Session M1 This presenter has nothing to disclose IHI S APPROACH TO REDUCING REHOSPITALIZATIONS IN THE STAAR INITIATIVE: OVERVIEW Pat Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement, Co Principal Investigator, STAAR Initiative Orlando, FL December 10, 2012 2 MINICOURSE OBJECTIVES After this session, participants will be able to: Describe common problems that contribute to rehospitalizations and identify promising approaches to reducing them Describe the STAAR initiative s two concurrent strategies to reduce avoidable rehospitalizations Compare and contrast case studies from sites that have implemented improvements to dramatically reduce avoidable rehospitalizations Identify strategies to remove systemic barriers and policy implications 1
HEART FAILURE PROGRAM St. Luke s Hospital Case Study Cedar Rapids, IA IHI Forum December 2012 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 Hospital 4 years; Heart Hospital 3 years Both achieved in 2012 Iowa Recognition for Performance Excellence Gold Award - 2010 Magnet Designation 2009 Joint Commission Disease Specific Certification in Advanced Heart Failure, Stroke, Palliative Care and Total Joint. Society of Chest Pain Center Chest Pain Certification Gold Award from Get with Guidelines for Heart Failure 2010-2012 2
WHY IS REDUCING AVOIDABLE REHOSPITALIZATIONS STRATEGIC FOR ST. LUKE S HOSPITAL? It is part of our mission: To give the healthcare we d like our loved ones to receive Also an IHS system strategic initiative as well and we participate in the System Reducing Readmission Collaborative. It represents goals that are aligned with health care reform: providing better value for decreased costs. Learning has been incorporated into our present work with development of population management and ACO work. TRANSITION TO HOME TEAM MEMBERS CHAIR: Peg Bradke, Heart Care Svcs. Robinn Bardell, Case Mgmt Sarah Baumert, Mgr-5E Ann Beem, PCC-3C Alexis Benion, Living Center West Dean Bleadorn, Mgr-RT Myrt Bowers, Witwer Center Shelley Cahalan, VNA Christy Charkowski, STL Hospitalists Sara Claeys, Dietitian Krissy Elder, PCC-5C Karen Forster, Pharm Terri Grantham, Card Outcomes Renee Grummer-Miller, OP Pall. Care Barb Haeder, Card Outcomes Sue Halter, ARNP-STL HF Clinic Lesley Haro, Ortho Signe Henderson, VNA Sherrie Justice, Dir-PI Carmen Kinrade, Dir-Med/Surg Shirley McCloy, Resp Ther Sandi McIntosh, Dir-ED Jennifer Owens, Med Soc Svcs Julie Peterson, Mgr-Card Rehab Chris Pickering, Mgr-Rehab Ops Karen Pierce, Data Analyst, PI Kelly Pottebaum, PCC-5E Brandi Simmons, Living Center West Amy Schweer, STL HF Clinic Marilinne Staub, UM Spec. Aimee Traugh, Mgr-3C Sheila Tumility, Primary Care Office Practice PI Brook Van Dee, ARNP-OP Pall. Care Jean Westerbeck, Living Center West Pam Williams, JRMC Resp Care Sharon Zimmerman, Resp Care Dr. Todd Langager, Medical Director 3
VOICE OF THE CUSTOMER Patient/family-centered care Feedback from Heart Failure class Patient and family members on our Patient- Family Advisory Council Feedback from follow-up phone calls Feedback from Cardiopulmonary Rehab participants Feedback from Heart Failure Clinic Patients CROSS-CONTINUUM TEAM Meets monthly Reviews readmission to assess causes and opportunities for improvement (e.g., added signs/ symptoms of dehydration to discharge education; working on complement A. Fib information for applicable patients). Reviews process and outcome measures. Continually testing and improving, aggregating the experiences of patients, families and caregivers. Provides oversight for CMS Core Measures. Implement successes from the System Collaborative Team (e.g., Readmission Daily Report, Home Care trigger tool). 4
SEVERAL SUBGROUPS REPORT INTO THE LARGER TRANSITION TO HOME TEAM Data Management Patient Education processes Long-Term Care Work processes Physician Clinic PDSA work Case Management/Social work Care Coordination Several members of the Transition to Home team are members of the hospital ACO and Population Management work. Information is bidirectional between these teams. SHORT TERM-HOSPITAL BASED CARE MANAGEMENT (EPISODE OF CARE, TRANSITION CARE) IDEAL TRANSITIONS Ideal Transition s Patient/Family in Hospital Palliative Care Therapies Hospice Bedside Nurse Home Care Patien/ Family Attending Hospital MD/AHP Social Work MD / PCC AHP assuming care at D/C Patient Identification by Care Coordinators for additionalservice at Discharge / Transitions in care Hospice Health Coach Home Care Rehabilitation -Cardiac - Pulmonary -Stroke Palliative Care Cook Cancer Navigator Social Work SNF LTACH LTC - Chronic Disease Management - Community Resources - Primary Care Resources - Outpatient Clinics (Diabetes, Heart Failure, Wound Care, Coumadin) HME 11-26-2012 5
Heart Failure Continuum of Care o Standardized care through order sets. o Use of the clinical indicator sheet as a checklist for evidence-based care being met. o HF patients identified via BNP daily reports. o Teaching: Utilizing Universal Health Literacy Concepts Enhanced teaching materials Teach back o Utilization of whiteboard to individualize patient s plan of care and communicate to team. Heart Failure Continuum of Care (2) o Bedside report to involve patient and family caregivers as partners in care. o Daily huddles are facilitated with the patient care nurse, charge nurse, and care coordinator. Daily goals are reviewed providing opportunity to review plan for the day, available support for patient, discharge goals, and determine what it will take to get the patient home safely. Assessment of palliative care referral is part of discussion. o Standardized HF on-line discharge instructions. 6
Heart Failure Continuum of Care (3) Touch points post discharge o Home Care - care coordination visit 24 to 48 hours post discharge. o Hospital-based Heart Failure Clinic visit in 3-7 days with subsequent visits established with Clinic and PCP based on needs of each individual. o Follow-up phone call based on post discharge needs at 5-9 days. o Standardized tool for transfer of information to nursing facilities for next level of care. o Outpatient Heart Failure workshop every 6 weeks on Saturday AM for 3 hours (facilitated by Cardiac Rehab and Dietitian). o Telehealth monitor available through Home Care. o Chronic Disease Management Program/Stanford 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. Concentrated effort for Admission Nurse to complete home medication list and prepare an appropriate list for physician to address. 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. 7
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. 8
Interview Questions For patients that are readmitted within 30 days of last admission: Can you tell me in your own words why you think you ended up sick enough to be readmitted again? Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night? Have you seen your doctor since you were discharged from the hospital? Do you have all of your medications? How do you set your pills up every day? Were there any appointments that kept you from taking any of your pills? 9
ENHANCED TEACHING AND LEARNING The patient education materials facilitate the use of TeachBack, and the same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinic. TeachBack - 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 post-discharge phone call follow up in clinic or per phone. Short, succinct material developed for each Core Measure DRG. TeachBack 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 TeachBack and assure the documentation and utilization of the technique. PARADIGM SHIFT The patient is noncompliant. vs. Asking, What is our responsibility as the sender of the information? 10
HEART FAILURE PACKET CONTENTS Cover page Back page TEACHBACK 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? Who will you call if you have questions? 11
ENHANCE TEACHING AND FACILITATE LEARNING Use TeachBack: In the hospital During home visits and follow-up phone calls To assess the patient s and family caregiver s understanding of discharge instructions and ability to do self-care To on-board New Nurses Session in Nursing Orientation Session in Nursing Residency Program Net Learning module, competency validation, and in-house prepared instructional DVD with TeachBack demonstration HEART FAILURE MAGNET 12
LOW SODIUM EATING PLAN BROCHURE Cover page Back page LOW SODIUM EATING PLAN BROCHURE 13
LOW SODIUM EATING PLAN BROCHURE LOW SODIUM EATING PLAN BROCHURE 14
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31 Where To Start? Go to the Unresolved Education Tab Select the topic you educated on Begin charting on the right side of the screen 16
What you taught on Additional comments POST-ACUTE CARE FOLLOW-UP Home Care Visit set up for 24-48 hours after discharge. Home Care liaison in-house. TeachBack questions part of visit. Partnership with physicians offices resulted in redesign of scheduling HF visits to allow office visits within 3 to 7 days for all patients with HF in HF Clinic. Subsequent appointments established with Clinic, PCP or specialist based on patient s assessment and need. TeachBack questions used in clinic setting. At 5-10 days, a hospital nurse or HF clinic 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 17
Improving Teaching Across Settings 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Successful TeachBack Rate Aug-06 to Dec -11 7-day Post-discharge Call VNA In Hospital Teaching Using the same teaching materials, Teach Back questions and teaching techniques in hospital, in home by home care, and 7-day follow-up call As staff became more competent and used Teach Back more reliably, more patients could retain more vital information Least retention is seen in the hospital; reinforcement helps 35 VNA & HEART FAILURE SUCCESSFUL TEACHBACK Questions: o Name of water pill o What weight gain to report to physician o What foods to avoid o Recording weights on CHF calendar/weight log 100% 90% 80% 70% 60% 50% Successful 40% Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 VNA HF In Hospital 18
FOLLOW-UP OFFICE VISIT (2012) 80% 70% 60% 62% 59% 71% 70% 60% 71% 50% 40% 30% 20% 10% 24% 14% 14% 27% 25% 4% 19% 11% 39% 31% 31% 36% 4% 7% 23% 0% Jan Feb Mar Apr May June July 3-7 Day w/hf Clinic 3-7 Day w/other Beyond 7 Days REAL-TIME HANDOVER COMMUNICATIONS Medication Reconciliation is a joint physician and nurse accountability. The physician is provided a report at discharge to reconcile the home medication list with those in hospital. 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. A new interagency transfer form is now used. 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. HF clinic ARNP is doing clinic visits in these nursing facilities as needed 19
TOUCHPOINT: HOME CARE VISIT 24-48 HOURS POST DISCHARGE Education to all Home Care staff Visit 24-48 hours after discharge Visit outline o Medication reconciliation o Review of diet and foods in-house o Teach back on water pill, diet and weight o Vital signs Complimentary Visit Conversion to Full Service Home Care Referral has averaged over the past 15 months at 14%-17% 20
Base Discharge Disposition HF Acute Inpatient Readmissions within 30 Days Jul 2011 - Jun 2012 Rehab, 0, 0% Home, 22, 42% Home Health, 10, 19% ICF, 4, 8% SNF, 16, 31% 21
Readmit Admission Source Acute HF Inpatients Readmitted within 30 Days Jul 2011 - Jun 2012 Home, 37, 71% Skilled/ICF, 13, 25% Other Hospital, 2, 4% 22
Incomplete medical management Wrong site of post- acute care Socio-economic factors Physician follow-up Med problems Patient compliance with regime Disease trajectory Good HCAHPS RESULTS DISCHARGE INFORMATION (% Yes) 90 88 86 84 82 80 89 82 82 87 87 84 78 2009 2010 Apr 2011 - Mar 2012 St. Luke's National The following questions make up this composite measure: #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? 23
prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI) http://www.mitre.org/work/health/news/bundled_payments/st_lukes_case_study.pd f CRITICAL CAPABILITIES FOR CARE REDESIGN INCLUDE: Cross-continuum participation and alignment The development and use of standardized tools and compatible information infrastructure Horizontal Leaderships and executive sponsorship; and engaged physicians Effective external and internal learning Scale up changes cannot be a project, they must become the new way to do work, built into the culture 48 24
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 patient s home environment Impact of Information Technology Stories are as important as the data 25