UCSF Transitional Care Program Maureen Carroll RN CHFN Transitional Care Manager Heart Failure Program Coordinator November 1, 2016
Session Objectives Describe elements necessary for building a cross continuum team Summarize interventions to improve transitions in care after hospitalizations and to reduce avoidable readmissions Discuss the ROI and processes implemented to sustain improvements Describe post acute projects to decrease readmissions Review what UCSF is doing to improve hospital flow 2
Mission: UCSF is advancing health worldwide 2015 2016 U.S. News Best Hospitals Surveys #8 overall UCSF is the second largest employer in San Francisco, paid employees about 25,000 UCSF Medical Center and UCSF Benioff Children s Hospital San Francisco have 722 beds and generate 763,000 outpatient visits per year UCSF is the nation s top public recipient of funding from the National Institute of Health (NIH). In 2014, receiving $538.1 M through 1,210 NIH research and training grants. Earned Magnet designation for excellence in nursing by the American Nurses Credentialing Center (ANCC). 3
Frequent Why focus on Readmissions? Costly Improvement 20% Medicare beneficiaries readmitted within 30 days $17B in Medicare spending *Estimated $60B by 2030 76% of readmissions are avoidable MedPAC Report to Congress. Promoting Greater Efficiency in Medicare. June 2007 Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008. Commonwealth Fund State Scorecard on health System Performance. June 2009 4
Institute of Healthcare Improvement 5
Care Transition Models The Good News 6 The Care Transitions Program - Eric Coleman MD The Transitions Care Model - Mary Naylor PhD, RN- Institute of Healthcare Improvement- STAAR Initiative- Avoiding Readmissions Through Collaboration ARC- Gordon and Betty Moore Foundation SF Bay area Project BOOST ( Better Outcomes for Older Seniors through Transitions) Mark Williams MD Project Red- Brian Jack MD Interact Project- Improved communications with SNFs
What do these Models have in common? Comprehensive patient and family education Coordination of Care Medication reconciliation Coaching- Primary convener Discharge planning Post hospital Follow up
Readmissions- We ve come a long way CMS Hospital Readmission Reduction Program Focus on potentially preventable readmissions Focus on patients most at risk National Medicare all-cause 30-day readmission rates decreased- 19.8% - 2010 -- 18.02% - 2014 Goal is lower readmission not zero readmissions Possible moving toward 90 days oversight 8 Presentation Title and/or Sub Brand Name Here 10/28/2016
Institute of Healthcare Improvement Cross-Continuum Teams- STAAR STAAR Initiative CCTs are one of the most transformational changes we found CCTs reinforce the reality that avoidable readmissions are not solely a hospital problem Involvement is needed at two levels: 1) At the executive level to remove barriers and develop overall strategies for ensuring care coordination and support 2) At the front lines, power of senders and receivers co-designing processes to improve transitions of care
UCSF Heart Failure Program Our Story and Building a Team
Gordon and Betty Moore Foundation Grant 30 and 90 day readmissions by 30% Began November 2008 February 2011 GOAL: Reduce all cause Heart Failure Readmissions Collaboration with Institute for Healthcare Improvement (IHI) 1 of 4 Bay Area Hospitals chosen Primary AND Secondary diagnosis of Heart Failure on 3 pilot units Patients 65 years and older 11
Why Heart Failure? 1.1 Million 3 Million 5.7 Million # 1 Medicare Discharge diagnosis Over 8 Million Hospital admissions per year with primary heart failure Hospital admissions per year with primary and secondary heart failure People in US with heart failure Cost $32 Billion Year Expected by 2030- Silver Tsunami Mozaffarian D, Benjamin EJ, Go AS; for American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics 2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail. 2013;6(3):606-619.
Heart Failure Program Heart Failure Program Coordinators Patients Enrolled 1.6 FTE 7 days a week coverage 2008-2014 Current coverage 5 days a week Supported by Large Multidisciplinary Cross Continuum team 500 Admissions a year ~ 50 patients per month Average Age: 80 years old Culturally diverse Multiple Languages 30% non English speaking 13 10/28/2016
Building the Team Building Relationships Meeting face to Face Moving out of the silos Learning about each other s Roles Gaining an understanding of work flows Getting Buy In Team Meetings Gathering Multidisciplinary team frequently Working towards common goal 14
The Team it takes a village! Outpatient Clinics Physicians Senior Leadership SNF Partners Case Managers Community Partners The Patient and Family/Caregiver Social Workers Managers and Nurses Dietitians Chaplains Pharmacists Palliative Care Home Care Team 15
Pillar One IHI: Creating an Ideal Transition Home Enhanced Admissions Assessment for Post- Discharge Needs Pillar Two Enhanced Teaching and Learning/Patient Readmission Interview Pillar Three Patient and Family Centered- Handoff Communication Pillar Four Post Acute Care Follow Up Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.ihi.org. 16 Presentation Title and/or Sub Brand Name Here 10/28/2016
Timeline of Heart Failure Program Transitional Care Program 2009 2010 2011 2012 2013 2014 2015 2016 Inpatient Focused Outpatient Focused Sustainability & Community Collaboration Research & Expansion Hospital Wide Readmission & Transition Work Quality Division and expanded Disease Management Programs Office of Population Health, Expansion in outpatient setting Expansion of populations, SNF Collaborative 17
The First Year ~ 2009: Inpatient Focused Developing The Team with monthly meetings Palliative Care Collaboration Staff trained on teach Back & HF Education Comprehensive Patient Education Patient Advisory Group Patient Stories Shared to drive change Care Coordination Implemented IHI Evidence Based Interventions Heart Healthy Classes on unit Development of Data Collection System Focus on Continuum of care Communication and Collaboration 18
The Second Year~ 2010: Outpatient Focused Collaboration with outpatient providers High Risk Pt F/U at Advanced HF Clinic with NP Hospital wide projects to standardize and improve discharge process and readmissions Virtual Team email to connect providers In-services for staff, home care, skilled nursing staff MD House Calls Program for High Risk HF Patients Project BOOST Collaboration 19
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Interventions and Readmissions... Fundamentals are Essential
Interventions Patient Identification Daily Chart Reviews Multidisciplinary Rounds Patient Education Teach Back method, Meeting Family and Caregivers Four different languages for HF printed materials Coordination Inpatient/Outpatient consult and referrals Virtual Team Email, Care at Home Programs Community resources, Post acute facilities, outpatient program referrals Follow Up F/U Appts: Within 7 days Follow Up Calls Initially Manual calls 7, 14 days Currently 5x month automated 22
Email to Virtual Team on Admission: Dear Medical Team, We wanted to let you know that we are following Mr. XXXXXXXXXXX in the Heart Failure / Transitional Care Program. We are very familiar with this high risk patient from previous admissions (5 th in past 4 months). We have provided education, initiated palliative care consults, and coordinated services in the past. We would like to provide as much support as possible for the patient and family. Recommendations: 1. Bridges Program- MD home visits 2. UC RN home care 3. Pharmacist consult for discharge medications 4. Follow up appointment within 7 days 5. Goals of care discussion/palliative care consult The goal of the program is. Please let us know if there is anything that we might do to assist and thank you for the great care that you provide our patients! 23
TEACH BACK Evidence based technique of patient education that assesses the patients and family caregivers understanding of instructions and ability to do selfcare. In Teach Back, the caregiver explains important information to the patient or family caregiver and then asks in a non-shaming way for the individual to explain in his or her own words what was understood. 24
Teach Back is not enough In addition to Teach Back and Heart Failure education, chronic diseases require life style changes. Time Trust Support Accountability 25
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Readmission Interview: Patient Perspective Why? Why? Why? Why? Why? Find the barriers 27
Avoidable Readmissions Low health literacy, unable to Teach Back Medication issues, lack of access, multiple co morbidities Inadequate support, caregiver fatigue, lack of self management skills 28
IHI s Approach: Assess the Patients Medical and Social Risk for Readmission High Risk Admitted two or more times in the past year Patient or family caregiver is unable to Teach Back, or has a low confidence to carry out self-care at home Moderate Risk Admitted once in the past year Patient or family caregiver is able to Teach Back most of discharge information and has moderate confidence to carry out self-care at home Low Risk No other hospital stays in the past year Patient or family caregiver has high confidence and can Teach Back how to carry out self-care at home Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.ihi.org. 29
30 Modified LACE Tool Attribute Value Points Prior Admit Length of Stay Less 1 day 0 1 day 1 2 days 2 3 days 3 4-6 days 4 7-13 days 5 14 or more days 6 Acute Admission Comorbidity (Comorbidity [points are cumulative to a maximum of 6 points) Emergency Room visits during the previous 6 months Risk Stratification Tools Inpatient 3 Observation 0 No Prior history 0 DM no complications, 1 Cerebrovascular Disease, Hx of MI, PVD, PUD Mild Liver Disease, DM with 2 end organ damage, CHF, COPD, Leukemia, lymphoma, any tumor cancer, or moderate to severe Renal Disease Dementia or connective tissue 3 Disease Moderate or severe Liver 4 Disease or HIV infection Metastatic Cancer 6 0 visits 0 1 visits 1 2 visits 2 3 visits 3 4 or more visits 4 Sum of the points Present Admit Risk Level HIGH MODERAT E LOW Criteria UCSF Tool Four or more admissions in the past 12 months Readmission within one week Lack of social support GOC/End of life/pc/hospice Max needs (functionally) Medically complex Advanced Disease Process Low Health Literacy History of Substance abuse Adherence issues medications, dietary, f/u appointments Psych history Three admissions in the past 12 months Multiple Co-morbidities Lack of social support Psych history and/or substance abuse Decreased functional status Low health literacy Adherence Issues (Meds/diet) Patient nor family speaks/reads English First or second admission in the past 12 months Minimal co-morbidities High health literacy
The role of Palliative Care with Heart Failure Patients
Goals of Care Conversations There is a need to have GOC discussions documented in EMR to ensure continuity across settings 32 Presentation Title and/or Sub Brand Name Here 10/28/2016
PC MD now on Advanced Heart Failure Service Proven to improve sx, QOL, satisfaction 25% of our HF die within one year Fewer latelife hospital admissions Palliative Care Up to 50% of deaths with HF are due to sudden death Pantilat and Steimle JAMA 2004;291:2476-82 Wright et al. JAMA 2008;300:1665-73 Morrison J Palliat Med 2005;8:S79-87 Advanced Care Planning Standardize consult on 3 rd readmission/ year 33
UCSF Palliative Care Collaborative Increased Advance Care Planning Increase PC inpatient consults Increased outpatient PC programs-clinics Coordination of UCSF Palliative care programs Longitudinal Care across settings Effective GOC discussion documentation in EMR 34 Presentation Title and/or Sub Brand Name Here 10/28/2016
Data and Business Case
30 Day Readmissions: Primary & Secondary Heart Failure 65+ 40.0% 35.0% 30 Day Readmissions Primary & Secondary Heart Failure UCSF Medical Center Heart Failure Program Annual Averages 2009 = 24% 2010 = 19% 2011 = 13% 2012 = 12% 30.0% 25.0% 20.0% 15.0% Goal Line: 10.0% 5.0% 0.0% 36
Financial Implications during grant period to UCSF, of Reducing Medicare HF Readmissions Compared utilization and financial outcomes for four different study periods: Pre grant, first and second year of grant and the year following the grant 30D Readmission Rate decreased from 22.5% to 12.6% in the year post grant As a result, the overall number of bed days per 100 unique MRNs is also declining Average LOS for readmissions CY2008 = 5.3 CY 2011 = 8.0 37
Financial Implications In calendar year 2011, Medicare payment for all cause Heart Failure primary or secondary diagnosis was $23,239 per case The number of UCSF avoided readmissions at a 12.6% readmission rate would result in approximately $1.1 MILLION Annual savings to Medicare Report generated by Karen Rago, RN, MPA, FAAMA, FACCA 38
UCSF Primary HF Readmissions 65+ CMS 39
Quarterly Chart ~ Progress over 8 years Medicare pts 65+ with Primary Dx of HF 40
AMI, CHF, COPD, PNA, STK, THA, CABG 11.34% 9.53% 41 10/28/2016
UCSF Readmission Dashboard 42
Outpatient Focus Follow Up Calls, SNF Collaborative and more 10/28/2016
ACO work Follow Up Call Program Transitional Care Health Care Navigators Office of Population Health & Accountable Care PRIME/ DSRIP Complex Care with NPs Ortho Bundled Payment BRIDGES and Home Based Palliative Care 44
Office of Population Health and Accountable Care Prepare UCSF for Payment Reform & Succeed in current risk arrangements Accountable Care (50,000 lives in risk based payment) CANOPY Health Bundle Payment (CMS Ortho Bundle payment program) PRIME Analytic Capabilities to support transition to Value based payment Analytic team Ambulatory Quality Design, Develop & Implement Clinical Programs to Fill Gaps that must be filled in new payment paradigms Care Support Care at Home Forge partnerships necessary to take and succeed in new payment world Canopy Post Acute Care Collaboratives Provider and Payer partnerships Discharge Phone Call Program/Transitions
California s Medicaid Waiver Dec 2015: Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Sept 2005: CA Safety Net Care Pool CMS approved CA s 1115 application for the Medi-Cal Hospital/Uninsured Care Demonstration. This allowed CA to create a Safety Net Care Pool (SNCP) to fund uncompensated care and the expansion of health care coverage to the uninsured in certain counties. Nov 2010: CA Bridge to Reform CA s demonstration was renewed and renamed California Bridge to Reform. This demonstration included new Delivery System Reform Incentive Payments (DSRIP) which promoted the development of programs that improve quality of care in our public hospital systems. CMS approved California s demonstration extension through 2020. The new redesigned pool, now called the Public Hospital Redesign and Incentives in Medi-Cal (PRIME), is meant to support the state's efforts to prepare public hospitals for success under alternative payment models focused on health care value. Source: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/1115/section-1115-demonstrations.html 46
UCSF Follow Up Calls Program Cipher Health Automated Calls with UCSF Nurse voice Original content Alerts to email, dashboard if patient needs call back All Patients Receive a discharge phone call within 48 hours RN available for assistance- trouble shooting F/U Appt, Symptoms, Home Care, Medications, Satisfaction Disease Management Heart Failure & COPD One call weekly for 5 weeks Disease specific questions Currently only in English, working on Spanish, Chinese and Russian 47
Post Discharge Automated Calls 48
Initial F/U Heart Failure Call Evaluation Initial evaluation: August November 2015 119 HF patients 96% reach rate 94% of patients who engaged with the HF Follow Up Call program were NOT readmitted within 30 days Program Evaluation done by Cipher Health, Kristen Gagliardi and team. November 30, 2015 49
Co-Design and Coordination
Real-Time Handover Communications Warm Hand overs Skilled Nursing Facilities Home Care Agencies Outpatient Clinics Providers Email Notifications Creating a Virtual Team Time Consuming but valuable Inpatient team, case manager, consultants, HF Clinic, Home Care RNs, SNF and PCP on admission Home Care Referrals Medication Reconciliation Focus on self management skills Match appropriate care with individualized needs of the patient and family 51
Changes in Law and Incentives Affecting skilled nursing facilities (SNF), home health agencies, inpatient rehabilitation facilities (IRF), and long-term care hospitals (LTCH). Financial penalties for failing to report quality measures beginning 2019. Since January 2015,MDs, NPs. PAs, and clinical nurse specialists can start receiving separate Medicare fee for chronic care management for seniors with 2 or more chronic conditions, delivered outside regular office visits Transitions Care Management Codes- designed to promote and incentivize face to face and non face to face encounters Compensation for End of Life discussions
UCSF & SNF Collaborative UCSF & 6 local SNFs Senior Leadership & key stakeholders Communication Accountability Reliability Transparency Encouragement Collaboration Quarterly Collaborative Meetings Quarterly 1:1 meetings Staff In-services Weekly Huddle calls MD:MD and RN:RN Warm Hand Overs Metrics/Patient Stories 30 D Readmissions Falls -5% relative decrease Discharge before noon LOS, Acceptance rates Readmission Analysis Patient issues shared across settings 53
UCSF SNF Collaborative Improvements Identification of processes in need of improvement on both ends Discharge Packets- collaborative effort What is essential info needed? Communication Improvements- Falls risk, RN RN, MD- MD calls, Readmission reviews Relationships established- discuss shared concerns, high risk pts, plans of care Metrics and best practices shared- collective lessons learned 54 Presentation Title and/or Sub Brand Name Here 10/28/2016
Interventions to Reduce Acute Care Transfers (Interact) Website Designed to improve identification, evaluation, and communication about changes in resident status. The overall goal of the INTERACT program is to reduce the frequency of transfers to the acute hospital. Three basic tools: Communication tools Care Paths or Clinical tools Advance Care Planning tools http://interact2.net/ 55
Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals: Lessons Learned for Reducing Unnecessary Hospitalizations After completing the RCA, SNF staff identified 1044 (23%) of the transfers as potentially preventable. http://interact2.net/docs/publications/rca%20on%20snf %20Transfers%20Overview%20JAMDA%20March%202016. pdf 56
Lessons Learned Improvements, Changes, Work in Progress
Power of the PATIENT and Family STORY Collaboration with IHI Dedicated Coordinators Technology has incredible potential Test, trial and change interventions Change is the Norm Lessons Learned Exec Leadership and Champions necessary Teach Back and Health Literacy focus essential Committed multidisciplinary teams Communication and Relationship Building Home Care Collaboration and referrals Palliative Care Team Collaboration 58
Improvements SNF Collaborative Disease management workgroups (COPD, HF) Readmission Data Dashboard all readmissions Transitions Executive Steering Committee- Hospital wide goal UC Care at Home, MD Home visits expansion Readmit reviews Roundtable Readmission, Cardiology faculty meetings Increased access for patients Doc of the Week, NPs in clinics, increased open appointments Cipher Follow Up Phone Call Program Shared work between Teams- ACO, Transitions, SNF, Palliative Care 59
What is UCSF doing to improve hospital flow? Efforts to Increase Access Doc of the Week- open cardiology appointments Cardiology Outpatient Recovery clinic COR Discharge Calls program- prevent ED visits Discharge Before Noon ( DBN) Goal- 20% before noon ED Efforts- Clinical Decision Unit- decrease admissions- strict criteria High Utilizer efforts OR, Periop, PACU - Efficiency Work/Consultants Efficiency Improvements in Transfer Center Focus on Prevention programs- Admission prevention 60 10/28/2016
True North Boards Posted on several units Increased visibility Involving all in goals 61 Presentation Title and/or Sub Brand Name Here 10/28/2016
Patient Stories Patient pictures used with permission. 62