Transitions of Care ACOI Clinical Challenges in Inpatient Care March 31, 2016 John B. Bulger, DO, MBA
Disclosure I have not accepted any honoraria, additional payments of reimbursements related to the material presented 2
Overview Why transitions of care? Public reporting Drivers of readmissions/change targets Screening IP Team communication Proactive outreach Transition Bundle Post-discharge engagement Outcomes discussion 3
Why Transitions of Care? Readmissions increasingly represent quality indicator One in five seniors are readmitted within 30 days Up to three-quarters may be preventable $15 billion to Medicare program The Billion Dollar U-turn Jencks, Williams & Coleman, NEJM 2009 MedPAC, 2007 Taylor, H &HN 2008 4
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Silver Bullet? No single intervention implemented alone was regularly associated with reduced risk for 30- day rehospitalization. There is not a silver bullet Ann Intern Med. 2011;155:520-528. 9
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Where do we start? Successful interventions are: comprehensive extend beyond hospital stay have the flexibility to respond to individual patient needs The strength of evidence should be considered low because of heterogeneity in the interventions studied, patient populations, clinical settings, and implementation strategies. Journal of Hospital Medicine 2016;11:221 230. 11
Geisinger s Transitions Approach Screening of all admissions Daily interdisciplinary communication Transition planning Timely transition communication Post-discharge engagement 12
Transformational Change PROCESSES
Process Changes SCREENING
Risk Screening - Premise Resources are finite One cannot bring all resources to bear on each patient Highlighting High Risk patients raises awareness within the health care team 15
BOOST - 8Ps Problem medications DIANA Psychological (Punk) Principal diagnosis (cancer, stroke, DM, COPD, CHF) Polypharmacy (> 5 meds) Poor health literacy Patient support Prior hospitalization (last 6 months) Palliative care 16
Screening Question Potential Score Odds Ratio P-value Age 65 or Greater? 1 1.24 <0.0001 Admitted from SNF or Requires Paid or Family Care 1 1.49 <0.0001 Currently has CHF, COPD, ARF, CRI, or is on dialysis 2 1.71 <0.0001 Takes more than 5 Prescription Medications 1 1.93 <0.0001 Takes Digoxin, Insulin, Anticoagulants, Narcotics or ASA /Plavix 1 1.58 <0.0001 History of Wound Infection or Poor Healing Wound 1 1.62 <0.0001 History of Pulmonary Embolism or DVT 1 1.31 <0.0001 Uses Cane, Walker, Wheelchair or Person to get Around 1 1.46 <0.0001 Will be alone after discharge or unable to attain assistance 2 1.09 0.0787 Hospital Admit in Past 12 Months 5 2.19 <0.0001 On Disability 2 1.39 <0.0001 Patient Considers own Health 2 1.21 <0.0001 Internal Data, FY 2010 GMC and GWV 17
Screening All patients screened Nursing driven ED and floor Surgical pre-admission screening Resource management 18 16 14 12 10 8 6 4 2 0 Screening score and readmission rate 37,735 patients Two hospitals Negative predictive value = 90.8% 0% 10% 20% 30% Internal Data, FY 2010 GMC and GWV 18
Process Changes INTERDISCIPLINARY TEAM MEETINGS (IDT)
Interdisciplinary Teams (IDTs) Daily meetings (Every patient, every day) Nursing Care management Physicians Social Work Pharmacy Palliative care Revenue cycle Prompted by EHR Readmission Always Events Mortality Flow 20
Topic Physician Checklist Responsible Facilitate Only Text page Manage directly Phone call to team Prevention and Alerts Code Status X x Foley Order X x Foley Review X x Central Line Review X x Restraint Order X x Immediate Clinical Needs Uncontrolled blood sugar X x Uncontrolled HTN X x Uncontrolled HR X x Palliative Care Needs X x Documentation and Orders Heart Failure Identification X x IP Problem List Management X x Primary Diagnosis designation X x Appropriate level of Care Telemetry needed? X x Patient Flow Delay in care/flow X x Communication Post-IDT call (when?) X x 21
Process Changes PROACTIVE OUTREACH 22
Proactive Outreach Building outpatient care manager into the transition team earlier in the stay Identifying the high risk cases Outreach from the IP team, not just IP CM Notification of patients who have OP CM who are admitted in the ED 23
Process Changes TRANSITION BUNDLE 24
Transition Bundle Electronic Discharge Instructions Signed copy to patient prior to discharge Electronic Discharge Summary Delivered within 48 hours of discharge over 90% of time Automatic Document Delivery At time of document authentification Discharge Appointment within 7 days Leave hospital with appointment over 80% of time 25
Process Changes POST DISCHARGE ENGAGEMENT
Hospital Discharge Appointments Goal all patients leave hospital with appt scheduled within 7 days of discharge Appointments made for both GHS and non-ghs providers HD Appointment rates: GHS ~ 90% of pts w/ appt w/in 7 days 28
Post Discharge Engagement ProvenHealth Navigator Hospitalist alignment Communication Document completion Readmission rates Keystone BeaconCommunity The Kitchen Table Program 29
Post Discharge Engagement Skilled Nursing Facilities (SNFists) Connection of SNFists to the Outpatient Care managers Connection of SNFists and other SNF docs/medical directors to the Inpatient team Creating a non-site specific SNFist or SNF team 30
GHS Home Medication Management Referral Program The Kitchen Table Program Home Care RN visit for secondary medication reconciliation and patient education post-dc HHC RN coordinates w/ IP Pharmacist for questions/issue resolution Eligibility: Pt screened as HIGH risk for readmission on TOC tool Pt discharged to home setting Pt not actively enrolled with ProvenHealth Navigator Pt lives in GHC service area & agrees to home care visit 31
Readmission Rate GHS Home Medication Management Referral Program The Kitchen Table Program 30% 25% 20% 15% 10% 25.2% 20.2% 19.8% 5% 0% 12.5% Not referred Referred Floor average Hospital average Internal Data, FY 2011 pilot 32
The best of what we know Successful interventions are: comprehensive extend beyond hospital stay have the flexibility to respond to individual patient needs Journal of Hospital Medicine 2016;11:221 230. 33
Summary Systemic approach to transitions Screening to effectively deploy resources Engage health care team and patients/families Plan post-acute follow-up Deliver accurate information in timely manner Engage patient longitudinally post-discharge 34
jbulger@geisinger.edu @JohnBBulger QUESTIONS?