Improving Patient Safety Across Michigan and Illinois Grand Rounds April 6, 2016 1
Agenda Grand Rounds Overview and Questions Care Transitions Vignette Fairfield Memorial s Care Check Program Grand Rounds Questions Hospital/Community Vignette- Gateway Regional Medical Center and Senior Services Plus Grand Rounds Questions and Q/A 2
Grand Rounds 1. What was the most surprising/interesting/valuable thing you heard from your readmission interviews? 2. What has been the best model you have tested/implemented to reduce readmissions for a particular patient population? 3. Have you considered novel, out of the box strategies to address the needs of specific patients? 4. What did you learn when you drilled down on your highest utilizers? What have you done/are you testing for this population? 5. What is the most unusual partnership you have created in your community? 6. I would like to hear from my peers about 7. What is an area I have lessons learned in that others might benefit from knowing? (Successes, failures...you don't need to have figured it all out in order for others to benefit from it...don t be too humble!) 8. What is an area I need help with? 3
Grand Rounds: 1. What was the most surprising/interesting/valuable thing you heard from your readmission interviews? Surprised how may dialysis patients skip treatment sessions. Our CHF and Dialysis patient have been found to be non-compliant with daily weights and overall treatment. It is surprising that with all of the interventions we have put in place to address medication issues, that we continue to have issues with patient's understanding medications. Also we have found that often the patient has a follow up appointment scheduled with community PCP, but that sometimes they readmit before they can get to the appointment. Our team had not previously made use of readmission interviews and is excited to implement this tool in the near future. Our initial focus will be on our pneumonia and AMI Medicare readmissions. As we gather information from these interviews, it will be evaluated to identify gaps in our current processes and opportunities for possible intervention in these populations. Our goal will be to determine the value of the interviews as an ongoing process moving forward. 4
Grand Rounds: 2. What has been the best model you have tested/implemented to reduce readmissions for a particular patient population? Following the opening of our APN-led Heart Failure Clinic several years ago, the HF Program achieved a significant reduction in readmissions for this patient population. A key component to this success was a redesign of our inpatient discharge process so that it included a specified outpatient follow-up appointment in the Heart Failure Clinic. We have recently expanded upon our success by opening a COPD/pneumonia clinic and have linked our Afib patients to this clinic as well. We are hoping to see similar readmission reductions in these populations as well. Frequent flyers are put in a special call-back process where they are called daily to prevent return to ED, preventing readmission. 5
Grand Rounds: 2. What has been the best model you have tested/implemented to reduce readmissions for a particular patient population? We have implemented a preferred network with SNFs. Partner with this network and staff an APN there to follow patients post-discharged from the hospital. Required the SNFs in the network to utilize the IMPACT tools, implemented pharmacy discharge medication reconciliation for CHF, COPD, and Stroke patients. Implemented a Heart Failure Clinic in which one of our nurses follows the patients through the continuum. Transition coach model with the heart failure toolkit. 6
Grand Rounds: 3. Have you considered novel, out of the box strategies to address the needs of specific patients? We have Care Managers in the Emergency Department identifying placement for patients to avoid readmissions. Each patient discharged has a plan B discharge plan in the event they come back into the ED, we can implement plan B. We bring family in for care planning for our behavioral health patients. We did have a company come into discuss telemedicine. I think that it would be helpful to have this service for our patients who have no PCP to ensure that they have timely follow up appointments post discharge. We will be expanding our inter-facility readmission review process to include staff from those skilled nursing facilities who admit the majority of our patients. We currently have strong relationships with our area Preferred Skilled Nursing Facilities as well as hospital employed Advanced Practice Nurses practicing in a number of these facilities to assist with preventing readmissions as well as a number of other quality improvement goals. 7
Fairfield Memorial Hospital 25 Beds Typical diagnosis: PN, HF, COPD 8
CARE TRANSITIONS: WHAT WE DID Our Care Check program began in the 1 st Qtr of 2014. A Care Check is a free one time home visit, for patients that are identified as being at high risk for readmission. Administration built upon existing daily huddles to address patient needs. Care Checks were mandated by administration and facilitated by staff management. 9
CARE CHECK: HOW IT WORKS During Morning Huddles we assess each patient on the floor. Each employee in the huddle is able to refer a patient for a care check. After the referral is made, a home health nurse completes a free one time home visit. Paperwork is kept separate from Home Health documentation. 10
HOW IT WORKS 11
How Care Checks Help Review of medications Review of adherence to d/c instructions Referral to Home Health services Fall Prevention Assessment Referral to ER Assessment of living situation Updated status communicated to primary physician 12
Do We Have To? These meetings are a pain. How did we start to recognize the value? Sometimes we had to adjust per larger census. 13
HOW WE KNOW IT WORKS IN-HOUSE ALL-CAUSE 2012 2013 2014 2015 Average 11.88 8.62 8.16 6.73 14
OUR HUMBLE ADVICE Huddles improve the most important aspect of day to day operations communication Share and Celebrate Successes Don t let the program fade away. Reminders! 15
Grand Rounds: 4. What did you learn when you drilled down on your highest utilizers? What have you done/are you testing for this population? Highest utilizers include those that have care plans (super users). We work closely with physician groups regarding pain management patients and track patients by ED visits and implemented a predictive tool to determine high risk for readmission. CHF and COPD patients have opportunity to be placed into hospice, palliative care (discussion missed). Specialists may not want to address the conversation with patients on hospice and palliative care. We found that our "high utilizers" are not necessarily our readmission problem. These patients are high risk, but also consume a high amount of resources and time. We have employed transition coaches within the cardiac population to address the needs of these patients; however we have found that it is equally important to address the needs of patients who are not the high utilizers. If the transition is done properly, then it is equally effective in reducing readmissions with less resources. Our drill-down revealed opportunities with patients in our pneumonia population. As our patients within this population are readmitted, we will be interviewing them to identify potential gaps in our discharge plan as well as possible interventions to target those gaps. We have also included key leads from all of our service-line teams, including pneumonia, to champion performance improvement and readmission initiatives. 16
Grand Rounds: 5. What is the most unusual partnership you have created in your community? Our preferred network of SNFs. Conduct RCAs on preferred network SNF CHF readmissions. Our transition coaches often reach out to HHC to assist with patients when a need is identified. We work closely with VNA and regularly communicate with them on patients, but we also reach out to other home care agencies to ensure that they are aware when a patient is having some concerns. Also ensuring that they have recent discharge information. Recently contracted with Family Pharmacy who fills and delivers patient s scripts before the patient is discharged home. 17
Improving Patient Safety Across Michigan and Illinois Using the Healthy Connections program Developed at Senior Services Plus, Inc In Alton IL and implemented at Gateway Regional Medical Center Granite City, IL 18
ABOUT US Gateway Regional Medical Center 2100 Madison Ave. Granite City, IL 62040 343 Bed Facility 19
And about Senior Services Plus SSP is a non-profit agency established to help enrich the lives of older adults through programs and services that encourage independent living. We are headquartered at 2603 N Rodgers Ave. Alton IL 62002 Our services include: Healthy Connections, Home Care, Information and Assistance, Transportation, Foster Grandparents, Congregate Dining, Meals on Wheels, Travel, Events and Activities, Wellness Center, Safe Connections 20
CARE TRANSITIONS: WHAT WE DID Started with Coleman Model Too technical/medical Evolved to a more social work-led model Re-branded with Healthy Connections Still looking for Red Flags Still helping clients find resources to better understand diagnosis and medications 21
BARRIERS AND HOW WE OVERCAME THEM Getting people to consent while they are in the hospital and feeling overwhelmed Confusion that we don t start our program with them until after discharge Patient s Fear of letting us into the home Hospital s concerns of who pays for this Our own issues to remain funded 22
HOW IT WORKS The Care Transitions coach receives a daily list of patients who meet the criteria of the program. Coach visits the patient in the hospital to gain consent for the program A 30 day relationship is initiated at discharge which includes a home visit and 3 follow up phone calls. 23
HOW WE KNOW IT WORKS Clients were surveyed on a scale of 1-5 Did coach make discharge plans easier to understand (90% rated 4 or 5) Was coach helpful in reviewing Medications (80% rated a 4 or 5) Was coach helpful in explaining red flags(90% rated 4 or 5) After working with coach, are you more equipped to handle your health conditions (90% rated 4 or 5) 24
ADVICE FOR OTHERS Coaching to schedule follow up appointments, affordable medication programs, and other community resources will reduce readmissions Utilize staff social workers or reach out to Area Agency on Aging to establish a network of resources Don t neglect educating your staff to promote the program to patients. 25
Grand Rounds: 6. I would like to hear from my peers about How do they manage readmission dialysis patients? Who has palliative care in the hospital? How are they addressing the lack of POLST forms on patients and opportunities for palliative/comfort care and hospice discussions to be had prior to admission? How are they addressing COPD patients? Could someone share the process they used to implement Nurse Navigators/Transition Leaders? 26
Grand Rounds: 7. What is an area I have lessons learned in that others might benefit from knowing? (Successes, failures...you don't need to have figured it all out in order for others to benefit from it...don t be too humble!) Good discharge planning takes time, does not always happen overnight. There needs to be involvement from family, community (not just one person) Plan B for all discharges assists with preventing readmissions. Involving ED Care Manager for preventing Understanding the depth of interventions that are started in the hospital or another setting. When rolling out a large initiative, it is important to ensure that community providers are aware of what is being done in the hospital so that it can be continued in the outpatient setting. Having campus-based, disease-specific aftercare clinics has provided our at-risk patients with access to continuum of care services designed to proactively address medical concerns/educational needs appropriately without over-utilization of resources. Our readmission teams include key stakeholders at multiple levels. 27
Next Steps Register for the April 20 th Medication Reconciliation webinar. Let us know what you thought of this Grand Rounds structure and if there are particular topics you would like us to focus on this Spring/Summer. ihen@team-iha.org 28
Email: IllinoisHEN@IHAstaff.org April 20 th -Medication Reconciliation 29