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.

Transcription

1 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 for CMS. This handout is intended for use by this audience only. Please do not distribute. After the presentation the learner will be able to: 1. Describe the role of nursing home leaders on cross-continuum teams Explain how a QAPI program such as INTERACT, when fully implemented, may lead to reduced avoidable hospitalizations, improved quality of care and quality of life Discuss how use of the Advancing Excellence hospitalization quality measure can help an organization to meet the intent of the Affordable Care Act (ACA) nursing home QAPI provision 1

2 How can we transform our communities so that people have a choice about how and where they age? How can we ensure quality of life during transitions for the most vulnerable older adults and their caregivers? Health and Well-being Model Deeper dive into the issue: Who are all these old people and where did they come from????? 2

3 3

4 4

5 The demand for direct-care workforce is set to increase by 48% over the next decade This demand and lack of retention could lead to a shortage Turnover and issues with access create particular problems during care transitions 5

6 Specifically: lack of affordable and accessible housing, transportation, nutrition programs (meals on wheels) Lack of behavioral/mental health services Need for personal attendant service/additional service hours Need to acquire independent living skills prior to transition Many others 6

7 What tools and systems will you use to understand your data and make meaningful changes based on that data? How will you excite your staff around using data? Advancing Excellence Hospitalization Tool Preferences for Everyday Living Inventory (PELI) Consistent assignment tool Having the same caregivers makes a difference! Staff stability High turnover may lead to ineffective transitions. It may also put facility at risk of deficiency citations on surveys, risk of more complaints from residents, families 7

8 Care Transitions Model Four pillars Dynamic, person-centered record Medical self-management Follow up Red flags Care management (coaching model) CTM-3 measure Transitional Care Model Uses APRNs with high risk populations (e.g., CHF, dementia, SMI) Early data showed cost savings of about $5,000 per patient in frail older adults with CHF Care management whatever it takes 8

9 The INTERACT Quality Improvement Program A Practical Approach To Safely Reducing Rehospitalizations Thanks to Laurie Herndon, APRN-BC, GNP The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Centers for Medicare & Medicaid Services (CMS). The current version of the INTERACT Program was developed by members of the INTERACT interdisciplinary team under the leadership of Dr. Joseph G. Ouslander, M.D. with input from many direct care providers and national experts in projects based at Florida Atlantic University (FAU) supported by The Commonwealth Fund. INTERACT Strategies 1. Prevent conditions from becoming severe enough to require hospitalization through early identification and evaluation of changes in resident condition 2. Manage some conditions without transfer when this is feasible and safe 3. Improve advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents 4. Improve documentation and communication within LTC facilities and programs, and between LTC and acute care 9

10 Rehospitalizations of SNF Residents are Common and Costly 1 in 4 patients admitted to a SNF are re-admitted to the hospital within 30 days at a cost of $4.3 billion Source: Mor, et al. (2010) Medicare SNF Rehospitalizations: Implications for Medicare Payment Reform, Health Affairs. Why Does This Matter? Hospitalization At the beauty salon At risk for complications Delirium Polypharmacy Falls Incontinence and catheter use Hospital acquired infections Immobility, de-conditioning, pressure ulcers Some Hospitalizations and Readmissions are Avoidable Several studies suggest that a substantial percent of hospital transfers, admissions, and readmissions are unnecessary and can be prevented 30 10

11 Background: Many Are Avoidable Subjects: The population of interest is a cohort of long-stay NH residents. Data are from the Nursing Home Stay file, a sample of residents in 10% of certified NHs in the United States ( ). Results: Three fifths of hospitalizations were potentially avoidable and the majority was for infections, injuries, and congestive heart failure. Medical Care: August Volume 51 - Issue 8 - p doi: /MLR.0b013e bff Changes in Medicare and Health Care Financing are Changing Incentives Pay-for-Performance ( P4P ) No payment for certain complications; disincentives for avoidable hospitalizations Bundling of payments for episodes of care Accountable Care Organizations that include hospitals, physicians, home health agencies, and SNFs that are responsible for the care of a defined group of patients State Duals Programs and Medicaid Managed Care Other models e.g. most recent CMS contracts for reducing unnecessary hospitalizations of long-stay NH residents The Bottom Line Collaboration among hospitals and community-based providers is essential for improving transitions between care settings and keeping discharged patients out of the hospital. Fostering partnerships among providers, payers, and health plans can help identify causes of avoidable rehospitalizations and align programs and resources to address them A. E. Boutwell, M. B. Johnson, P. Rutherford et al., "An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions," Health Affairs, July (7):

12 Quality Improvement Tools Communication Tools Decision Support Tools Advance Care Planning Tools CMS Pilot Study Results 1. Tools and implementation strategies were pilot tested in 3 Georgia NHs with relatively high hospitalization rates 2. Tools were acceptable to staff 3. Significant reduction in hospitalizations 4. Significant reduction in transfers rated as avoidable by an expert panel Ouslander et al: J Amer Med Dir Assoc 9: , 2009 Implementation Model in the Commonwealth Fund Grant Collaborative On site training (part of one day) Facility-based champion Collaborative phone calls with up to 10 facility champions twice monthly facilitated by an experienced nurse practitioner Availability for telephone and consults Completion and faxing of QI Review Tools 12

13 Commonwealth Fund Project Results Facilities Mean Hospitalization Rate per 1000 resident days Mean Change Relative Reduction in All- Cause Hospitalizations Pre intervention During Intervention p value All INTERACT facilities (N = 25) % Engaged facilities (N = 17) % Not engaged facilities (N = 8) % Ouslander et al, J Am Geriatr Soc 59: ,

14 How many transfers from your nursing home? When do they occur? How many days since admit? Ah ha moments Online version Root Cause Analysis: The Rest of the Story Demographics What happened Contributing factors Attempts to manage in SNF Avoidable? Staff thoughts about this Opportunities for improvement Cross continuum review of cases Enhanced Nursing Assessment Builds on early recognition Standard approach MD/NP response Warm hand over How might this complement disease management? 14

15 Communication Tools Across Settings Nursing Home Capabilities Checklist Medication Reconciliation Worksheet Transfer forms both directions Data lists both directions Can use as platform to start discussion about which elements nurses will use for warm hand off Returned Unopened Poor Communication=Poor Outcomes Decision Support Tools 15

16 Decision Support Tools For the SNF: one unit For the hospital: one SNF For HH/AL: one case For surveyors: one conversation For all: one CC meeting The Important Role of Your Facility Team Facility Leaders: Improving Relationships Direct Care Staff: Improving Quality of Care 16

17 Connect across provider types within each community Take the initiative don t wait for an invitation Use existing resources Hospital Engagement Networks (HENs) State Coalitions to Improve Dementia Care Quality Improvement Networks (QINs, formerly QIOs). National Nursing Home Quality Care Collaborative (NNHQCC) change package Advancing Excellence Local Area Networks for Excellence (LANEs) Create the change you want to see! Model the attitudes and behaviors you would like to see in your staff Be visible Send a clear, consistent message about your organization s philosophy around transitions Ask questions ( what do you need from me? What is most broken what needs to be fixed first? How can we be the best at getting better? ) Help staff embrace measuring improvement Take action but don t try to do everything all at once. Start with small steps but keep going! Facility Leaders Be prepared Initiate contact Know your data Share your story Know what tools, data, information you want to share Set date for next meeting 17

18 Lots of interest in this form Bring it with you Offer to update regularly Be sure you can do what you say you can It is not about the forms: It is about the relationship Enhancing the relationship by using the Warm Hand Over The Warm Hand Over The Power of One One SNF nurse One hospital nurse One meeting One trial How did it go? Modify Try again Spread Results Are Shared Cross Continuum Meeting Frontline work intersects with work of leadership= improved care 18

19 Person-centered Nurse led APRN supported Evidence is building Scalable Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents 4 year initiative 15 partner facilities required, with average census >100 residents Focus is long stay, dual eligible residents Funded through the CMS Innovation Center and Medicare-Medicaid Coordination Office Approximately $100 million for 7 projects IU Geriatrics Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care $13.4 million over 4 years 19 partner facilities (~2000 residents) Independents, regional and national chains represented Greg Sachs & Kathleen Unroe Project Directors 19

20 Reduction in avoidable hospitalizations of long stay nursing home residents through: improving medical care, enhancing transitional care and access to palliative care RNs are embedded in each facility to lead delivery of the intervention, supported in managing residents by NPs who cover a group of facilities Unroe et al, JAGS 2014 RNs (18) placed at each facility to lead delivery of the intervention, supported in managing residents by NPs (6) who cover a group of facilities 2 RN managers (one with 50% and one 25% managerial time) IU Geriatrics Dedicated to one building Full-time Monday-Friday Quality Improvement champion Mentorship in clinical assessment for facility staff Liaison to the NP IU Geriatrics 20

21 Acute Change in Condition INTERACT implementation; mentoring and coaching Support NPs identify patients; communication Advance Care Planning 2-3 patients per week Collaborative Care Reviews gather information Quality Improvement transfer root cause analyses; integrate into the QI facility efforts IU Geriatrics Cover 4-5 facilities Available 10am-6pm Monday-Friday; 8-12 on weekends Ability to see residents with a change in status or identified by RN as needing evaluation discussing with PCP Resident, family, staff education IU Geriatrics Acute change in condition Transition Visits Collaborative Care Reviews Support RN in education efforts IU Geriatrics 21

22 IU Geriatrics Wrist worn devices physical activity (time, distance, calories, steps), sleep quality, temperature, galvanic skin response, heart rate, heart rate variability ) Wall mounted sensors motion, activity level, inferred behaviors, nicotine in air, etc. Smart phone Location, orientation, distance, voice quality (mood), light level, noise level Others clothing (ECG, respiration, ), tatoos (blood glucose), contact switches, computer interactions (cognitive measures), weight, BP, SaO2 Drs. Holly Jimison & Misha Pavel Home health based on unobtrusive, continuous monitoring 22

23 Pavel et al., IEEE Special Issue, in press 67 Activity Monitoring in the Home Sensor Events Private Home Bedroom Bathroom Living Rm Front Door Kitchen Hayes et al., Hayes, ORCATECH 2007 In 2013, 15.5 million caregivers provided over 17.7 billion hours of unpaid care Valued at more than $220 billion The vast majority of caregivers are women Caregivers had over 9.3 billion in additional health care costs of their own 60% of caregivers rate the emotional stress of caregiving as high or very high; more than 1/3 report symptoms of depression 23

24 Most care provided in the community by family members or others Some through state Medicaid waiver programs ( money follows the person, community first and others) Only about 5% of older adults (about 1.5 million people) live in nursing homes So what are some of the clinical and social issues that could benefit from innovation? Respite, falls, incontinence, self-care/selfmanagement, exercise, cognitive games, medication management The future is now. Payment reform is driving change. Acute care hospitals are very interested in what is going on in post-acute care and are asking about care coordination and programs for care transitions Inform your local hospitals and other partners and help develop a dynamic working relationship Be the leaders in innovation! 24

25 Photo: Alex Tenappel 25