M7: Improving Transitions and Reducing Avoidable Rehospitalizations Peg M. Bradke, RN, MA St. Luke s Hospital, Cedar Rapids, Iowa This presenter has nothing to disclose. St. Luke s Hospital Member, Iowa Health System Private hospital Cedar Rapids, Iowa Affiliate in the Iowa Health System Licensed for 500 Beds with more than 17,000 admissions Thomson-Reuters Top 100 Heart Hospital 3 years Iowa Recognition for Performance Excellence Gold Award - 2010 Magnet Designation - 2009 The Joint Commission Disease- Specific Certification for Heart Failure since 2008; Stroke since 2006; Chest Pain Accreditation 2010 1
Why is Reducing Avoidable Rehospitalizations Strategic for St. Luke s Hospital? It is part of our mission: To give the care we would like our loved ones to receive. It represents goals that are aligned with health care reform: providing better value for decreased costs. Heart Failure Team Formed in 2001 In February 2006, St. Luke s joined the RWJF/IHI TCAB Collaborative with a focus on improving discharge processes and reducing avoidable rehospitalizations Initial focus was on the heart failure population with the goal of creating an ideal transition to home In 2010, changed focus to all Core Measure patients to develop reliable processes to ensure smooth transitions and compliance with CMS Core Measures 2
Heart Failure Team Members Peg Bradke, Chair, Heart Care Svcs. Robinn Bardell, PI Ann Beem, PCC-3C Alexis Benion, Living Center West Christy Charkowski, STL Hospitalists Krissy Elder, PCC-5C Karen Forster, Pharm Terri Grantham, Card Outcomes Renee Grummer-Miller, OP Pal. Care Barb Haeder, Card Outcomes Sue Halter, Card Outcomes Lesley Haro, Ortho Sherrie Justice, Dir-PI Carmen Kinrade, Dir-Med/Surg Shirley McCloy, Resp Ther Sandi McIntosh, Dir-ED Signe Munson, VNA Jennifer Owens, Med Soc Svcs Julie Peterson, Mgr-Card Rehab Diane Pfeiler, Mgr-5E Kelly Pottebaum, PCC-5E Nikki Robson, Pal Care Amy Schweer, CLC -#944 Aimee Traugh, Mgr-3C Jean Vorwald, VNA Jean Westerbeck, Living Center West Pam Williams, JRMC Resp Care Sharon Zimmerman, Resp Care AD HOC: Doralyn Benson, Mgr-Med Soc Svcs Dena Fisher, STL Hospitalists Cross-Continuum Team Meets every other week Reviews readmission to assess causes and opportunities for improvement Reviews process and outcome measures Continually makes improvements, aggregating the experiences of patients, families and caregivers. Provides oversight for CMS Core Measures 3
Heart Failure Continuum of Care Standardized care through order sets Patients identified via BNP daily reports Teaching Utilizing Universal Health Literacy Concepts Enhanced teaching materials Teach Back Touch points Home Care -care coordination visit 24 to 48 hours post discharge Hospital Based Heart Failure Clinic visit in 3-5 days with subsequent visits established with clinic and PCP based on needs of each individual Follow-up phone call on post discharge at 5-9 days Outpatient Heart Failure class 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? Information added to the whiteboard. RN and physician do medication reconciliation. 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. Automatic referral to Respiratory Care for all new inhaler orders for inhaler education. 4
Enhanced Admission Assessment (2) Referral to Palliative Care for patient with advanced stages of disease -The referrals have increased from less than 5% to over 20%. Bedside report to involve the patient and family caregivers as partners in their care. Daily discharge huddle is facilitated daily with the RN caring for the patient, the charge nurse, and unit-based case manager. Daily goals are reviewed and written on the whiteboards in each room, providing the opportunity to review the plan for the day, anticipate discharge needs, and determine what it will take to get the patient home safely. 5
Whiteboard Update New Section: Goal to Go Home Current State: We have the anticipated d/c date in the upper left box. This is an area that has not been filled out for a variety of reasons. Often, there was a discrepancy in the date among the HCT or uneasiness in putting an exact date in for fear the date would change and patient and family would lose some trust. Test of Change: 3C and 5E trialed a new entry on the whiteboard. A small additional magnet has been added to address Goal to Go Home. It is put in the Plan and Goal for the Daybox. Feedback from the staff was positive. They found this provided a more tangible step that the patient and family must achieve to be sent home. It can aid in engaging the patient and family more in working towards the time to discharge which is part of our CARE MODEL. We hear over and over again how much our patients/ families and the healthcare team rely on the whiteboards for information. This new way to address goals towards discharge seems to meet our patient/family needs better. Whiteboard Update (2) New Section: Goal to Go Home Outcome: We will now be adding this item to all the standard whiteboards. The Daily Goals will continue to be changed daily. The Goal to Go Home for the most part will probably not change. Below is an example for a Heart Failure patient. Plan/Goal for the Day Walk to Nurse s Station and back 2 times today Eat all meals out of bed. Goal to Go Home Learn Heart Failure diet plan to go home Weigh self and monitor changes in weight Identify Warning Signs and Symptoms to report to doctor 6
Enhanced Teaching and Learning The patient education materials facilitate the use of teach-back, and the same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinic. Teach-back -the process of asking patients to recall and restate in their own words what they have been taught -was incorporated at the patient s bedside during the 24-48 hour post-discharge followup visit by Home Health and in the seventh day post-discharge phone call to the patient. Short, succinct material developed for each Core Measure DRG Teach-back question part of packet for staff and patient reference Patients and families are given a 12-month calendar for Heart Failure Patient teaching flowsheets are set up to address teach-back and assure the documentation and utilization of the technique. Lung Packet Contents Cover page Inside 7
Heart Failure Magnet Heart Failure Zones 8
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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? Successful Teach-back Rate Aug 06 Aug11 VNA teachback initiated Follow-up phone calls initiated Nurse competency evaluations in health literacy started Updated 9/26/11 12
Post-Acute Care Follow-Up Home Care Visit set up for 3-5 days. Home Care liaison in-house. At 5-10 days, a hospital nurse conducts a follow-up phone call. During this call, the RN uses the same teachback questions used in the hospital to determine the patient and/or caregiver understanding of the critical self-care instructions. HF patients called through Clinic, Hospitalist program calls their patients after discharge. Partnership with physicians offices resulted in redesign of scheduling HF visits to allow office visits within 3 to 5 days for all patients with HF in HF Clinic. Subsequent appointments established with Clinic, PCP or specialist based on patient s assessment and need. The Cross Continuum Team continually makes improvements by aggregating the experiences of the patients, families and caregivers. Readmissions are monitored, and failures are reviewed by the Cross Continuum Team to assess opportunities for improvement. Attending MD during Hospitalization (11/07 10/11) 13
Discharge Status (11/07 10/11) Real-time Handover Communications Medication Reconciliation is a joint physician and nurse accountability. The physician is provided a report at discharge to reconcile home medication list with those in hospital. The nurse puts the reconciled list in the patient s discharge instructions. All patients going home are offered a care coordination visit with Home Care in the first 24-48 hours after discharge. The home care does a certified content visit including medication reconciliation. St. Luke s partnered with the hospital s home care agency (VNA) and two long-term care facilities to standardize and enhance the quality of the handoff communication process. Standardized form. Warm handover with those patients with complex issues. Provided education for home care and long-term and skilled care RNs and CNAs on HF and continuity process. CNAs often observe symptoms. Provided the receiving nursing home facilities with the patient education packet. 14
Number of Days after Discharge Patients are Readmitted 25 20 # of patients readmitted 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 # of days between discharge and readmission Three to Five-Day Follow-up (Nov 07 Aug 11) Updated 9/26/11 15
Heart Failure Readmissions (for Any Cause) within 30 Days 35% 30% 25% Percent 20% 15% 10% 5% 0% 2006 2007 2008 2009 2010 2011 YTD %HF to Any Reason Median 16
Heart Failure Readmissions (for Any Cause) within 30 Days 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2006 Q2 2006 Q3 2006 Q4 2007 Q1 2007 Q2 2007 Q3 2007 Q4 2008 Q1 2008 Q2 2008 Q3 2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009 Q4 2010 Q1 2010 Q2 2010 Q3 2010 Q4 2011 Q1 Percent 2011 Q2 %HF to Any Reason Median HCAHPS RESULTS DISCHARGE INFORMATION (% Yes) 90 88 86 84 82 80 78 76 74 89 89 88 87 85 83 82 82 82 82 80 80 Dec-07 Apr-08 2009 Jun-10 Sep-10 Dec-10 St. Luke's National #19 During hospital stay, did doctors, nurses or other hospital staff talk about whether you would have the help you needed when you left the hospital? #20 During the hospital stay, did you get the information in writing about what symptoms or health problems to look out for after you left the hospital? 17
Leadership Activities and Learning Executive Leader facilitates reports to Senior Leaders and Board Day-to-Day Leader manages bi-weekly Transition to Home meetings and assures ongoing testing and implementation of changes and monitors results Barriers and Breakthroughs Limitations of the electronic medical record to capture and transmit information. Access to physician offices for follow-up visits. Complexity of patients with multiple comorbidities. Challenges to completing reliable medication reconciliation. 18
Lessons Learned Importance of engaged executive leaders Explicit focus on patient and family-centered work Front-line clinicians and staff involvement in developing process improvements Physician engagement Cross Continuum Team power of relationship building and collaboration Importance of understanding patients home environment Impact of Information Technology Stories are as important as the data 19