REDUCING READMISSIONS UnityPoint Health - St. Luke s Hospital Cedar Rapids, Iowa IHI National Forum December 2014 - Orlando, Florida ST. LUKE S HOSPITAL UNITYPOINT HEALTH SYSTEM Private hospital Cedar Rapids, IA Affiliate in the UnityPoint Health System Licensed for 500 Beds with more than 17,000 admissions Truven Top 100 Hospital 4 years; Heart Hospital - 3 years Iowa Recognition for Performance Excellence Gold Award - 2010 Joint Commission Disease-Specific Recertifications in Stroke (2006-14), Heart Failure (2008-14), Total Joint (2008-14) and Palliative Care (2010-14). Society of Chest Pain Center Chest Pain Certification (2010, 2013) Gold Award from Get with Guidelines for Heart Failure 2010-2012 Magnet Re-designation 2014 Mayo Clinic Care Network 2014 1
WHY IS REDUCING AVOIDABLE REHOSPITALIZATIONS STRATEGIC FOR ST. LUKE S HOSPITAL? It is part of our mission: To give the healthcare we d like our loved ones to receive It represents goals that are aligned with healthcare reform: providing better value for decreased costs. Learning has been incorporated into our present work with development of population management and ACO work TRANSITION TO HOME TEAM MEMBERS CHAIR: Peg M. Bradke, MA RN VP Post-Acute Care Denise L. Abel, BSN RN OCN Pt Navigator for AMT, UPH Clinics Gretchen O. Aschoff, BSN, RN, CPHQ - PI Robinn M. Bardell, MSN RN Mgr Case Mgmt Sarah J. Baumert, MSN RN Mgr 5E Alexis Benion, RN - Dir Nursing, Living Center- East Dean A. Bleadorn, BS RRT RCP Mgr Resp Ther Shelley M. Cahalan, MSN RN CHCA - Mgr, Home Care Christy D. Charkowski, BSN RN CCM Clin Liaison-STL Hospitalists Carrie J. Dempsey - Mgr Home Med Equip/ Lifeline Christina M. Djerf, Prog Coord - Lifeline Kristina R. Elder, BSN RN PCC 5C Karen Forster, RPh Pharm Jo Ellen Frommelt, RN Nurse Navigator Lori L. Gaster, MSN RN Mgr ED Terri K. Grantham, MS RN APN-Card Outcomes Renee M. Grummer-Miller, LISW - OP Pal. Care Barb R. Haeder,, MSN RN APN-Card Outcomes Lesley J. Haro, MSN BA RN ARNP-BC Prog Mgr, Ortho Kent Jorgensen Admin, Living Center West Sherrie L. Justice, MA RN Dir PI Teri L Keleher, RN Supv, UPH at Home Carmen K. Kinrade, MSN RN VP Nursing Excellence Patty A. Koelker, BSN RN PCC 5E Jennifer L. Mahoney, CMA Proj Mgr-Quality, UP Clinic Jena L. Maloney, LISW Supv, Social Svcs Lynn M. McArthur Proj Mgr-Qual-CR Region Shirley A. McCloy, BAS RRT RCP - Resp Ther Sandi L. McIntosh, MA RN NE-BC Dir ED Kristin M. McVay, MHA, MSN, RN Prog Mgr, Musculoskeletal Jill M. Morgan, MBA BSN RN NE-BC Dir UPH at Home, Hospice, Pall. & Spiritual Care, HME Jennifer M. Owens, LMSW - Med Soc Svcs Julie L. Peterson, BSN RN Mgr Card Rehab Karen A. Pierce, Data Analysis Spec PI Brandi Simmons, RN Dir Nursing, Living Center West Amy Schweer, BSN RN CHFN - HF Clinic Aimee M. Traugh, MSN RN Mgr 4W Telemetry Brook N. Van Dee, MSN, ARNP, ANP-C, GNP-C, ACHPN OP Pal Care Pam J. Williams, RRT - JRMC Resp Ther Sharon M. Zimmerman, RRT RPFT - Resp Ther 2
VOICE OF THE CUSTOMER Feedback from Integrated Care Management class Patient and family members on our Patient- Family Advisory Council Feedback from follow-up phone calls Feedback from Cardiopulmonary Rehab and Therapy participants Feedback from High-Risk Clinic Patient CROSS-CONTINUUM TEAM Meets monthly Reviews readmissions for each month related to core diagnosis to assess causes and opportunities for improvement Reviews process and outcome measures Continually testing and improving, aggregating the experiences of patients, families and caregivers Each site/level of care reports on testing occurring in their area 3
SEVERAL SUBGROUPS REPORT INTO THE LARGER TRANSITION TO HOME TEAM Data Management Patient Education Processes Home Care SNF/Nursing Facilities Work Processes Physician Clinic Processes Case Management/Social Work/Care Coordination Several members of the Transition to Home team are members of the hospital ACO and Population Health Management work. Information is bidirectional between these teams. CONTINUUM OF CARE PROCESS Standardized evidence-based care through order sets. Patient Education/Teaching: Utilizing Universal Health Literacy Concepts Enhanced teaching materials Teach back Utilization of whiteboard to individualize patient s plan of care and communicate to team. 4
WHITEBOARD 9 CONTINUUM OF CARE (CONT D) Bedside shift report To involve patient and family caregivers as partners in care Daily discharge huddles Patient care nurse Charge nurse Social Worker Cardiology ARNP Spiritual Care Department Representative 5
CONTINUUM OF CARE (CONT D) Daily discharge huddles Identification of patient/family needs/concerns Daily goals are reviewed Available support for patient: need for Palliative Care Referral Educational needs Identification of home care needs Assessment of palliative care referral for appropriate patients Nurse sensitive indicators: fall risk, skin issues CONTINUUM OF CARE (CONT D) Touch points post discharge: Home Care - care coordination visit 24 to 48 hours post discharge on high-risk patients Physician Clinic follow-up appointment made prior to discharge for 3-7 days after Work closely with PCP offices on Transitional Code (TCM) and Patient Centered Medical Home Standardized tool for transfer of information to nursing facilities for next level of care. Telehealth monitor available through Home Care Emergency Department Consistent Care Program Advanced Medical Team Outpatient Social Worker/ Palliative Care Program. 6
ENHANCED ADMISSION ASSESSMENT During Admission Assessment, the patient and family are asked, Who would you like to have present when we provide your discharge information? Medication reconciliation Dedicated Admission Center RN s complete home medication list and prepare an appropriate list for physician to address. At times, the pharmacy or physician offices need to be called to get additional information. If the patient is a home care patient, the home care agency is called to get the current list of medications INTERVIEW QUESTIONS For patients readmitted within 30 days of last admission: Can you tell me in your own words why you think you ended up sick enough to be readmitted again? Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night? Have you seen your doctor or talked to your provider since you were discharged from the hospital? Do you have all of your medications? How do you set up your pills every day? Were there any appointments that kept you from taking any of your pills? 7
PARADIGM SHIFT The patient is noncompliant. vs. Asking, What is our responsibility as the sender of the information? ENHANCED TEACHING AND LEARNING The patient education materials facilitate the use of Teach Back Same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinics. Short, succinct patient/family education packet utilized for each Core Measure DRG. Teach Back questions part of packet for staff and patient/family reference. Patient teaching flowsheets close the loop to help staff nurses address Teach Back and assure the documentation and use of Teach back. 8
INTEGRATED CARE MANAGEMENT ONGOING PROGRAM FOR STAFF/CLINICIAN DEVELOPMENT 2013 6-hour ICM class for unit champions 2014 Winter Part 1 --Frontline staff K.I.S.S. (Keep It Super Simple health literacy) Roll with It (identify barriers/concerns) Connect the Dots (Focus on connecting the dots with transition of care) 2014 Spring Part II - Med/Surg Division Demonstrate competency in addressing four key areas of the Community-Based Transitions Model during discharge instructions Identifications of patient/family concerns Medication management Early follow-up Symptom management Demonstrate competency in motivational interviewing techniques (emphasis on open-ended questions) and teach-back during discharge instructions 9
EXAMPLE OF MI PACKET EXAMPLE OF MI PACKET 10
21 Where To Start? Go to the Unresolved Education Tab Select the topic you educated on Begin charting on the right side of the screen 11
What you taught on Additional comments TEACH BACK WITH DISCHARGE INSTRUCTIONS Can you show me on these instructions: How you find your doctors office appointment? What other tests you have scheduled and when? Is there anything on these instructions that could be difficult for you to do? Have we missed anything? Who will you call if you have questions? 12
DISCHARGE SMARTPHRASE 13
Percent Yes Institute for Healthcare Improvement HCAHPS RESULTS DISCHARGE INFORMATION (% YES) 90 88 86 84 82 80 St. Luke's State National 78 76 2009 2010 2011 2012 3Q 2012-2Q 2013 Composite Score Q19 During this hospital stay, did doctors, nurses or other hospital staff talk to you about whether you would have the help you needed when you left the hospital? Q20 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? EMERGENCY DEPARTMENT CONSISTENT CARE PLAN Consistent Care Program (EDCCP) for patients who had visited the Emergency Room 12 or more times in the previous 12 months. Care Plans are a communication tool that provide data specific to that patient s medical history and current medical needs, along with Goals of Care for when patients present in the Emergency Dept. Using care plans and with intervention by a social work case manager, there has been a reduction in patient s Emergency Department use. 14
CONSISTENT CARE PROGRAM n = 103 patients REAL-TIME HANDOVER COMMUNICATIONS Interagency standardized transfer form Warm handover Communication ARNP s assigned to Post Acute Facilities to oversee care management Transition Feedback opportunities 15
Rate DESIRED DIRECTION PATIENTS RESIDING AT SNF ADMITTED TO ST. LUKE S ED OR INTO AN INPATIENT STATUS 10 9 8 7 6 5 4 3 2 1 0 8 6 7 3 6 4 4 2 4 3 4 1 1 0 5 4 4 1 3 2 6 5 5 3 3 6 4 4 2 6 4 9 8 0 0 9 5 1 1 2 0 4 2 1 0 Readmission ED Visit Acute Inpatients Readmitted to Same Status within 30 Days January 2009 - July 2014 P-Chart 0.15 0.14 0.13 0.12 0.11 0.10 0.09 0.08 0.07 0.06 Pre-EHR EHR Two Day Rule Jan-09 Aug-09 Mar-10 Oct-10 May-11 Dec-11 Jul-12 Month 1 Feb-13 Sep-13 Apr-14 UCL=0.12920 _ P=0.10041 LCL=0.07162 16
LESSONS LEARNED Importance of engaged executive leaders and physicians. Patients and families help transform care in profound ways. The patient and family home environment must be understood. Involving frontline staff in the changes helps them understand why they are important and grows ownership by engaging them in redesign. The power of relationship building and collaboration of the cross-continuum team builds new ideas to work and removes many of the silos in the care. LESSONS LEARNED (CONT) The role of Information Technology in the process should be addressed simultaneously with the work. Ongoing monitoring of Process and Outcome Measures is important to hardwiring best practices. Using patient stories unleashes energy and participation that becomes evident in process and outcome results. 17
QUESTIONS: Peg Bradke RN, MA Vice President, Post Acute Care Services UnityPoint Health St. Luke s Cedar Rapids, IA Peg.bradke@unitypoint.org 18