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1 The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 3/1/ , American Heart Association 1 1

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3 Presenter Disclosure Information Name: Elissa Della Monica RN, MSN Title: Executive Director Hospital: Abington Health, Abington, Pennsylvania FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USES DISCLOSURE: None 3/1/ , American Heart Association 3 3

4 Presenter Disclosure Information Name: Catherine Melly, BSN, RN, CCP Title: Heart Failure Transitions Hospital: Abington Health, Abington, Pennsylvania FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USES DISCLOSURE: None 3/1/ , American Heart Association 4 4

5 Presenter Disclosure Information Name: Patty Barrella, MSN Title: Heart Failure CNS Hospital: Abington Health, Abington, Pennsylvania FINANCIAL DISCLOSURE: None UNLABELED/UNAPPROVED USES DISCLOSURE: None 3/1/ , American Heart Association 5 5

6 Improving Heart Failure Transitions: Focus on the Transitioning of the Heart Failure Patient, Highlighting Follow-Up Visits, Follow- up Phone Calls and Heart Failure Education Elissa Della Monica RN, MSN Executive Director Cass Melly, BSN Heart Failure Transitions Patty Barrella, MSN CNS Heart Failure Coordinator 6

7 Presentation Outline Chronic Care Interesting Facts Affordable Care Act Why are Patient s Re-Hospitalized IHI Recommendations Care Transition What is it AMH Collaborative Approach Challenges Ahead Action Plan Conclusion 7 7

8 Definition of Chronic Care Chronic conditions are defined as health problems that last 12 months or longer and restrict an individual s self care, independent living, and social interactions and require ongoing medical interventions and services. (Agency for Healthcare Research and Quality) 8 8

9 Did You Know 9 Almost one-fifth of the Medicare Beneficiaries who had been discharged from an acute care facility were readmitted within 30 days (Jencks, Coleman 2009) Nearly 90% of readmissions are unplanned and potentially preventable which translates into $17 Billion or nearly 20% of Medicare hospital payments (Hernandez et al,

10 Did You Know 10 7X greater risk for re-hospitalization for patients with 5 or more chronic conditions with an estimated cost of $17.4 billion (Agency for Healthcare Research and Quality) 60% of Pennsylvanian s suffer from chronic disease (Pa Chronic Care Management and Cost Reduction Commission) Cost to Pennsylvania is estimated to reach $170.2 billion by (Milken Institute 2006) 10

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12 Patient Protection and Affordable Care Act 12 Value Based Purchasing (VBP); a pay for performance system. VBP links Medicare prospective payment to quality performance and pays a bonus for good performance and reduces payment for poor performance. Hospitals with higher than expected 30-day readmission rates will receive reduced Medicare payment by 1% in 2013 escalating to 2% by

13 VBP 13 Initiated in October 2012, that payment policy will apply to readmissions for 3 conditions: heart attack, heart failure and pneumonia. In 2015 the payment policy will be expanded to COPD, and select vascular procedures. Estimated Payment Reduction to AMH for Heart Attack, CHF and Pneumonia: $1,062,

14 The discharge problem The hospital discharge is poorly standardized and is characterized by discontinuity and fragmentation of care; lack of coordination in the handoff from the hospital to community care, and poor delineation of discharge responsibilities among hospital staff. This process places patients at high risk of postdischarge adverse events and rehospitalization 1. Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Dis Mon.2002;48:

15 Why are patients re-hospitalized 15 Don t understand medications Can t recognize red flags Unable to manage health care 15

16 Why are Patient s Re-Hospitalized Lack of Primary Care communication 16 No follow-up care Call 911 to ED 16

17 IHI Best Practice Interventions 17 Improving Transition processes between care settings Redesigning Primary Care- Medical Home Patient education and self management training during hospitalization and after discharge Timely referral to Home Care 17

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19 IHI Best Practice Interventions Management and communication of changes in medication regime Timely communication (handoffs), between care settings 19 Early post acute care follow-up (by home care nurse or care coordinator) Proactive discussions of advance care planning and or end of life preferences and communication of those preferences among providers 19

20 What is Transitions A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care. (Coleman and Berenson 2004) 20 20

21 21 Transitions = Handovers in Care 21

22 Care Transitions 22 Include transfer of patient information as well as professional responsibility to both deliver the information and assure it is understood Significant Patient Safety Issue 22

23 Transitions = Paradigm Shift 23 Patient Centered Clinician Controlled does to the patient and controls the agenda Patient receive information and advice on medications, diseases Patient tells the transition nurse their goals and what prevents them from meeting their goals Patient tells the nurse what they know about their health and meds 23

24 AMH Proposed Approach 24 Integration of Transitions and Post Acute Care Management AMH Home Care, Case Management, and AMH Health Physician Collaborative 24

25 In Patient Transition Nurse Care Model Intense discharge planning starting within 48 hours of admission Medication reconciliation and education Education on disease specific Red Flags Scheduling of Physician follow-up appointment 25 25

26 Transition Coach Heart Failure trained RNs provide: Chronic Care Certified Population management Coordination of care Facilitate transitions of care across the continuum of care Teach back Post discharge follow up for 30 days 218 patients followed by transition coaches < 30 day HF readmission rates for patients followed by our Transition RN s is 3.8% % patients received f/u call within 72 hours of referral 26

27 In-Patient Transition Nurse Care Model 27 Communication with physician office and SNF Accurate discharge instructions Post discharge phone call to verify that post acute services are in place 27

28 Transition Coach Heart Failure trained RNs provide: Population management Coordination of care Facilitate transitions of care across the continuum of care Teach back Post discharge follow up for 30 days 218 patients followed by transition coaches < 30 day HF readmission rates for patients followed by our Transition RN s is 3.8% % patients received f/u call within 72 hours of referral % patients received f/u call within 72 hours of referral 28

29 Heart Failure Red Flags 29 Green Zone: All Clear No shortness of breath Your Goal Weight: No swelling No weight gain No chest pain No decrease in your ability to maintain your activity level Yellow Zone: Caution If you have any of the following signs and symptoms: Weight gain of 3 or more pounds Increased cough Increased swelling Increase in shortness of breath with activity Increase in the number of pillows needed Anything else unusual that bothers you Call your home health nurse if you are going into the YELLOW zone Red Zone: Medical Alert Unrelieved shortness of breath: shortness of breath at rest Unrelieved chest pain Wheezing or chest tightness at rest Need to sit in chair to sleep Weight gain or loss of more than 5 pounds Confusion Call your physician immediately if you are going into the RED zone Green Zone Means: Your symptoms are under control Continue taking your medications as ordered Continue daily weights Follow low-salt diet Keep all physician appointments Yellow Zone Means: Your symptoms may indicate that you need an adjustment of your medications Call your home health nurse. Name: Number: Instructions: Red Zone Means: This indicates that you need to be evaluated by a physician right away Call your physician right away Physician: Number: 29

30 Post Acute Care Management Services 30 Care Managers imbedded in select physician practices Intermittent skilled home care Disease care manager for those patients that do not meet homebound criteria and for patients living in skilled nursing facilities Clinical oversight by Home Visiting Physician or Nurse Practitioner for bed bound elderly 30

31 Skilled Facility Project Goal: Continued provision of HF expertise >30% of Heart Failure readmissions from SNFs Innovative Circle Grant project Partnership with 2 skilled nursing facilities SNF commits to bed availability, dietary department changes, daily weights, patient appointments at HF center Education provided to all levels of staff at the facility Provides continuity of HF medical management and education for our patients Follow up post SNF discharge by Transition Coach 20% < 30 day re-hospitalization all cause 0% < 30 day re-hospitalization for heart failure 31

32 Physician Practice Care Manager 32 Accepts handoff from inpatient transition nurse and home care nurse Tracks patient to ensure compliance with NCQA Medical Home standards 32

33 Physician Practice Care Manager Ensures compliance with health screening interventions Conducts telephonic monitoring and education Refers and coordinates with outpatient services Meets data collection and documentation requirements 33 33

34 Home Health Care Manager Intermittent skilled care Disease specific care management (MI, HF and pneumonia Telehealth Community Palliative Care Service 34 34

35 Transition and Care Management Outcome Measures day re-hospitalization Patient Satisfaction Physician practices: NCQA outcome measures such as LDL, A1C for diabetics, blood pressure, weight loss. 35

36 Process Measures Transition nurse post acute phone call Transition nurse call to physician office at admission and discharge Medications reconciled at discharge Discharge information sent to PCP in 48 hours Smoking cessation, health screening exams, foot and eye exams 36 36

37 Challenges Ahead RESOURCES POST ACUTE 37CARE MANAGEMENT IS NOT FUNDED Return on Investment REAL TIME DATA COLLECTION AND ANALYSIS 37

38 Challenges Ahead RISK ASSESSMENT FOR READMISSION 38 THUS TRIGGERING INTENSITY OF CARE TRANSITIONS ELECTRONIC PATIENT DISCHARGE INSTRUCTION POST ACUTE CARE MANAGEMENT SYSTEM 38

39 AMH Action Plan 39 Case Management Structural Changes Home Care Liaison role change Process Changes Flow Chart Automated re-admission risk assessment Identification of MI, and HF patients 39

40 AMH Action Plan Nursing department discharge phone calls Joint Commission Advanced Heart Failure Certification Heart Failure SNF project Business Plan for Post Acute Care Management Discussion with IT department 40 40

41 In Conclusion As stated by IHI, there is No Silver Bullet An organization must adopt a suite of interventions that suit their unique characteristics Acceptance of the need for palliative and end of life care is essential for success 41 41

42 Patient Centered Heart Failure Care Primary Care Office Interventionalist/ EP Transition RN Cardiac Surgery/VAD Program Community Outreach P a t i e n t Patient Inpatient Heart Failure Unit / HF Consultative Service Palliative Care/ Hospice Home Heart Failure Program SNF / Rehab Outpatient Heart Failure Center 42

43 It Takes a Village to implement these needed changes In Conclusion 43 43

44 There is No Place Like Home 44 44