Improving Patient Safety Across Michigan and Illinois

Transcription

1 Improving Patient Safety Across Michigan and Illinois Designing Your Readmission Reduction Approach February 17, 2016

2 Agenda Peer to Peer Learning Network/Improvement Poster (Illinois) Designing your Readmissions Approach Covenant HealthCare Vignette Franklin Hospital Vignette Q/A 2

3 Peer to Peer Learning Network Share Resources Request Resources Step up to be a Mentor N/Resources/PeerToPeerLearningNet work.aspx 3 3

4 IHA Advocacy Day Improvement Poster Posters turned into IHA by this Spring will be printed and showcased at the State Capitol Building on Thursday, April 14 th. Posters due February 24th We will be accepting posters in 5 different categories 1. Care Coordination 2. Patient Safety 3. Integrated Behavioral Health 4. Medication Safety 5. Population Health 4

5 Designing Your Readmission Reduction Approach Pat Teske, RN, MHA

6 Plan for today Share learnings from skill building exercise Compare and contrast leading evidence based models Creating your own evidence Using an outsourced approach Bringing it all together to Adopt successful approaches from other organizations Adapt these approaches for your organization Abandon approaches that are not a good fit and or do not work in your organization

7 What did you learn? From your skill building analysis of: Data Patient Interviews Provider Interviews Record Review Process Review What surprised you? What was confirmed?

8 Evidence-based models

9 Eric Coleman, MD

10 Key Elements of The Care Transitions Intervention TM Low-cost, low-intensity, adapt to different settings One home visit, three phone calls over 30 days Transition Coach is the vehicle to build skills, confidence and provide tools to support self-care Model behavior for how to handle common problems Practice or role-play next encounter or visit Elicit patient s health related goal Create a gold standard medication list (c) Eric A. Coleman, MD, MPH

11 Four Pillars Medication self-management Follow-up with PCP/Specialist Knowledge of red flags or warning signs/symptoms and how to respond Patient-centered record (c) Eric A. Coleman, MD, MPH

12 Personal Health Record Remember to take this Record with you to all of your doctor visits (c) Eric A. Coleman, MD, MPH

13 Hospital Visit Introduce the Program and explain how it will feel different Introduce the Personal Health Record Schedule home visit (with family caregiver) (c) Eric A. Coleman, MD, MPH

14 Home Visit Patient identifies a 30-day health related goal Patient asked: Show me what medications you take and how you take them Transition Coach models the behavior for how to resolve discrepancies, respond to red flags, and obtain a timely follow up appointment Patient and Transition Coach practice or role play next encounter(s) Patient identifies 2-3 questions for next encounter (c) Eric A. Coleman, MD, MPH

15 Three Phone Calls Follow-up on active coaching issues Review the Four Pillars Estimate progress made in activation Ensure that patients needs are being met (c) Eric A. Coleman, MD, MPH

16 Care Transitions Intervention (CTI) Summary of Key Findings Significant reduction in 30-day hospital readmits (time period in which Transition Coach involved) Significant reduction in 90-day and 180-day readmits (sustained effect of coaching) Net cost savings of $300,000 for 350 pts/12 mo ($8,571/pt) Widely adopted by leading health care organizations nationwide (c) Eric A. Coleman, MD, MPH

17 N= day readmits Care Transitions Intervention Control 30-day readmits 60-day readmits 8% 13% 15% 17% 20% 29% P-value Eric A. Coleman, MD, MPH

18 Brian Jack, MD

19 RED Checklist Adopted by National Quality Forum as Safe Practice Ascertain need for and obtain language assistance. 2. Make appointments for follow-up medical appointments and post discharge tests/labs. 3. Plan for the follow-up of results from lab tests or studies that are pending at discharge. 4. Organize post-discharge outpatient services and medical equipment. 5. Identify the correct medicines and a plan for the patient to obtain and take them. 6. Reconcile discharge plan with national guidelines. 7. Teach a written discharge plan the patient can understand. 8. Educate the patient about his/her diagnosis. 9. Assess the degree of the patient s understanding of this plan. 10. Review with the patient what to do if a problem arises. 11. Expedite transmission of the discharge summary to clinicians accepting care of the patient. 12. Provide telephone reinforcement of the Discharge Plan.

20 Operationalizing RED After Hospital Care Plan Discharge Advocate Follow-up phone call

21 Components of RED Intervention In Hospital Nurse Discharge Advocate (DA) Interacts with care team: medication reconciliation, appointments, and national guidelines Prepares and teaches After Hospital Care Plan (AHCP) Post Discharge Clinical Pharmacist Calls for 72 hours post-dc Reinforces dc plan and review medications

22 COVER PAGE

23 MEDICATION PAGE (1 of 3)

24 PATIENT ACTIVATION PAGE

25 Components of RED Intervention In Hospital Nurse Discharge Advocate (DA) Interacts with care team: medication reconciliation, appointments, and national guidelines Prepares and teaches After Hospital Care Plan (AHCP) Post Discharge Clinical Pharmacist Calls for 72 hours post-dc Reinforces dc plan and review medications

26 Randomized Controlled Trial Enrollment N=749 Randomization RED Intervention N=374 Usual Care N= day Outcome Data Telephone Call EMR Review Enrollment Criteria: English speaking Have telephone Able to independently consent Not admitted from institutionalized setting Adult medical patients admitted to Boston Medical Center (urban academic safety-net hospital)

27 Primary Outcome: Hospital Utilization within 30d after dc Hospital Utilizations * Total # of visits Rate (visits/patient/month) ED Visits Total # of visits Rate (visits/patient/month) Readmissions Total # of visits Rate (visits/patient/month) Usual Care (n=368) Intervention (n=370) P-value * Hospital utilization refers to ED + Readmissions

28 Outcome Cost Analysis Cost (dollars) Usual Care (n=368) Intervention (n=370) Difference Hospital visits 412, , ,602 ED visits 21,389 11, ,104 PCP visits 8,906 12,617-3,711 Total cost/group 442, , ,995 Total cost/subject 1, We saved $412 in outcome costs for each patient given RED

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34 Results The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = for signed rank test comparing differences in readmission rate reduction in BOOST units compared to sitematched control units). Journal of Hospital Medicine 2013;8: Society of Hospital Medicine

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36 Mary Naylor, PhD, RN

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42 Models At-A-Glance CTI RED TCM BOOST Staff Coaches (RN) Discharge Advocates (RN) Pharmacists Advance Practice Nurses Unspecified Setting Primarily post discharge Primarily in hospital Primarily post discharge Primarily in hospital Duration post discharge 30 days 72 hours Approx. 8 weeks 72 hours

43 Different Models, Common Themes

44 There s a plan

45 Patient Centered

46 Medications

47 Self Management Knowledge

48 Connections

49 Reinforcement

50 Get into the weeds

51 Select your model

52 Approaches to Reducing Cardiac Readmissions Karen S. Bush, MSN, FNP, BC, NCRP Transition Coach Nurse Practitioner Covenant HealthCare

53 Disclosure Statement I work for Covenant HealthCare I am the President of Selfcare Solutions LLC I own the patents related to this project Covenant HealthCare owns copyrights related to this project

54 Covenant Healthcare Transitions Addressing the Needs of all patients Primary Care and Community Resources Boost Initiatives F/U Appt. Scheduled, Timely D/C summaries, Teach Back, Med. Rec. Case Resource Management Transition Coach

55 What s a Transition Coach?

56 Transition Coach A transition coach is someone who coaches patients in their own health so that they can safely transition from the hospital to the home setting. Typically they start working with patients in the hospital and then follow them post discharge either telephonically or with in home visits. Target is to enhance the safety of the patient s transition which results in a reduction of readmissions

57 Why is a Safe Transition (discharge) Important? It impacts patient s health and well being Physical, emotional as well as financial It impacts family and caregiver burden Physical, emotional as well as financial It impacts how people view care provided at your institution Now with payment reform it impacts reimbursement

58 Where was Covenant? According to the most recently published hospital compare data the U.S. national rate of readmission for heart failure patients was 23% The rate of readmission for Covenant Healthcare during the same time using the same criteria was 26.6% Hospital Compare Quality of Care Profile Page Accessed 2014

59 Everyone has an Opinion How hard can it be to keep people from coming back to the hospital for 30 days? It s just those 4-5 people This research study says to This hospital is doing this We should to this Look at the research and the data Decide what will work and STAY THE COURSE!!!

60 How Patients Feel Patients may have negative feelings and emotions related to their limited reading ability or limited understanding Institute of Medicine, 2004 The health care environment can make it hard for patients to tell us they don t read well or do not understand They hide this with a variety of coping techniques Parikh N Pt Educ and Counseling, 1996

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62 The Challenge Studies demonstrate that 40-80% of the medical information patients receive is forgotten immediately. Kessels, RP (2003) Nearly half of the information that patients retain is incorrect. Anderson JL et al (1979) Patients remember and understand less than half of what clinicians explain to them Ley, (1988)

63 Necessary Knowledge for a Heart failure patient The Heart Failure Society of America and the American College of Cardiology identify 6 areas for essential education of the hospitalized patient prior to discharge Recommended activity level Diet (Sodium and Fluid Restriction where appropriate) Discharge Medications Follow up appointment Weight Monitoring What to do if signs or symptoms worsen

64 Current Research is great, but you need to go to the source. Go to the front line Talk to people on the front line Interview, survey, interact Worked with patients Talked to staff

65 I went to the front line I have heart failure??? I just watch what I drink I don t add any salt to my food. Well I wasn t feeling good so I was eating chicken soup and my kids thought I should have gator-aid. They don t weigh me here so why do I have to weigh myself at home

66 Balancing your Daily Fluid An interactive tool Covenant HealthCare All rights reserved. Bus Dev (AQ/PK ) 414 Balancing Beads Patent Selfcare Solutions LLC July 2015 Education that flows across the continuum of care Address symptoms of fluid overload, but also address the potential for dehydration and acute kidney injury Involvement of caregivers and family

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68 Research Study Pretest-Intervention-Posttest-30 day Posttest Primary goal was to improve Heart Failure Maintenance, Management, and Confidence with the use of Diagnosis Specific Toolkit. Pretest for baseline prior to introduction of toolkit Posttest was completed post intervention Posttest 30 days after discharge from the hospital to determine sustainability of change Secondary aim was to reduce 30 day readmission rates

69 Why not just look at readmission rates if that is the goal?

70 Subjects Identified for Study Targeting hospitalized heart failure patients with working DRG of 291, 292, 293 Primary exclusion criteria Discharge disposition other than home Renal Failure on Renal Replacement Therapy Co-morbid COPD with active treatment Kidney or heart transplant patients

71 Study Population: Target 50 patients 6 patients were lost to study 41 patients completed all 3 surveys Return rate of 93% 34.1% female and 65.9% male 29.5% disposition home alone and 70.5% home with family 36.4% received education with a caregiver & 63.6% received education alone

72 Clinical Implications 70 or greater mean=self care adequacy More than ½ of a standard deviation improvement is considered clinically relevant 50 th percentile-marked reductions in the odds of having episodes of hemodynamic congestion and risk of death or hospitalization 75 th percentile=direct inpatient cost savings are seen. Reigel, B et al (2009)

73 Impact of Toolkit on HF Maintenance, Management and Confidence Maintenance Management Confidence Pre Test Immediate Post Test 30 Day Post Test

74 Section/Time Number Mean Std. Deviation Results P Value Pre Test HF Maintenance <0.05 Immediate Post Maintenance < day Post Maintenance <0.05 Pre Test HF Management <0.05 Immediate Post Management < day Post Management <0.05 Pre Test HF Confidence <0.05 Immediate Post Confidence < day Post Confidence <0.05

75 Patient Feedback I used it every day I thought it was an excellent idea and very helpful Because we were at Ludington for several days with our families over Thanksgiving I let my guard down and over indulged in fluid and salt. Because of the study and tool kit I realized something wasn t right. Got my act together and got back on schedule which got me back to feeling better! I liked it very much. I would see it and it would remind me to drink more or less. Weighing myself everyday keeps me in the safe zone. I have been in the safe zone since I started the program. I think this program helped me out a lot. Thank-you The tool kit works. Thank-you Very easy to follow and use. Helpful in getting control of the situation. Great as is. Thank you for the opportunity of doing this study. I never before realized that just one little thing could have such a bearing on my every day living. I will continue the program forever. Thank you again s-o-o-o much

76 Readmission Data 44 patients in the study 40 patients successfully stayed out of the hospital 30 days 4 readmitted within the 30 day window Readmission rate of 9% Hospital purchased 100 more kits Used by NP and RN transition coaches 41 patients received kits in January and February 37 patients successfully stayed out of the hospital 30 days 4 patients readmitted within 30 days post discharge Readmission Rate of 9.8% This demonstrated that an RN or an NP could use this kit successfully with patients

77 Something was missing

78 We needed comparison data

79 Admission Source 255 Heart Failure Patients Admission Source 7% 7% 7% 2% Non Health Care Facility=197 Clinic or Physician Office=18 Transfer from another Hospital=17 Transfer from SNF=17 77% Other=6

80 13.7% 19.2% 17.2% 25.7% 43.0% 57.0% Volume of HF Patients Admitted to PCCU and Effect of Toolkit 255 Heart Failure Patients VOLUME OF PATIENTS ADMITTED TO PCCU VS OTHER UNITS AND READMISSION DATA Volume of Total HF Patients Readmit Rate Readmit Rate for these Units with Toolkit PCCU OTHER UNITS

81 Volume of HF Patients Admitted to PCCU and Effect of Toolkit 255 Heart Failure Patients Units # of 255 CHF patients # of CHF patients readmitted # of CHF patients with kit # of patients readmitted with kit on each unit PCCU /146 or 19.1% Other Units /109 or 25.7% 51 7/51 or 13.7% 29 5/29 or 17.2%

82 12.5% 23.5% 23.5% 33.3% 31.4% 45.1% No Intervention vs TC without and with Toolkit 255 Heart Failure Patients TRANSITION COACH DATA Volume of HF Patients Readmission Rate NO INTERVENTION (N=60) TRANSITION COACH ONLY (N=115) TC WITH TOOLKIT (N -80)

83 No Intervention vs TC without and with Toolkit 255 Heart Failure Patients Intervention # of the 255 CHF patients Percentage of total CHF patients # of CHF patients readmitted Readmit Rate No Intervention % % Transition Coach Only Transition Coach with Toolkit % % % % Transition Coach with & without Toolkit % %

84 Casting a Broader Net The hospital purchased 1,000 more kits for this fiscal year Implement the toolkit for high risk patients (LACE score 10 and above 65) with ejection fraction less than 50% and diagnosis of AMI and CHF patients. Implement the toolkit additionally on any other appropriate heart failure patient. A consult to transition coach has been added to our epic system Toolkit is provided with video education and reinforced using teach back with the transition coaches Each patient will receives at least one post discharge call within 72 hours of discharge by the transition team.

85 How are we doing now? July through December 2014 the readmission rate for our Medicare population discharging with heart failure was 24.31% July through December 2015 the readmission rate for our Medicare population discharging with heart failure is 17.33% We began implementation of the broader use of toolkits with a tracking system integrated into EPIC for the months of October and November. We had 48 high risk patients with the diagnosis of AMI or CHF who received toolkits. The readmission rate for this population was 14.58%

86 Final Thought In the space between chaos and shape there was another chance. Jeanette Winterson

87 Karen S. Bush MSN, FNP BC, NCRP

88 16-bed Critical Access Hospital

89 TipOff program - Our goal is to reduce the readmission percentage Issue: COPD readmissions within 30 days for all causes range from 17% to 25% For moderate-to-severe COPD patients Hospitalized within the last 6 months Discharge home with ability to care for their own chronic condition. Patients can self-monitor and alert provider to critical signs and symptoms before they lead to hospital readmissions or ED visit.

90 Why did Franklin Hospital choose to participate in TipOff? Our strategic plan includes population health goals pertinent to our community. COPD is relevant to our southern Illinois community of farmers, coal industry and allergies. Early interventions and tracking of symptoms at home will result in decreased ER visits and hospitalizations for our patient.

91 How it works The Case Manager screens MIP s for COPD Primary or secondary diagnosis. Determine if patient is discharged home and determine ability to manage chronic condition at home. If both criteria are met, the patient is informed about the TipOff program and permission is required to participate before notification of TipOff. If patient agrees, enrollment is completed. The hospitalist signs consent and attending physician practice is notified of patient s participation. DME s are chosen by the patient from area selection and plays no part in the TipOff program. If home health services are needed by the patient, case management offers a choice of area services at discharge.

92 Results Program started late October We have experienced 3 patients that met criteria. No patients declined to participate. None of the three patients have visited the ED or been readmitted through January 31, We are approaching the RHC for interest in this program.

93 Next Steps Identify a Readmissions Model or Best Practice and design your approach: delsandresources.pdf Next month s webinar will be focused on Care Transitions Illinois Hospitals download your Readmissions Activity Profile and Dashboard Reports: 93

94 March 16 th -Care Transitions 94