SKILLED NURSING FACILITY HOSPITAL COLLABORATION: ANTIOCH & LONE TREE CONVALESCENT

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1 04/24/13 1 SKILLED NURSING FACILITY HOSPITAL COLLABORATION: ANTIOCH & LONE TREE CONVALESCENT Phylene Sunga, NHA Wednesday, April 24, 2013

2 Change is NOW and NOT Tomorrow "If I am interested in change I need three things: the will to change; ideas and alternatives to the status quo; and the management of change as an on going process" Don Berwick, MD* * (third slide on QIO home page)

3 Readmissions in Contra Costa County Hospital Name Hospital Ownership FY 2013 Readmission Payment Adjustment Factor Excess Readmission Ratio for Pneumonia Excess Readmission Ratio for Heart Failure Acute Myocardial Infarction Excess Readmission Ratio SUTTER DELTA MEDICAL CENTER Voluntary non-profit - Private JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS Voluntary non-profit - Private KAISER FOUNDATION HOSPITAL - ANTIOCH Voluntary non-profit - Private CONTRA COSTA REGIONAL MEDICAL CENTER Government - Local SAN RAMON REGIONAL MEDICAL CTR Proprietary KAISER FOUNDATION HOSPITAL - WALNUT CREEK Voluntary non-profit - Other JOHN MUIR MEDICAL CENTER - WALNUT CREEK CAMPUS Voluntary non-profit - Private DOCTORS MEDICAL CENTER-SAN PABLO Government - Hospital District or Authority Payment adjustment is percent of Medicare Discharge Reimbursement Withheld NOTE: Penalty Doubles 10/1/2013 What do you think the Hospitals might do to reduce avoidable readmissions?

4 How Important is Performance Improvement? 31 SNFs in Contra Costa County Total Number Of Residents Percent Of Occupied Beds Special Focus Facility Over-all Star Rating Health Inspections Stars Nurse Staffing Stars RN Only Stars Quality Measures Stars Totals / Averages Does your facility have an above average rating that the hospitals will see? Does your facility need to explain its rating?

5 04/24/13 5 Causes of Re-Admission Hospitals will say: Pneumonia Fracture-Hip Stroke Heart Failure UTI COPD Dementia-Altered Mental Cellulitis Urosepsis SNF s will say: Pneumonia Shortness of Breath GI Bleed, Coughing Blood Resp. Failure No Urine Output/Renal Failure Change in Mental Status Chest Pain, Severe Pain UTI Febrile Illness

6 04/24/13 6 Building a Common Vision Hospital Too many readmissions are reducing $ payment SNF Readmissions will eventually have a $ impact admission growth Inter-facility handoffs are messy Inter-facility handoffs are messy High quality care and reputation matter High quality care and reputation matter

7 04/24/13 7 Lean Six Sigma Improvement Strategy (RCA) Methods Manpower Materials Lack of info SNF reports Type of transport Pt supplies, O2, Wound Vac, Walkers Accurate pt info Machines/equip ment Can SNF s Have more serv 24/7? Family/pt Understanding Expectation education Notification of pt DC d from SNF To home What can SNF s Handle? Tech, Care, Procedures, Monitoring Levels of Care Acute v. Chronic Mode (processes) Nursing staff/ Anc staff ED physicians Attending physicians Liability, care Rendered outside Of hospital Management support For project Management EMS Patients/ Families Unplanned readmissions Hospital View Financial challenges

8 04/24/13 8 SNF s Are a Solution For Acute Care Want short term care alternative Treatment and stabilization of acute problem Management of secondary diagnosis or co-morbidity What is not being addressed Rehab Patient education Eventual patient discharge to home

9 4/24/13 9 How Do We Begin?

10 04/24/13 10 Grass Roots Effort There was a dilemma between 1 SNF and 1 Acute SNF s are required to have an informed consent for the use of psychotropic drugs SNF s in need of a triplicate for narcotics Acute not understanding why

11 4/24/13 11 Meet the Neighbors Create a Committee 1 Acute /5 SNF s Roles/ Responsibilities Identify areas for improvement between healthcare entities i.e. communication, forms, electronic health records access, best clinical practices Develop strategies Share and provide education i.e. Heart Failure, Pneumonia, Urinary Tract Infections Review agreed upon outcomes No marketing of programs during Committee meetings

12 4/24/13 12 Meet the Neighbors Committee Members At least two members from each participating entity Committee Structure and Operations 2 co-chair: Director of Case Management and an Administrator from the SNF

13 4/24/13 13 Discerning Common Concerns Prioritization of Issues Missing/poor documentation at handoff Patient needs unclear No planning for potential decline in patient health Medication reactions, inability to obtain meds Physician involvement at SNF Complexity of patient monitoring

14 4/24/13 14 Key Issue Agreement Communication must strengthen Patients and Families need to understand why re-admission is not always the best action SNF Physicians are a key factor in preventing re-admissions Early Identification of impending patient decline is vital

15 4/29/ SNF Tools INTERACT Tools Stop & Watch SBAR Best Practice Care Paths SNF Skill Sets POLST

16 4/29/ interact2 Stop and Watch (Early Warning Tool) Seems different Talks less Overall need more help Pain Ate less No Bowel movement Drank less Weight change Agitated or Nervous Tired, weak, confused Change in skin Help more than usual

17 4/29/ interact2 SBAR (Communication Form) Situation Background Assessment Request

18 4/29/ interact2 Nursing Home Capabilities List (SNF Skill Set)

19 4/29/ Interact2 Care Paths (Best Practice) Acute Mental Status Change Change in Behavior Dehydration Fever GI Symptoms Shortness of Breath Symptoms of CHF Symptoms of Lower Respiratory Illness Symptoms of UTI

20 4/29/ Interact2 POLST

21 4/29/ What We ve Done First Meeting-Kick Off March 2012 Training on Heart Failure July 2012 Meeting with SNF Medical Director September 2012 Started Nursing Home Capabilities List October 2012 Meeting with SNF Directors, Case Managers, February 2013 and Hospitalists Team Spoke at Senior Care Link March 2013 SNF invite to Surgical Committee April 2013 SDMC Heart Failure 30 day all cause readmission rates from SNF % % % TRENDING DOWN with largest decrease in 2012 Cautiously optimistic that collaborative efforts may have assisted in this trend

22 % Readmit 4/29/ Trending Reduction in Readmissions From SNF s Sutter Delta 30 Day All Cause Heart Failure Readmissions from SNF *Numerator includes those patients readmitted w/in 30 days for any cause with an admit origin of SNF/ Denominator includes all patients discharged to SNF with a principal diagnosis of Heart HF Readmissions from SNF Linear (HF Readmissions from SNF ) : 31.9% 2011: 29.7% 2012: 17.9% SNF/Sutter Delta Collaborative Started Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 2Q12 3Q12 4Q12

23 4/29/ Carry On Invitation to speak at ARC April 2013 Invitation to speak at Commons at Dallas Ranch May 2013 Collaboration to begin with: Emergency Department and Home Health May 2013 Dialysis/Ambulance/Transportation June 2013 Assisted Living, Board & Care, Cancer Centers,..and so on (Re-admission SNF s immunization rates, facility acquired pressure ulcers, physical restraints under 3%, Nursing hours 3.2 or higher,

24 Why It Matters

25 4/29/ Shout Out Lisa Stroud, RN Director of Case Mgt Sutter Delta Medical Center Beth Guo, RN, MSN, CCNS Sutter Care at Home Gwenmarie Hilleary, NHA, FACHE Hospital Association of San Diego and Imperial Counties Brion S. Pearson MD Sutter Delta Medical Center Derek Johnson DO Sutter Delta Medical Center John Sheridan e Health Data Solutions

26 4/24/13 26 HELPFUL REFERENCE TrendTrachttp://

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