Preventing Unplanned Acute Care Admissions A Nursing Home Quality Initiative UPMC Senior Communities Skilled Nursing Facilities UPMC Senior Communities: Who are We? 5 Skilled Nursing Facilities 5 Personal Care Facilities 6 Independent Living facilities 1 CCRC Expands through 5 Counties in Western Pa: Allegheny Butler Westmorland Venango Washington UPMC SRC Quality Approach to Unnecessary hospitalization Identified Unplanned Acute Care Admissions as a Quality Indicator for improvement in 2007. A CQI workgroup was initiated which consisted of representatives from each facility and included Medical Directors, DONs, and Administrators. Conducted review and evaluation of unplanned transfers. Determined adjustable actions and interventions most likely to improve rate of unplanned transfers. Initiated actions. 1
Blueprint : QI for unplanned acute care admissions 1. Assessment Collect data & Analyze admissions, discharges, and reasons for them. 2. Planning Develop a preliminary plan & Determine what resources are needed. 3. Implementation Keep objective records during the implementation. Do not be disappointed if the plan is not 100% effective. This is normal. Identifying and working through problems encourages growth. Set a target date for evaluating the plan. 3. Evaluation The frequency of admissions and discharges in your facility will help you determine the target date for evaluating the plan. Facilities with many admissions and discharges will be able to evaluate the plan more quickly than facilities with little resident turnover. When you have collected the necessary information, evaluate the effectiveness of the plan based on the information you have collected and comments from residents, families, and staff. Make modifications as needed and begin again until you have fine tuned your facility processes and the plan is as effective as it can be. INTERACT Four Components 1. Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some residents 2. Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in resident condition 3. Managing some conditions in the NH without transfer when this is feasible and safe 4. Communicating efficiently and effectively with the next care setting when appropriate TINTERACT program includes 3 types of tools: Advance Care Planning Tools Communication Tools Care Paths 2
Review and Evaluation of Unplanned Transfers occurring in SRC SNFs--2007 Facilities collected detailed data on unplanned transfers for 3-4 months in 2007-2008. Data was reviewed to determine most frequent components related to unplanned transfer. FINDINGS: Diagnosis was the highest predictor/indicator for potential for unplanned transfer. This included all 3 diagnosis criteria: 1. Diagnosis on admission to facility: Renal Failure, Fractures, CHF, Pneumonia, COPD 2. Reason for Transfer: Fever, Respiratory problems, Change Mental status change 3. Hospital Diagnosis after Transfer Pneumonia, UTI, Dehydration, Mental Change Data Collection Tool UNPLANNED HOSPITAL DISCHARGES* MONTH/YEAR FACILITY: UNIT *This includes ALL RESIDENTS who are transferred out & admitted to the hospital unexpectedly (unplanned) whether there is a "Bed Hold" or not. IF DISCHARGING PHYSICIAN IS DIFFERENT THAN WAS MD DAY ATTENDING, WAS NOTIFIED OF LIST NAME DISCHARG WITHIN 48 DATE OF DATE WEEK REASON AND WITHIN 48 HRS. MOST RESIDENT ATTENDING DATE OF ADMITTIN OF of SHIFT of FOR HOSPITAL CIRCUMSTANCE HRS. OF PRIOR TO RECENT NAME PHYSICIAN ADMISSION DIAGNOSIS DISCHARGE DISCH DISCHAR DISCHARGE DIAGNOSIS (E.G. ON-CALL) ADMISSION DISCHAR MD VISIT COMMENTS Findings Prompted Training needs: Findings supported the need for increased skill to identify and manage clinical conditions: Fever, infection, UTI, pulmonary problems Dehydration Findings supported the need for increased skill to identify the atypical signs of illness in the elderly such as a change in mental status. 3
Nursing Education Implemented to increase skills: Preventing Dehydration Care of pneumonia in LTC UTI Prevention Peri Care & Catheter Care Respiratory Assessment Physical Assessment, Identifying Change in Condition Education conducted throughout 2008 & 2009 Nurse to Physician Communication Enhancement Nurse Education conducted: Communicating Change to physician Use Care Paths and Communication tools Education Focus 2009-2010 Required repeated training and emphasis to hard wire into daily operations Ongoing Enhancement to Nursing Education 2010 Education added to annual Core Curriculum for nursing staff: Hydration & Preventing Dehydration Physical Assessment and Identification of Change in Condition Physician Notification & Communication Respiratory Assessment UTI Prevention Peri care Catheter Care 4
Initiative Expanded--2010 UPMC SRC Clinical Operations joins the Aging Institute, University of Pittsburgh Division of Geriatric Medicine and UPMC Health Plan to expand the efforts to reduce acute care re-admissions from post acute sites. Group focus on four main evidence based components: 1. Improve the use and adoption of POLST and other advance directives (e.g., Five Wishes). 2. Improve the identification and management of acute change of resident status. 3. Improve and standardize clinical management and inter-clinician communication. 4. Improve and standardize communication during transitional care from NH to ED/hospital. Enhancing Clinical Care Capabilities 2011 1. Consistent Assignment Definition: having 85% of residents have a maximum of 8 CNA caregivers over the course of one month (long stay residents) or 2 weeks (short stay residents) Increases staff familiarity with resident and ability to identify early change in condition. 1. STOP & WATCH Early Warning Tool Tool to assist CNA with identification of change; Provide method to communicate change effectively to nurse. Palliative Care and POLST 2011 Focus POLST Policy revised Palliative Care Initiative including Staff education Care Planning and Conversation Guides Goals of Care Care Plan for every resident Adopt 5 WISHES as preferred Advanced Directive Resident/family education/informational brochures on Advance Directives and 5 WISHES 5
Ongoing Enhancement to Nursing Education 2011 Education added to orientation for all clinical new hire employees: Senior Communities focus on reducing unnecessary/unplanned admissions to acute care Early Identification of Change in Condition Stop & Watch tool for CNAs Physical Assessment of change in condition Notification/communication with physician WHAT HAPPENED? 9 SRC Consolidated Unplanned Acute Care Admissions Rate per 1000 Resident Days 2008 to 2012 8 7 6 5 4 3 2 1 0 2008 2009 2010 2011 2012 6
Tips for success Determine baseline/extent of Acute Care Transfers. Identify unique specifics of facility/organization. Determine implementation activities according to available resources. Support tools implementation with both clinical content and process education. Track results and share with all staff on a regular basis. Sustainability depends on continued education and support of the process. 19 INTERACT TOOLS Available: INTERACT Website: interact2.net/ Paper Tools: Med Pass: www.medpass.com E-tools: Point Click Care: www.pointclickcare.com 20 One must wait until evening to see how splendid the day has been. 7