PARAMEDIC-NURSE READMISSION PROJECT VALLEY AMBULANCE- REGIONAL WEST MEDICAL CENTER

Transcription

1 PARAMEDIC-NURSE READMISSION PROJECT VALLEY AMBULANCE- REGIONAL WEST MEDICAL CENTER

2 PROJECT PURPOSE To reduce hospital readmissions for CHF, pneumonia patients To improve patient satisfaction with the discharge process: -discharge information -talking to patients about help after discharge -providing written discharge instructions

3 CURRENT STATE MS-DRG Pneumonia Group Quarter Q Q Q Q Q Q Q Q Total Cases At Risk Rx Actual Readmit Rate (%) 4.26% 6.67% 3.17% 2.74% 3.03% 5.41% 6.25% 4.00% 4.51% Expected Readmit Rate (%) 5.18% 6.30% 6.37% 6.12% 6.66% 6.38% 6.30% 7.85% 6.37% Risk-Adjusted Readmissions Index (RARI) Year Norm: National 1.00 Cases At Risk Rx Bench: National 0.74 Actual Readmit Rate (%) 5.61% 3.40% 5.38% Expected Readmit Rate (%) 5.81% 6.33% 6.90% ** a 95% confidence level Risk-Adjusted Readmissions Index (RARI) * a 75% confidence level ** a 95% confidence level * a 75% confidence level Pn - Risk-Adjusted Readmissions Index (RARI) Risk-Adjusted Readmissions Index (RARI) Q Q Q Q Q Q Q Q2 2012

4 CURRENT STATE MS-DRG Congestive Heart Failure Group Quarter Q Q Q Q Q Q Q Q Total Cases At Risk Rx Actual Readmit Rate (%) 0.00% 13.89% 7.41% 10.71% 0.00% 0.00% 8.00% 0.00% 6.67% Expected Readmit Rate (%) 11.11% 12.19% 12.27% 12.06% 12.34% 11.97% 12.86% 11.87% 12.13% Risk-Adjusted Readmissions Index (RARI) Year Norm: National 1.00 Cases At Risk Rx Bench: National 0.80 Actual Readmit Rate (%) 9.43% 5.62% 5.26% Expected Readmit Rate (%) 11.84% 12.14% 12.52% ** a 95% confidence level Risk-Adjusted Readmissions Index (RARI) * a 75% confidence level ** a 95% confidence level * a 75% confidence level CHF - Risk-Adjusted Readmissions Index (RARI) Risk-Adjusted Readmissions Index (RARI) Q Q Q Q Q Q Q Q2 2012

5 CURRENT STATE Question 100% Top Box Discharge Information Y8AA Talking to patients about help after discharge Y8AB Providing written discharge instructions # of Completes Top Box Improved 2010 Top Box Jan 2011 Top Box Feb 2011 Mar 2011 Top Box Top Box Inpatient - HCAHPS Top Box Worsened April 2011 Top May 2011 Box Top Box June 2011 Top July 2011 Box Top Box August 2011 Top Box Sept 2011 Top Oct 2011 Box Top Box Nov 2011 Top Box Dec 2011 Top Box Most recent Month % YTD Your HSTM DB Pos Top Box Top Box % 89.2% 94.4% 91.7% 91.9% 83.7% 94.2% 86.6% 82.9% 89.9% 91.5% 94.2% 95.2% 95.2% 90.5% 84.7% % 84.8% 97.8% 92.3% 89.6% 82.3% 92.1% 83.1% 80.7% 88.0% 89.6% 95.0% 94.2% 94.2% 89.1% 82.3% % 93.8% 90.9% 91.0% 94.2% 85.2% 96.2% 90.0% 85.2% 91.8% 93.5% 93.4% 96.2% 96.2% 92.0% 87.1%

6 QUALITY MEASURES Better patient understanding of discharge instructions Better patient health management resulting in reduced patient readmissions Better patient satisfaction with discharge process

7 DESIRED OUTCOMES Patients verbalize understanding of discharge instructions by the end of home visits Reduction in readmissions for CHF and Pneumonia patients from baseline to completion of the project Improvement in patient satisfaction scores related to discharge process from baseline to completion of the project

8 STRATEGIES Provide information about the project to physicians, nurses, discharge planners, and seek input on the project and processes to be developed. Work with physicians, hospital nursing staff, and discharge planners to develop the process for identification, consent, and referral of these patients for the project. Work with paramedics and homecare RNs to develop an assignment process to see the patient within 24 hours of discharge and weekly for a total of four visits.

9 STRATEGIES CONTINUED Work with the paramedics and homecare RNs to ensure buy-in and clear processes to focus the visits on health maintenance and teaching. The emphasis of the maintenance and teaching is on patient s learning self- care techniques to remain healthy. Paramedics and RNs will meet at weekly team meetings to discuss process, action sheets, strategies, and outcomes.

10 STRATEGIES CONTINUED Outcomes data will be reviewed monthly with stakeholders, quarterly with physicians and leaders, every 6 month presentation to executives.

11 CONCEPTUAL MODEL

12 Task Name Start Date End Date Assigned To Comments Readmission Prevention Project 07/31/12 08/01/13 Major Milestones Brainstorm concept of project project 08/21/12 09/11/12 RM, DR, SK SK to schedule stakeholders meeting key stakeholder's meet to gauge interest in 09/11/12 09/21/12 RM, DR, SK BN to distribute minutes gather evidence based practice articles 0911/12 09/25/12 RM, DR, SK BN to schedule group review date review articles with stakeholders 09/26/12 10/10/12 RM, DR, SK discuss project with MD-medical director 10/01/12 10/01/12 RM RM to report back to DR, SK Medical Director commitment 10/01/12 10/01/12 RM Proj leads discuss feasability of project 09/17/12 10/01/12 RM, DR, SK assignments broken out equally with deadline Present project to hospital execs for 09/17/12 09/18/12 RM, DR, SK SK to get on Ops agenda Prepare and submit to IRB 09/19/12 09/26/12 RM, DR, SK SK to prepare draft send to RM, DR for input prepare outline of project 09/24/12 09/28/12 SK SK to send to RM, DR for input break project into phases 10/08/12 10/08/12 RM, DR, SK BN to send draft from meeting to RM, DR, SK Received IRB approval 10/30/12 10/30/12 SK send approval to RM, DR make project assignments 11/06/12 11/06/12 RM, DR, SK BN to type, distribute work on development of tools, protocols 11/06/12 12/07/12 RM, DR send drafts to group medical director approval of drafts 11/20/12 11/30/12 RM report to group consent for participation draft to attorney 11/13/12 11/30/12 RM report to group build of documentation templates 11/15/12 11/30/12 RM SB to work with RM and State of Neb. orientation of medics to hospital HIPPA 1112/12 11/23/12 RM to schedule with JS, Education Dir Present proj update to stakeholders 11/27/12 11/27/12 SK report back to group finalization of protocols with medical 12/04/12 12/14/12 RM report back to group Flow chart identification process 12/04/12 12/21/12 DR, RM all four flow charts can be done in one meeting Flow chart consent process 12/04/12 12/21/12 DR, RM Flow chart referral process 12/04/12 12/21/12 DR, RM Flow chart visits process 12/04/12 12/21/12 DR, RM Train medics, RNs doing visits in process, 01/07/13 01/18/13 DR, RM schedule with staff to be done by DR, RM Presentation of project to Dept.Directors, 12/04/12 12/04/12 SK, DR, RM SK will prepare power point for input Presentation of project to Med Exec FYI 12/19/12 12/19/12 SK, DR, RM, Dr.HSK will prepare abbreviated pp Presetation of project to all med staff FYI 12/20/12 01/18/13 Dr. H, SK, RM, Dabbreviated pp train hospital staff 01/07/13 01/18/13 RM, DR, SK RM, DR to develop with 3rd floor leadership, disc train visit staff in protocols, processes 01/07/13 01/18/13 RM, DR put into curriculum, arrange room, schedules Final run through with stakeholders 01/22/13 01/29/13 RM, DR, SK prepare updated power point Begin seeing patients 02/04/13 02/04/14 RM, DR, SK oversight of process weekly jointstaff meetings,address issues 02/04/13 02/18/13 RM, DR follow up on issues monthly joint staff meetings, issues 03/18/13 02/04/14 RM, DR follow up on issues, data review monthly project team mtgs 03/04/13 02/04/14 RM, DR, SK follow up on issues, data review Review of project results quarterly with PL 04/30/13 02/04/14 RM, DR, SK review results with Dr. H., share with execs present project results to hosp execs q 6mo 08/15/13 02/04/14 RM, DR, SK do more indepth presentation of project

13 PRIORITIES 1. Assess support for the project from physicians, staff, administration. 2. Focus on empowering the patient to self actualization of improved health through health monitoring and teaching. 3. Development of tools, processes, education, communication to accomplish goals. 4. To build measurements for success

14 BARRIERS TO CHANGE New concept Lack of knowledge about current state Fear that the paramedics would take over what the RNs do Paramedics fear that the RNs would resent them, shut them out Paramedic scope of practice concerns on the part of RNs, homecare state association

15 BARRIERS CONTINUED Physician fear that this would reduce clinic visits Administration concern that expenses won t be covered as these are not reimbursable visits

16 EVALUATION The Compass model balanced scorecard format is used. Target for readmission rate reduction is 25% reduction from baseline Target discharge HCAHPS scores are 98 th percentile ranking

17 Paramedic Readmission Prevention Project February 2013-December 2013 Total Patients Total Readmissions Readmission Rate *Total Patient Population % Study Participants - Sample Group % Non-Participants - Comparison Group % Total Patients Total Readmissions Readmission Rate Study Participants - Sample Group % Heart Failure Diagnosis % Pneumonia Diagnosis % Other Diagnoses % Total Patients Total Readmissions Readmission Rate Study Participants - Sample Group % Paramedic Home Visit % Home Health RN Home Visit % * "Total Patient Population" includes all patients discharged from the RWMC Medical/Oncology unit with a diagnosis of PN or CHF, whose primary residence was within the Scottsbluff/Gering corporate limits. Non-participants include both those patients who met the population definition but chose not to participate in the study, as well as those who fit the population definition but were not given the opportunity to participate in the study. "Other Diagnoses" includes study participants who were identified by the discharge nurse as having CHF or Pneumonia but did not have CHF or Pneumonia on final coding.

18 LESSONS LEARNED Education about the program to the patients and families was a given, but education to the community is also essential as friends and neighbors who see the ambulance in front of someone s home assume the worst and start calling the patient s families. Holding regular meetings with paramedics and home health RNs together was very beneficial for joint problem solving. Medication confusion was the most common problem for patients of both diagnoses in the beginning of the project; this became less of an issue as the project progressed. Simple things like not owning a scale to monitor weight were barriers to compliance. Follow-up appointments with primary care providers did not always occur within the first week of discharge, more calls to the provider occurred on these patients to prevent readmissions. Compliance with follow-up visits to their primary provider was best when the patient had the appointment made for them before they were discharged from the hospital. Weekend discharges where appointments could not be made prior to discharge had the greatest difficulty with the patient being seen within the first week of discharge.

19 LESSONS LEARNED The discharge instructions often would say to call the Primary Care Provider if the patient experiences a weight gain of two pounds in 24 hours however, when they call their provider, they may reach an answering service or an office nurse who tells them to go to the emergency department. Discharge instructions sometimes were taken home by the family member who did not live with the patient. Typed instructions were easier for patients to be able to read, hand writing was a problem in some cases on discharge instructions. Some patients stated they could not afford their medications. When a patient was dismissed on the weekend and called on Monday for a follow-up appointment, the family physician did not know yet that the patient had been in the hospital.

20 CONCLUSIONS Health monitoring and teaching post hospital discharge is beneficial due to the complexity of the heart failure and pneumonia patients. This can be safely provided by paramedics when the right support is available. Examples of that support are a medical director; primary care, nursing and pharmacy leadership. This partnership is essential as lessons learned can be addressed real time to improve outcomes.

21 RECOMMENDATIONS Seek funding for the readmission prevention project utilizing paramedics to continue with the goal being to: Request a project manager to develop a plan to transition this from a research project to a service offered Partner with critical access hospitals and ambulance squads to provide in home health maintenance and teaching visits expanding the population served

22 RECOMMENDATIONS Expand to include total hip and knee patients, a new CMS readmission measure Partner with the Physician s Clinic to create a process for scheduling prompt follow up appointments before discharge Partner with the Physician s Clinic to create a nurse navigator role to manage these patient populations. Nurse Navigator would be the contact for patients and paramedics Nurse Navigator would provide ongoing follow-up via phone with those patients the paramedics or providers identified as at risk for readmission

23 REFERENCES Berry, D., Costanzo, D. M., Elliott, B., Miller, A., Miller, J. L., Quackenbush, P., & Su, Y. (2011). Preventing avoidable hospitalizations. Home Healthcare Nurse, 29(9), (Centers for Medicare and Medicaid Services (CMS), 2012) (Centers for Medicare and Medicaid Services (CMS), 2012) Hospital Readmissions Clark, D. D., Savitz, L. A., & Pingree, S. B. (2010). Cost cutting in health systems without compromising quality care. Frontiers of Health Services Management, 27(2), Hines, Steven, PhD, Vice President Research, Health Research and Educational Trust, (2010) AHRQ Home > Special Interest > AHRQ's Knowledge Transfer/Implementation Program > Implementing Re-Engineered Hospital Discharges (Project RED)>Reducing Avoidable Hospital Readmissions Hodges, P. (2009). Factors impacting readmissions of older patients with heart failure. Critical Care Nursing Quarterly, 32(1), Regional West Medical Center internal reporting data from data analysis software, report run October 3, 2012.

24 REFERENCES Rudisill, P. T., & Thompson, P. A. (2012). The American Organization of Nurse Executives system CNE task force: A work in progress. Nursing Administration Quarterly, 36(4), Wentz, Scott, Finance Director, RWMC,(October 3, 2012), report of patients discharged from RWMC between January 2011 and August 2012 by address differentiating those within the city limits. Werner, R. M., & Dudley, R. A. (2012). Medicare's new hospital value-based purchasing program is likely to have only A small impact on hospital payments. Health Affairs (Project Hope), 31(9),

25 QUESTIONS? Contact information: Shirley Knodel, RN, MS