Hospital Readmission Reduction: Not Just Nursing s Job David Farrell, LNHA, MSW Affordable Care Act - Three Aims Better patient experience Better outcomes Lower costs 1
Linking Payments to Quality Outcomes Bundled Payments seek to incentivize improved care by fostering coordination among providers Accountable Care Organizations groups of providers that come together to coordinate and manage care of a defined population Medicare/Medicaid Integration states contract with health plans that manage the care of groups of their high cost dual- eligibles Medicare/Medicaid Become Managed Care Goal encourage coordinated care Reward providers that meet three aims Excellent outcomes Safe, efficient and effective transitions Low rehospitalization rates 2
CMS Estimates In year 2 Applies to 65 Years-Olds Diagnosis of acute myocardial infarction, heart failure, pneumonia (FY 2013 and 2014) Oct. 2014 elective hip and knee replacement, COPD 2,225 Hospitals will be penalized $227 million because of excess readmissions 34% No Penalty Hospitals serving low-income are twice as likely to be penalized 5 Safe Transitions Reimbursement Based on Outcomes and Value Institutional Care Individualized Care Reimbursement Based on Volume Fragmentation 3
Measurement Components Structural measures the capacity to prevent avoidable rehospitalizations Process measures performance necessary to prevent avoidable rehospitalizations Outcome measure Re-Hospitalization Rate Structural Measures Staffing ratios Total nursing hours per day Total RN hours per day # of vacant positions = 0 # of shifts worked by agency staff = 0 # of shifts understaffed = 0 4
Structural Measures Staff turnover Total departures/average number of staff = 30% Staff retention Staff with one year of service/avg. number of staff = 80% Structural Measure Staff Satisfaction Overall satisfaction = 90% Excellent/Good Recommendation to others = 90% Excellent/Good 5
Power of Staff Satisfaction Influences Staff turnover Quality of life Relationships - co-workers, residents, families Quality of care Regulatory compliance Castle et al., 2007 Process Measures The% of new admissions with risk assessments complete and care plan initiated within the first 72 hours = 100% Presence of physicians = 10 hours per week Consistent Assignment = 85% 6
Process Measures Employee absenteeism = less than 30 call-outs per month per 100 staff Call light response time = 3 minutes The % of new admissions seen by their attending physician in the first 12 hours = 90% Process Measures The % of new admissions with an updated POLST form in the chart within 24 hours The % of new admissions who meet with the social worker and confirm the POLST with 3 days 7
QAPI Data Dashboard Outcome Measures Process Measures Structural Measures 15 Measurement Triggers Action What are we going to change? How will we know if it works? When will it start? How can I assist? When will we get people involved? How will we keep people informed? 16 8
Safety Team Employee Engagement Team QAPI Steering Committee Clinical Care Team Quality of Life Team Marketing and Community Relations Team Identify and Prioritize Your Quality Problems Structural measures Process measures Outcomes Observations Feedback/comments 18 9
Uncover the Root Causes Identify all possible causes Brainstorming Keep asking - what else? What have we missed? Are there other factors? Arrange these causes along bones Avoid discussing solutions Vote on the most influential 19 Cause and Effect Diagram Policies People Environment Equipment/Supplies 20 10
Root Cause Analysis Used to examine adverse events Used to learn about poor outcomes Used to identify why produced good outcomes Used to help staff understand causes and effects Used to build teams and relationships and move organizations forward 21 Root Cause Analysis How to get teams un-stuck Conduct more interviews Staff, residents, families Get those most affected at the table Ask better questions Simulate the current process Go and watch 22 11
Root Cause Analysis QAPI Leadership Paradigm Causes are many Solutions multi-faceted Root cause analysis - a path to knowledge Stakeholders involved Need cooperation 23 Causes of Rehospitalizations - SNFs Pneumonia CHF Gastrointestinal bleed Respiratory distress Renal failure Change in mental status Chest pain UTI COMS Resident Episode Profile Database, 2013 12
Rehospitalizations Can Be Avoided Studies have estimated that 30% -67% of hospitalizations of nursing home residents could have been avoided Jacobson, et al: 2010 45% of hospital readmissions among dualeligible's could have been avoided Walsh, et al: 2010 Percentages are People Transfers to ER lead to - Disorientation Hospital-acquired infections Falls Skin breakdown Adverse drug effects Atrophy Transfer trauma Ouslander, 2011 13
Reduce Avoidable Rehospitalization Rate Strategic Plan: Implement INTERACT III Involve physicians Red flag measures Leadership Systems of communication 27 Biggest Challenges to Implementing INTERACT General Systems Thinking Utilizing Root-Cause Analysis Forming effective teams Specific Stop and Watch SBAR Advance Care Planning 14
STOP and WATCH Challenges Clinical: Competence of follow-up Time to follow-up Physician or NP available Getting physician or NP to respond with more than just watch to mild symptoms Noticing the change in the elder too late Organizational: Staff instability Only a few use tool No system to review together Steep hierarchy stifles sharing information Lack of team approach Polling Question -Effective Solutions for STOP and WATCH Working with NPs to follow-up Physician supported protocols Getting all staff to complete S and W Review of all S and W forms post transfer Regular huddles shared goals, knowledge and mutual respect Rewarding catching early signs of change 15
SBAR Challenges Clinical: Competence to efficiently and accurately complete RNs available to complete Physician or NP available Lack of equipment, labs, medications Lack of assessment skills Lack of understanding or adherence to end-of-life care Organizational: Unstable clinical staff Lack of time to complete SBAR form Completing after calling physician Making recommendations to physicians in uncomfortable Doctors sometimes yell and/or do not listen Polling Question Effective Solutions for SBAR Systemic, organized critical information available for accurate assessment and decision making Huddles with physicians and NPs to review highrisk together, anticipate changes Medical Director involvement in facilitating good communication between physicians and nursing Minimize distractions for nurses 16
Advance Care Planning Challenges Clinical: Competence to accurately interpret and follow RNs available to assess Physician or NP available to communicate with family Lack of equipment, labs, medications Lack of understanding or adherence to EOL wishes Organizational: Unstable clinical staff Lack of time to meet with patient and family to document EOL wishes Lack of system to learn about and share EOL wishes Lack of Physician and/or NP involvement Lack of tracking system Polling Question Effective Solutions for EOL Care Getting EOL wishes on admission Initiate meeting early in stay Involve physician and NP Ensure communication system is in place Monitor and measure - % of new admits with EOL wishes updated and in record 17
Polling Question Effective Solutions for Organization Open relationship with acute hospital Send nurse with patient to ER learn what happens Assume all rehospitalizations were preventable and leadership helps to find the causes Teach all staff how to notice changes Ensure staff can connect - S&W with SBAR with EOL wishes Focus on New Admissions The most dangerous day or time of admissions High risk in first 24 72 hours Frontload your interventions Risk of readmission declines each day Know who is critically ill Everyone focus on high risk and new admits Focus on evening and nights 36 18
Potentially Avoidable Re-Hospitalizations Preventable - but requiring hospitalization once they occur Discretionary - hospitalizations for conditions that are manageable in the SNF Futile care is care that neither extends life nor improves quality of life 37 Preventable Sentinel Events Consistent assignment Stability Knowing the person Staffing for quality Staff engagement 38 19
Discretionary Availability of RNs, NPs and Physicians Knowing the person Communication with physicians Skill level of staff Clinical assessment Timely lab tests and results 39 Futile Care Having the conversation Knowing the person Communication with physicians Acknowledge death Relationship with hospital To get their POLST 40 20
Identify High Risk Elders History Failed teach back Longer stay than anticipated Dual-eligible High risk diagnosis OnShift, 2013 Contributing Factors of Hospital Readmission Patients socioeconomic status Access to social supports Dual-eligibility Race English proficiency Access Number of chronic conditions Center for Healthcare Strategies, 2009 42 21
At Discharge - Every elder or family member knows what medication to take and how to get it Every elder or family member knows the signs of danger and who to call Every elder or family member has a prompt follow-up appointment and can keep it Jencks, S., 2013 Follow-Up Calls Conduct post discharge follow-up calls Ask about visit from home health Reinforce medications and treatments Reinforce follow-up visits with physicians Speak to both the patient and the caregiver 44 22
Message Treat Here Because You Care Transfers to ER lead to - Disorientation Hospital-acquired infections Falls Skin breakdown Adverse drug effects Atrophy Transfer trauma Ouslander, 2011 Factors That Supported Change Sustained leadership support Designated Champions of the cause Involved and on board physicians QI Focused data and staff feel supported Appropriate messaging to change behavior Mathematical Policy Research, Inc., 2010 46 23
Leaders who Trigger Quality Design systems of communication Keep staff informed Build community Build red flag measures 47 Quality Improvement Leadership Curiosity Respect, trust Humility Behavior, words Lead with questions Frame the issue so it engages staff 24
Contact Information David J. Farrell, MSW, LNHA (510) 725-7409 25