropriate to provide best care for patients Poor nurse staffing levels have been linked to the following clinical outcomes (Needleman): o Increased Mortality o Poor patient outcomes including pneumonia, shock, gastrointestinal bleeding, and urinary tract infections o Longer hospital stays Staff Turnover Hospital and skilled nursing facility staff turnover can be much higher than other industries. Decker reported that nurse assistant turnover can be as high as 100% in some skilled nursing facilities The average hospital may lose approximately $300,000 per year for each percentage increase in nurse turnover Factors that may contribute to nursing turnover include: o Adequate staffing levels o Feeling overworked o Poor communication and collaboration with co-workers and management o Not receiving recognition o Disengaged or unappreciated o Not feeling respected o Lack of career opportunities Nurse turnover may impact healthcare in a number of ways including: quality of care, increased staffing costs, increased absenteeism, and loss of patients 3

6 Impact of Ineffective Communication and Culture Communication problems were identified in more than half of sentinel events reported in 2011 Knaus reported in a study of 13 ICUs that higher mortality rate was linked to nurses and physicians who were less collaborative Dysfunctional nurse-physician communication has been linked to the following: o Medication error o Patient harm o Patient deaths Culture and other factors that may contribute to communication failures leading to errors include: o Hierarchy Traditionally physicians at higher level of hierarchy may perceive environment as more collaborative than nurses Can create barriers for people lower in the hierarchy reporting concerns to people with decision making authority o Avoidance of disagreement o Disruptive physician behavior o Healthcare providers may display different priorities caring for patients Disparity of Healthcare in Rural Communities It is well recognized that there are significant disparities in healthcare provided to rural communities. Rural residents are more likely than urban residents: o To suffer from chronic disease such as diabetes or heart disease o Less likely to receive preventative services o Poorer access to healthcare o Fewer physicians Almost 1/5th of residents in United States live in rural communities Less than 1/10th of physicians live in rural communities Excessive Acute Care Hospital Costs Ventilator Patients: Patients requiring prolonged mechanical ventilation are increasing with significant resource utilization (Zilderberg) o Projections are for a doubling of patient population by

7 o Costs are anticipated to be around 60 billion dollars Patients requiring prolonged mechanical ventilation frequently require extensive postacute care services, have multiple transitions, fair to poor outcomes and costs for care that are significant. (Unroe) o Patients surviving to discharge had a median of 4 transitions of care following acute care hospitalization o 67% of patient in their cohort had a hospital readmission o During 1 year follow-up, surviving patients spent an average of 74% of all days in a hospital, post-acute care facility, or requiring home health services o Mean cost per patient was $306,135 o Cost per independently functioning survivor was $3.5 million at one year Weaning or liberation success from mechanical ventilation from hospital based units vary o Gracey reported 60% of patients were liberated from invasive mechanical ventilation, 75% of patients were postoperative in his report o Scheinhorn reported that 56% of patients were liberated from ventilator and 71% of patients survived to discharge o Bagley reported that 38% of patients were liberated and 53% survived to discharge There are fewer outcome reports from skilled nursing facilities on prolonged mechanical ventilation o Ankrom reported 15% of patients were liberated from mechanical ventilation with 19% survival at one year o Report from a skilled nursing facility in Wisconsin, more than 60% of patients were liberated from mechanical ventilation with 70% survival at one year (Lindsay) Respiratory therapy and nurse directed weaning protocols are effective in the following: o More rapid liberation from mechanical ventilation o Reducing length of stay in ICU Successful Interventions Applied to Transitional and Post-Acute Care: Naylor and colleagues developed Transitional Care Model (TCM) which emphasizes care coordination for high risk elderly patients with chronic disease. Transitional Care Model demonstrated reduction in overall health care costs, improved patient satisfaction and fewer rehospitalizations. Key components of the program include: o Transitional Care Nurse coordinates care across an episode of illness. o Home follow-up visits for average of two months which includes telephone support. o Early identification and response to health risks with efforts to avoid harm and events that lead to readmission 5

8 o Engagement of patients, families, caregivers, and healthcare providers with emphasis on communication and education. Dr. Eric Coleman and colleagues from University of Colorado developed The Care Transitions Program. They demonstrated significantly reduced patient rehospitalization rates at 30, 90 and 180 days compared to controls. Key elements of The Care Transition Program include: o Patient centered record or Personal Health Record (PHR) o Follow-up with physician o Knowledge of red flags or warning signs and symptoms and how to respond o Medication self-management Dr. Brian Jack and colleagues at Boston University Medical Center developed an improved discharge coordination process called Project Re-Engineered Discharge (RED). They demonstrated significantly reduced hospital utilization. Key elements of the intervention included: o Educating patient throughout hospital stay o Follow-up appointments in place with clinician with discharge summary o Provide patient written discharge plan as well as patient s understanding of plan, and what to do if problem arises o Follow-up call 2-3 days after discharge. o Confirmation of medication plan Other efforts that have demonstrated reduced rehospitalization have included: o Nurse Practitioners as care managers o Remote patient telemonitoring o Multidisciplinary chronic care team interventions o Enhanced admission assessment for post-discharge needs Mayo Ventilator and Transitional Care Program Ventilator Program Ventilator Program was established in Chippewa Falls, Wisconsin Key elements of the program included: o Bedside rounds with patients and families o Respiratory therapy and nurse directed weaning protocols o Establishment of key roles Medical Director Respiratory Therapy Director Nursing Leadership Role 6

9 o Conversion from invasive mechanical ventilation to noninvasive ventilation o Emphasis on socialization o Data base Program has cared for over 60,000 ventilator patient days with more than 50% of all patients liberated from ventilator o More than 50 patients converted directly from invasive ventilation to noninvasive ventilation o Better outcomes at reduced costs relative to other reports in the literature (Lindsay) Figure: Outcomes from Wisconsin Ventilator Program Vent Unit % Weaned % Neuro Wi Program* 67% 27% Scheinhorn 56% 7.8% Mayo (Gracey) 60% NR Bagley 97 38% 19% Figure: Comparison of Ventilator Programs in Skilled Nursing Facilities NH Vent Unit %weaned %alive 1yr Johns Hopkins 15% 19% Geriatric Center Wi Program* 67% >70% *Lindsay JCJQS 04 7

10 Mayo Transitional Care Programs Transitional Care Units were initially established in critical access hospitals in Bloomer and Osseo, Wisconsin The program was expanded successfully to include 11 critical access hospitals in Minnesota, Wisconsin and Iowa Key components of the program included: o Bedside rounds with patients and families o Medical Director and Nurse Leadership positions established o Patient centered and clinical outcome measures Focused on rehabilitative care for patients recovering from variety of surgery and medical conditions o Complex medical (respiratory, cardiac, neurologic, renal, bariatric, diabetes, infectious disease) o Trauma o Wounds o Post-surgical patients Orthopedics Cardiac surgery Neurosurgery General Surgery o Other Benefits of Transitional Care Program included: o Patient Centered Outcomes More than 90% of patients: would recommend the program to others More than 90% of patients: rated their overall care as very good Vast majority of patients are discharged home or to their prior care setting with low 30 day readmission rates o High employee satisfaction Rural Community and Critical Access Hospital Maintain and improve access to healthcare Prevention of critical access hospital closures in rural communities Addition of new services not only benefitting transitional care patients but also inpatients and outpatients. Few examples include: Respiratory and Therapy (Speech, Physical and Occupational Therapy services) o Outpatient pulmonary rehab and pulmonary function testing 8

11 o Tracheostomy care, noninvasive ventilation, continuous positive airway pressure, cough assist device support and other services o Expansion of hours and breadth of services o Outpatient cardiac rehabilitation Maintain and improve revenues: o Critical Access Hospitals are certified to receive cost-based reimbursement, cost + 1%, from Medicare with intent to improve their financial status and prevent hospital closures. o The 1997 Balanced Budget Act was intended to strengthen rural healthcare. Critical Access Hospitals must maintain an annual length of stay of 96 hours or less for acute care admissions. o There is no limit on length of stay limit for swing bed patients as long as they have a skilled nursing or therapy need. Strengthening connections with acute care hospitals o Referrals o Telemedicine o Quality and Patent Safety Collaboration o Optimizing Continuum of Care Financial Impact of Program o 20/1 Return on investment o Acute Care Hospital and Health System cost savings in millions of dollars per year o Cost-based +1% reimbursement for critical access hospitals creates a long-term viability program for these facilities with significant positive impact on revenues and stability o Positively impacting readmissions reduces overall cost of care benefitting payers including Medicare and Medicaid 9

12 Transitional Care Guidelines and Program Components: Transitional Care and Ventilator Program Overall Description and Scope of Program Transitional Care Admission Guideline Transitional Care Discharge Guideline Transitional Care Bedside Rounds with Patient and Family Transitional Care Implementation Guideline Interdisciplinary Care Team and Transitional Care Patient Transitional and Ventilator Care Quality Program, Outcome Metrics, Benchmarking and Transparency Transitional Care Patient Safety Program Frontline A3 Problem Solving, Meeting the Needs of Patients and Care Team Patient Engagement Guideline Ventilator Patient and Transitional Care Team Guideline Respiratory Therapy and Nurse Directed Weaning for Ventilator Patient Conversion to Noninvasive Ventilation Guideline Transitional Care and Ventilator Patient Mobility Guideline Transitional Care Bundle Checklists for high risk processes Rehab Therapy Measures and Guideline Operational Guidelines: Descriptions identifying specific clinical competencies for key personnel positions Staffing model guidelines for each of the key personnel positions, including On-site and On-Call requirements Listing of recommended Program equipment and medical supplies Allevant On-Site Supported Activities: Allevant Medical Director, Respiratory Therapy and Nurse Leader facilitated implementation Initial On-Site Assessment Allevant Supported Activities: (Includes combination of on-site and conference call/ telecommunication meetings): Participation in Interdisciplinary Care Team Meetings Monthly Respiratory Care Director Meetings 10

13 Monthly Nurse Care Coordinator Meetings Quarterly Leadership Team Meetings Medical Director, Nurse Lead, Respiratory Therapy Director availability as needed by phone or telecommunication Quarterly Audits Facilitate working with payers on establishing competitive rates (includes working with State Medicaid to establish rates for ventilator rate in skilled nursing facilities Marketing and Promotion: Marketing materials to support Transitional Care and Ventilator Program Allevant Medical Director, Nurse Leader and Respiratory Therapy Director will help facilitate marketing with Acute Care Hospital and Long Term Acute Care Hospital Referral Site Targets Sample PowerPoint Marketing Templates will be provided Database and Reports: Web based tool will be provided with the following features: Administrative Data Collection Tool and Database Quality Indicators and Outcome Tracking Database Benchmarking and Trending Reports Definition of Metrics Training and Education: Training materials for key Hospital personnel related to Transitional Care and Ventilator Program Training materials on the use of recommended equipment and supplies Training materials for Hospital personnel in the marketing of the Program Training materials for web based Database and Reports Clinical Training and Education Programs: Select Modified Programs Speaking Valves Wound Care Introduction Spasticity Obesity Metabolic Syndrome Neurogenic Bladder Hypertensions 1 11

14 Hypertensions 2 Dealing with Difficult People 1 Dealing with Difficult People 2 New Material: Medication Safety Fundamentals of Transitional Care Fundamentals of Respiratory Patient Fundamentals of Ventilator Care Basics of Renal Patient Heart Failure Behavioral Health Basics Diabetes Anticoagulation 12

15 References: Anthony R, Ritter M, Davis R, et al. Lehigh Valley Hospital: engaging patients and families. Jt Comm J Qual Patient Saf 2005 Oct; 31(10): Aronson PL, Yau J, Helfaer MA, et al. Impact of family presence during pediatric intensive care unit rounds on the family and medical team. Pediatrics 2009 Oct; 124(4): Banazsak-Holl J, Hines MA. (1996). Factors associated with nursing home staff turnover. The Gerontologist', 36 (4): Callahan EH, Thomas DC. (2002). Geriatric hospital medicine. Med Clin North Am. 84 (4): Review Carey JS, Parker JP. (2003). Hospital discharge to other healthcare facilities: impact on inhospital mortality.j Am Coll Surg. 197(5): Coleman EA, Smith JD, et al. Preparing patients and caregivers to participate in care delivered across care settings: the care transitions intervention. J Am Geriatr Soc. 2004; 52 (11): Centers for Medicare and Medicaid Services: Medicare Coverage of Skilled Nursing Facility Care Communication and collaboration among physicians and nurses. Am J Crit Care Jan;14(1): Consensus Trial Study Group.(1987). Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (ConsQnsus). N EnglJ Med. 316(23): Cook CH, Martin LC. (1999). Survival of critically ill surgical patients discharged to extended care facilities. J Am Coll Surg. Nov; 189(5): Decker FH, Gruhn P. Results of 2002 American Health Care Association Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, 13

16 Dodek PM, Raboud J. (2003). Explicit approach to rounds in an ICU improves communication and satisfaction of providers. Intensive Care Med. 29(9): Dutton RP, Cooper C, et al. Daily multidisciplinary rounds shorten length of stay for trauma patients. J Trauma Nov;55(5): Friedman B, Basu, J. The rate and cost of hospital readmission for preventable conditions. Med Care Res Rev. 2004; 61(2): Garibaldi R, Brodine S, et al. (1981). Infections among patients in nursing homes: policies, prevalence, problems. N Engl J Med 305: Cambridge, MA: Institute for Healthcare Improvement; Gonzalo JD, Chuang CH, et al. The return of bedside rounds: an educational intervention J Gen Intern Med Aug;25(8): Greene J. (2002). Rural renewal. As momentum builds, critical access hospital program shows signs of success. Hosp Health Netw. 76(4):50-54, 2. Halm, M., Gagner, S., et al. (2003) Interdisciplinary Rounds Impact on Patients, Families, and Staff, Clinical Nurse Specialist, Vol 17(3), Holmes S, Cramer I, Charns M. Becoming patient-centered: approaches and challenges. Transition Watch 2003 Nov; 6(3). Home healthcare telemedicine Institute of Medicine (1999). To Err is Human: Building a Safer Health System. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. Washington, D.C.: National Academy Press. Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21 st Century. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. Washington D.C.: National Academy Press Landry, M., Lafrenaye, S., Roy, M., & Cyr. C. (2007). A randomized, controlled trial of bedside versus conference-room case presentation in a pediatric intensive care unit. Pediatrics, 120(2), Lindsay M, et al. Shifting care of chronic ventilator-dependent patients from the intensive care 14

17 unit to the nursing home. JCJQS. Vol. 30(5): Lindsay M., Continuum of Care Program. Patient Flow: Reducing Delays in Healthcare Delivery. Chapter 13, pages Randolph Hall Muething SE, Kotagal UR, Schoettker PJ, et al. Family-centered bedside rounds: a new approach to patient care and teaching. Pediatrics 2007 Apr; 119(4): Multidisciplinary rounds at bedside involve patients, families. Hosp Case Manag 2009 Feb; 17(2):23-4. Multidisciplinary Ward Rounds: A Resource Naylor MD, Brooten D, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999; 281: Naylor MD, Brooten D, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial> J Am Geriatr Soc. 2004; 52: Needleman, J., et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med May 30;346(22): Nielsen GA, Bartley A., Coleman E, Resar R, et al. Transforming Care at the Bedside How to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge MA: Institute for Healthcare Improvement; Available at Olson, D. P., & Windish, D. M. (2010). Communication discrepancies between physicians and hospitalized patients. Archives of Internal Medicine, 170(15), Patient Transitions and Handoffs Project Boost Team. The Society of Hospital Medicine Care Transitions Implementation Guide: Project BOOST: Better Outcomes for Older adults through Safe Transitions. Society of Hospital Medicine website, Care Transitions Quality Improvement Resource Room Rappaport, D. I., Ketterer, T. A., Nilforoshan, V., & Sharif, I. (2012). Family-centered 15

18 rounds: Views of families, nurses, trainees, and attending physicians. Clinical Pediatrics, 51(3), Rural Assistance Center: Health and Human Services Information for Rural America Silverstein M., Qin H., et al. Risk factors for 30-day hospital readmission in patients > 65 years of age. Proc (Bayl Univ Med Cent) 2008; 21(4): Simmons J. Family affairs: A fundamental shift: family-centered rounds in an academic medical center. The Hospitalist 2006 Mar. Available at Accessed April 4, Sisterhen LL, Blaszak RT, Woods MB, et al. Defining family-centered rounds. Teach Learn Med 2007; 19(3): Tonnelier JM, Prat G, Le Gal G, Gut-Gobert C, Renault A, Boles JM, L'Her E: Impact of a nurses' protocol-directed weaning procedure on outcomes in patients undergoing mechanical ventilation for longer than 48 hours: a prospective cohort study with a matched historical control group. Crit Care 2005 Uhlig PN, Brown J, Nason AK, et al. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv 2002 Dec; 28(12): Vazirani S, Hays RD, Shapiro MF, et al. Effect of a multidisciplinary intervention on workers. Soc Work Health Care 2007; 44(4): Young MP, Gooder VJ, Oltermann MH, et al. (1998). The impact of a multidisciplinary approach on caring for ventilator-dependent patients. Int J Qual Health Care. 10(1): Zilberberg, M., et al. Growth in Adult Prolonged Acute Mechanical Ventilation: Implications for Healthcare Delivery. Crit Care Med. 2008;36(5): Updated 2/5/13 (mel) 16

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20 For more information please contact: Jordan Tenenbaum Vice President Allevant Solutions Post Acute Care Solutions Developed by Mayo Clinic and Select Medical (m)