CareTrek : Nebraska s Journey to Safe Care Transitions

Transcription

1 CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement Organization for Nebraska, under contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 9SOW-NE-CT-133/0211

2 Welcome CIMRO of Nebraska Overview of Care Transitions CareTrek Evidence-Based Interventions CareTrek Implementation of Evidence-Based Interventions 2

3 CIMRO of Nebraska Medicare Quality Improvement Organization for Nebraska Work under contract with CMS Work with healthcare providers to improve the quality of care delivered to people with Medicare 3

4 CIMRO of Nebraska CMS 9 th Scope of Work (9SOW) includes care transitions 14 QIOs were selected through a competitive process Nebraska s community: Omaha metro area Goal: improve healthcare transitions with the specific aim to reduce rehospitalizations Innovative and cutting-edge work 4

5 CMS Care Transitions Projects 5

6 Definition of a Care Transition Moving a person from one level of care to another Examples include: Hospital to home Hospital to skilled nursing facility Skilled nursing facility to home health care Home health care to hospital Poor care transitions lead to rehospitalizations 6

7 Rehospitalization is an Expensive Issue For the patient, family and Medicare Preliminary 2007 Medicare data analysis finds 1 of 5 beneficiaries are rehospitalized within 30 days of discharge from a hospital 7

8 Affordable Care Act Contains language regarding adjustment of payments to hospitals with high rates of potentially preventable Medicare readmissions for AMI/HF/PNE 8

9 The Ideal Rehospitalization Rate? Not all rehospitalizations are avoidable, but many could be avoided Heart failure, pneumonia, COPD, Acute MI are readmission leaders CABG, PTCA, other vascular procedures lead surgical conditions Nationally, 76% of readmissions are potentially avoidable - MedPAC Report to Congress,

10 National Attention to Readmissions 10

11 National Attention to Readmissions Just under 25% of hospital discharges to SNF are readmitted within 30 days Cost to Medicare in 2006 over $4 billion 11

12 Discharge Destination of Initial Hospitalization Home 58% Skilled Nursing Facility 22% Home Health 14% 12

13 CareTrek Nebraska s care transitions project The goal is to improve safety in care transitions for Medicare beneficiaries living in Douglas and Sarpy counties Bringing together providers from PPS hospitals, SNF, home health and community support services 13

14 CareTrek Overview Reduce hospital readmissions by improving transitions of care Interventions are evidence-based All beneficiaries discharged from seven full service hospitals in Douglas and Sarpy Counties 14

15 CIMRO of Nebraska s Role in CareTrek Identify the gaps in transition process Determine the root cause of the gap Determine the result of the gap Bring together groups to work on improving the gaps between sender and receiver Help to identify evidence-based interventions Measure the results 15

16 Evidence-Based Interventions Program or Toolkit Coleman Model of Coaching Transitional Care Model Better Outcomes for Older Adults through Safe Transitions Best Practices Intervention Package Interventions to Reduce Acute Care Transfers (INTERACT) Transforming Care at the Bedside Project RED (Reengineered Discharge) 16

17 Evidence-Based Interventions Cross-Setting Care Standardization Enhanced information at discharge Follow-up care established at discharge Medication management Plan of Care Telemedicine Telephone Follow-up Palliative Care 17

18 Evidence-Based Interventions Patient, Family and Caregiver Support Education Coaching Personal Health Record Community Supports 18

19 CareTrek Community Learning Groups 1. Hospital to SNF- Standard communication patterns 2. Hospital to Home Health Medication list management 3. Hospital Discharge Standardize and enhance discharge process 4. AHRQ/QIO Mini-Collaborative Medication Reconciliation 5. Coleman Model Care Coaching 6. Senior Leadership and Community Involvement 7. Caregiver education 19

20 Community Learning Groups: Cross Setting Communication and Medication Reconciliation Jennifer Geisert, RN, BSN Quality Improvement Advisor CIMRO of Nebraska

21 Community Learning Groups Care Transition: Key participants Sender Receiver Patient How is information communicated? Timely? User friendly? Complete? Available? 21

22 Cross Setting Group: Communication One hospital and four SNFs Participating staff includes nurse case manager, social worker, director of nursing, nurse unit manager and admission nurse 22

23 Identified Gaps Gaps in known & standard processes of transfer of patient Ambulance transfer availability, differing transfer forms and medication lists, no contact information from sender Gaps in transfer of information - leading to omissions in care EMR access, hospital discharge summary 23

24 Interventions Transition Mapping: Structured exchange visits between the hospital staff and the nursing staff to map the patient transfer process 24

25 Interventions (Continued) Health Information Technology (HIT): Identified a gap between the information provided by the hospital and the SNF ability to obtain this information Additional SNF staff were trained to use the system and access the information 25

26 Interventions (Continued) Chart Audits: SNF collecting readmission data, including reasons for medical instability & transfer to the hospital 26

27 Instructions for Using Transfer Tracking Tool Resident Identifier: Enter information that will not make the resident easily identifiable to others, but will help the facility to identify each resident (do not use resident name, social security number, Medicare number, date of birth) Admission Date: Enter the date the resident was admitted to the facility Medical Instability: Enter signs & symptoms or medical conditions that prompted the transfer to the hospital Reason for Hospital Transfer: Enter the factors that led to the decision to transfer the resident to the hospital 27

28 Tracking Tool.continued Date Transferred to Hospital: Enter the date the resident was transferred to the hospital Efforts to handle situation without transfer: Enter the interventions/efforts that were tried in the facility prior to the transfer Time of transfer: Enter the time of day the resident was transferred to the hospital 28

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30 Identified Medical Instability September - October Chest Pain 3% Pain 8% Abnormal Lab 6% Respiratory Issues 21% Edema 1% Change in Vital Signs 17% Change in Mental Status 12% Availability of Services 17% GI Complaints 15% 30

31 Interventions (continued) Nurse-to-Nurse call: Communication implemented to provide handover information in a known and standard way 31

32 Interventions (continued) Educational Learning Sessions: The goal of the learning sessions is to improve communication skills and clinical competencies 32

33 Educational Learning Sessions cont Training focused on SBAR ( Situation- Background-Assessment-Recommendation) tools, management of diabetes, dyspnea, heart failure and the INTERACT II tool 33

34 INTERACT II: Interventions to Reduce Acute-Care Transfers INTERACT II: SBAR Situation, Background, Assessment, Recommendation Early Warning Tool: Stop and Watch Transfer Checklist Resident Transfer Form Transfer Form Quality Improvement tool Clinical Care Paths Change in Condition Cards Advanced Care Planning Tools 34

35 Educational Learning Sessions cont d Diabetes, CHF, Dyspnea and COPD Recorded WebEx Sessions: x 35

36 Community Learning Group: Medication Reconciliation National Patient Safety Goal #8: Accurately and completely reconcile medications across the continuum of care A process to compare the patient s current medications with those being ordered Communicate the reconciled list of medications to the next provider of services and the patient/caregiver 36

37 The Issue: Medication Reconciliation Coleman, Smith et al s (2005) study on Posthospital Medication Discrepancies found the 30- day re-hospitalization rate for patients with identified medication discrepancies on discharge was 14.3% and for those patients without a medication discrepancy, the rate was 6.1% 37

38 Medication Reconciliation Community Learning Group The group performed a mapping process that identified that SNFs were getting up to 7 different medication lists at transfer It was hard to identify which list was the most accurate and up-to-date. Multiple lists complicated the transfer and lead to errors in medication reconciliation 38

39 One True List Concept of the One True List was established The One True List was identified by the hospital and communicated to the SNF The One True List decreased the amount of medication discrepancies CIMRO of Nebraska produced a One True List toolkit as a resource 39

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41 Models for Transitions of Care Paula Sitzman, RN, BSN Quality Improvement Advisor CIMRO of Nebraska

42 Models for Transitions of Care Care Transitions Intervention (CTI): (Dr. Eric Coleman) Re-Engineered Discharge (Project RED): Jack Transitional Care Model (CTM): (Mary Naylor) Transforming Care at the Bedside (TCAB): Institute for Healthcare Improvement (IHI) Project BOOST Home Health Quality Improvement (HHQI) Campaign 42

43 Care Transition Intervention (CTI) Care Transition Intervention Coleman Model Patient empowerment through patient activation Four pillars Medication self-management, Personal Health Record (PHR), MD follow-up, knowledge of red flags Transition Coach 30 days 43

44 Re-Engineered Hospital Discharge (Project RED) Discharge Advocate - APRN Eleven discrete, mutually-reinforcing components After Hospital Care Plan (AHCP) Pharmacist phone follow-up post discharge Phone reinforcement of AHCP 44

45 Discharge Advocate Educate patient Make f/u appointments Inform pt of tests Organized post-dc services Confirm medication plan Reconcile DC plan Review steps if problem arises DC summary to post DC providers Assess pt knowledge Give pt written AHCP Pharmacist phone reinforcement of DC plan & problem solve with pt 2-3 days post DC 45

46 Project RED One Omaha hospital implemented Initiated on the Telemetry Unit & focused on heart failure patients Spread to other hospital units 46

47 Transforming Care at the Bedside (TCAB) - IHI Guide focuses on Heart Failure Can be adapted to improve the DC process for all patients 47

48 TCAB Creating an Ideal Transition Home Enhanced admission assessment for postdischarge needs Enhanced teaching and learning Patient & family-centered handoff communication Post-acute care follow-up 48

49 Enhanced Admission Assessment for Post-Discharge Needs Include family caregivers and community providers as partners in assessment, DC planning & needs at home Reconcile medications upon admission Initiate plan of care based on assessment 49

50 Enhanced Teaching and Learning Identify the learner(s) on admission Redesign the patient education to improve patient and family caregiver understanding of self-care Use teach-back daily in the hospital and during follow-up phone calls 50

51 Patient and Family-Centered Communication Reconcile medications for discharge Provide customized, real-time information to the next provider that: Accompanies patient to next provider, or Is transmitted to the physician at time of discharge 51

52 Post-Acute Care Follow-up High-risk patients: Prior to DC, schedule a face-toface follow-up visit to occur within 48 hours of DC Moderate-risk patients: Prior to DC, schedule a follow-up phone call within 48 hours and schedule a physician office visit within 5 days 52

53 Transitional Care Model (TCM) Transitional Care Nurse APRN Comprehensive in-hospital planning Coordination and continuity of care Ongoing communication, education and support Post-hospital follow-up for 2 months 53

54 Transitional Care Nurse In-hospital assessment and development POC Coordination of care Regular home visit and telephone support for 2 months post-discharge Patient and caregiver education and support Nurse and physician collaboration 54

55 Transitional Care Model Participants Improvement in post-hospital discharge health outcomes Enhanced patient and family caregiver satisfaction Avoidance of re-hospitalization for primary and comorbid conditions Reduction in healthcare costs 55

56 Project BOOST BOOST Better Outcomes for Older adults through Safe Transitions Reduce 30-day readmissions Improve patient satisfaction Improve information between providers Identify high-risk patients & interventions Improve patient / family preparation for DC 56

57 Home Health Quality Improvement National Campaign (HHQI) Best Practice Intervention Packages: Reducing Acute Care Hospitalization (ACH) Medication Management Fall Prevention Cross Setting I Care Transitions across settings Cross Setting II Chronic Care Cross Setting III Medical Homes 57

58 Community Learning Group Home Health Agencies and Hospitals Gaps in information transfer leading to medication delays & errors Reconciled medication lists Sender/receiver communication 58

59 Community Learning Group One Hospital & four SNFs Lack of complete DC information in known & standard format that is understandable for postacute setting Collaboration to determine what was needed by SNF electronically generated transfer information 59

60 CareTrek Continues Share the successes of the community Promote & facilitate the One True List within the community CareTrek listserv Education Research palliative care best practices & share info CareTrek Toolkit Care Transitions fellows 60

61 Intervention References Colorado Foundation for Medical Care Care Transitions Intervention Project RED Project BOOST _CareTransitions/CT_Home.cfm 61

62 Intervention References cont d Transforming Care at the Bedside ngcareatthebedside.htm Transitional Care Model INTERACT II HHQI National Campaign 62

63 Contact Information CIMRO of Nebraska 1230 O Street, Suite 120 Lincoln, Nebraska P: F: