Heart Failure Order Sets. Standardizing Care for the Heart Failure Patient 2012

Transcription

1 Heart Failure Order Sets Standardizing Care for the Heart Failure Patient 2012

2 Objectives: Standardize care for all heart failure patients in Legacy Base Practice on American Heart Association Guidelines and Best Practice Improve the Continuum of Care for CHF patients Decrease length of stay and readmissions associated with HF March 19, 2013 LEGACY HEALTH 2

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4 Co-Management Agreement Focus Areas Legacy Cardiovascular Service Line across system Designate Pillars of cardiac care: Heart Failure, Rhythms, Coronary Disease, and General Cardiology for initial agreement Heart Failure Pillar mandate crosses through all aspects of Legacy care > ED > Hospital Course > Discharge > Outpatient

5 What is Wrong With the Status Quo For CHF in-patients: > 29% readmission rate within 30 days For CHF out-patients: > Inadequate dosing of life saving drugs ACE Inhibitors Beta Blockers

6 Why CHF Pillar Heart failure is the most common hospital admission diagnosis in patients age 65 or older Accounts for more than 700,000 hospitalizations among Medicare beneficiaries every year Associated with severe functional impairments and high rates of mortality and morbidity CMS target for quality initiatives and Core Measures

7 Legacy Medicare Vulnerability/Opportunity FY10 EMC $51,401,110 FY10 GS $70,777,895 FY10 MP $33,419,171 FY10 MH $17,775,619 FY10 SC $39,315,706 FY10 Total $212,689,501 FY11 EMC $54,988,087 FY11 GS $70,521,181 FY11 MP $34,779,386 FY11 MH $17,574,637 FY11 SC $40,494,024 FY11 Total $218,357,315 $2,000,000-$6,000,000 Vulnerability plus Opportunity for Bonus From CHF readmissions

8 Why do CHF Programs work? They rescue the most vulnerable > recently hospitalized patients > Chronic NYHA Class 4 patients They titrate life saving drugs to full doses > Some CHF patients are not on life prolonging drugs at all > Of those who are, most are not on doses shown to provide the life saving benefit

9 Heart Failure Pillar Performance Measures Heart Failure Readmission Rate Heart Failure Appropriate Care Score Development of and Compliance with System-wide, Quality-driven Multidisciplinary Pathway

10 Intake Scope Determine disposition Medication List Medication Reconciliation Collection of baseline data Risk stratification / Risk assessment Initiate HF education process Hospital Stay Scope Multidisciplinary Rounds Medication reconciliation Continuing education Discharge planning / organization of post d/c services Accurate documentation / core measures HF treatment per pathway Cardiac rehab referral Treatment goals per HFSA/ACC/AHA guideline Evaluate specialist consultation/ referral Discharge Scope Discharge Criteria per HFSA/ACC/AHA guideline / readiness for discharge Medication reconciliation HF discharge instructions w pt and family/ teach-back Documented d/c summary Ensure follow up scheduled within 7 days Discharge checklist / Risk Assessment Scale, blood pressure machine, etc. PASS Provider notification of d/c Post-D/C Scope Follow-up phone call Home visit PCP/Cardiologist/HF Clinic visit Home tele-monitoring SNF/Home Health coordination Disease Mgt / Case Management Communication/Tracking/ Analysis of re-admissions Team Members Team Members Team Members Team Members Cardiologist Cardiologist Cardiologist Cardiologist ED physician Hospitalist Hospitalist Primary Care Hospitalist ED Nurse ED Manager Inpatient Nurse Care Management Pharmacy Inpatient Nurse / Nurse Mgr Cardiac Rehab Nurse Care Management Quality / Documentation Specialist Pharmacy Inpatient Nurse / Nurse Mgr Cardiac Rehab Nurse Care Management Pharmacy IT input Nurse / HF Coordinator/ Home Health/ Hospice Care Management/quality metrics management ED Visit Admission Hospital Stay Discharge Ambulatory F/U; Post-discharge Who? Ownership & Accountability What? Process, not people LEGACY HEALTH

11 Identifying Patients early in the ED If ED RNs note signs and symptoms of dyspnea, orthopnea, edema, weight gain, or history of HF an advisory will alert the use of the ED Protocol for Heart Failure with a decision tree 3/19/2013 LEGACY HEALTH 11

12 HF patients who are discharged from the ED Standard HF teaching instructions are given and reinforced. HF Education from Exit Care 3/19/2013 LEGACY HEALTH 12

13 Proper Identification if Heart Failure Patients HF Nurses/Case Mangers will run a workbench report each day for HF Admitted Patients 3/19/2013 LEGACY HEALTH 13

14 Order Set In Epic The IP adult Heart Failure Order Sets are in Epic and are based on AHA guidelines and best practice. Use of these order sets are essential to the success of the pathway 3/19/2013 LEGACY HEALTH 14

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16 Multidisciplinary Rounds Multidisciplinary Rounds is alive at most sites and on the units where HF patients are concentrated HF Nurses/Case managers will identify high risk patients during rounds and actively work with the team to develop discharge plan including: > discharge medications > transportation home > follow up clinic appointments (coag clinic, PCP) > Teaching including documentation 3/19/2013 LEGACY HEALTH 16

17 Daily Weights Standardize process for daily weights Document time, charting location Incorporate and document teach back Utilize Daily Weight Diary with patient involved in an active roll in daily weight management 3/19/2013 LEGACY HEALTH 17

18 Discharge Instructions with Teach Back Standardization still in process System-wide form utilization will be based on community standard and reviewed by health literacy experts 3/19/2013 LEGACY HEALTH 18

19 Teach-back Prompts I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine? We covered a lot today about your heart failure and I want to make sure that I explained things clearly. What are three things you can do that will help you control your heart failure? What are you going to do when you get home? I shared a lot of information today. Could you share with me what you heard? Can you show me how you are going to weigh yourself when you get home? What questions do you have? LEGACY HEALTH

20 HF Basic Teach Back Questions What food are you to avoid? Name some salty foods you should not eat? How often should you weigh yourself? What time of day are you going to weight? What weight gain will your report to your care provider? How are you going to remember to take your medications? What pill/pills are you taking for your heart? What warning sign would prompt (cause) you to call the care provider? Which provider would you call? LEGACY HEALTH

21 Core Measure Documentation Physicians will use the IP Medicine Discharge summary template the core measure check list is embedded in that template and must be used to ensure 100% compliance with core measure documentation 3/19/2013 LEGACY HEALTH 21

22 Heart Failure Discharge Guidelines-WORK IN PROGRESS (post Epic Upgrade) Discharge expected today if clinically stable last 24 hours Labs: Discharge BNP is less than admit BNP (BNP decrease of at least 30%) BUN/CR trending down Electrolytes stable or improved Respiratory status O2 sat > 92% or baseline. > Home oxygen therapy arranged as needed. Activity tolerance- documented O2 saturation with activity. > Activity level back to baseline Ambulation prior to discharge to assess functional capacity Optimal Fluid status achieved > Below baseline weight, if known. Aim net negative volume status if admission for volume overload. > Discharge weight less than admit weight. Pharmaceutical therapy near optimal- > On oral medications for 24 hours; and stable for 24 hours. > No IV vasodilators or inotropes for 24 hours VS stable T< 99.4 po ( 37.4 C ) > absence of orthostatic hypotension Heart rate /min or baseline Reminder: patient may meet these criteria but have different major diagnosis supporting continued IP stay. 3/19/2013 LEGACY HEALTH 22

23 Post Discharge Follow-Up Appointments All High Risk HF patients will have follow-up appointments made before discharge Each site will identify the appropriate person and work flow. 3/19/2013 LEGACY HEALTH 23

24 Follow up phone calls-post discharge A follow up phone call will be made within 7 days post discharge. Documentation will be in a common place under doc flow sheets, Heart Failure Follow up This will allow all clinicians, both out patient and inpatient to see note. 3/19/2013 LEGACY HEALTH 24

25 Alert to Epic in-box for HF readmissions When patients are re-admitted with Heart Failure diagnosis an alert will be sent to the Epic in-box of designated case managers/hf Nurse Coordinator All patients with readmission alerts will be seen by case managers/hf patients with in 24 hours of alert and discharge plan reviewed for possible misses Care conferences will be planned for patient who have been readmitted 3/19/2013 LEGACY HEALTH 25

26 Readmission chart review Each readmission fall out will be reviewed by the respective hospital committee A common process will be used and opportunities for improvement will be identified (form to be developed) HF Pillar Medical Director will follow up on care issues 3/19/2013 LEGACY HEALTH 26

27 HF Nurses at each site EH-Laura Wheeler, Lynn Holter GS-Robin Klotz SC-Sue Frederick MP-Sue Willeson MH-Jill Sager, Bernadette Hoover and Brenda Grossnickle 3/19/2013 LEGACY HEALTH 27

28 HF Volumes 12 month rolling averages May 1 1 Jun 11 Jul 1 1 Aug 11 Sep 11 Oct 1 1 Nov 1 1 Dec 1 1 Jan 12 Feb 12 Ma r 12 Apr 1 2 May 1 2 Jun 12 Jul 12 Aug 12 LEH LGS LMP LMH LSC LEGACY HEALTH

29 HF Compliance, all measures/all sites ! Feb 11 Apr 11 Jun 11 Aug 11 Oct 11 Dec 11 Feb 12 Apr 12 Jun 12 Aug 12 LEGACY HEALTH

30 HF Inpatient Measure Compliance, August 2012 Top 10% US Avg LH comp num den EH GS MP MH SC DC Instructions LVF Assessment ACE/ARB for LVSD Overall compliance n= Total fallouts ACS (target 96.5) n= LEGACY HEALTH

31 Legacy HF Pillar Dashboard US Avg readmit rate for Medicare pt population = 24.8% LEGACY HEALTH

32 HF 30 Day Observed/Expected Readmission Rate Medicare Pts Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 EH GS MP MH SC LH Linear (LH) LEGACY HEALTH

33 1.40 HF 30 Day Observed/Expected Readmission Rate All Pts Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 EH GS MP MH SC LH Linear (LH) LEGACY HEALTH

34 Number of HF Deaths HF Mortality: All patient populations Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 EH GS MP MH SC LH LEGACY HEALTH

35 Next Steps Medical Executive Committee Approval JUNE/JULY Quality Council Approval/Presentation JUNE/JULY Nurse Exec Committee Approval of Education Plan JUNE/JULY Education plan for Physicians roll out AUG/SEPT Education plan for nursing staff roll out AUG/SEPT Epic Projects testing completed and Operational SEPT/OCT Baseline data for HF order set compliance-clarity report SEPT Audit for HF order set compliance OCT/NOV

36 Tracking Implementation % Utilization of Heart Failure Admission Order Set % Utilization of Heart Failure Discharge Order Set 30-day Readmission Rate If Order Sets Followed, 100% Core Measurements Will Be Reached

37 Summary Physician and Nurse Education is planned for fall All Epic pieces to be complete by fall Heart Failure Pillar will continue to adjust pathway to meet American Heart Association guidelines as they are updated HF Nurses at each site will meet monthly for continuous process improvement Heart Failure Joint Commission Accreditation in 2013! 3/19/2013 LEGACY HEALTH 37

38 Any Questions? Lynn Pappas, Cardiovascular Service Line Director > Dr. Sandy Lewis, HF Pillar Medical Director > Desi Shubin, RN Manager > Mark Roady, CNS > LEGACY HEALTH

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40 Questions? LEGACY HEALTH

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