Meet DEAN & EDNA: The Application of HHQI Resources in the Reduction of Avoidable Hospitalizations Cindy Sun, MSN, RN Objectives At the conclusion of this session, the participant will be able to: Access and locate HHQI tools and resources Design evidence based change strategies to improve hospitalization and oral medication rates Interpret their agency s HHQI Data Reports and focus quality improvement in identified areas of need Home Health Quality Improvement Goal: Improve the quality of care home health patients receive Special Project funded by Centers for Medicare & Medicaid Services Evidence based practice Free tools, resources, & networking 3 1
History 101 Phase 1: 2007 2008 Focused on reducing ACH Phase 2: 2010 2011 Focus on reducing ACH & Improving Oral Medication Rates Home health setting Home health focus but shifting towards cross setting care Focus on agency leadership More than 5,500 home health agencies enrolled to participate Patient Centered, Interdisciplinary More than 8,000 participant representing 4,000+ home health agencies 4 Phase 3: Sept. 2012 July 2014 Focusing on quality of home health care measured by : ACH reduction Improvement in oral medication management Improvement of immunization rates Continuing HH focus, but all care settings and patients encouraged to participate Introducing Underserved Population Network (UP) More than 10,000 participants 5 Patient-Centered Care 6 2
Evidence-Based Practice Evidence based clinical decision making External evidence from research, theories, opinion leaders, expert panels Clinical expertise Patient preferences and values Melnyk and Fineout Overholt, 2011, p. 4 Current State of Home Health >3 million recipients of Medicare paid home health services in the Unites States each year, including: Medical, nursing, social, or therapeutic treatment Assistance with the essential activities of daily living Volume increasing over time Patients prefer to stay home when possible, but >25% of home health episodes end in rehospitalization Readmissions Almost one fifth of the Medicare beneficiaries who had been discharged from an acute care facility were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days (Jencks, Williams, and Coleman, 2009) Nearly 90% of readmissions are unplanned and potentially preventable, which translates into $17 billion or nearly 20% of Medicare s hospital payments (Hernandez et al., 2010) 3
ACH Essential Interventions ACH risk assessment Emergency Care Planning Front loading based on risk assessment Easy access to a nurse (24/7 call, office nurse) Phone monitoring and/or telehealth Patient self management programs www.homehealthquality.org 11 BPIP 12 4
BPIP Sub menus Corss Settings BPIP Release Date Focused BPIP Primary BPIP LAN Creation November 1, 2012 Patient Self Management BPIP Schedule February 1, 2013 Underserved Populations (UP) X X April 2, 2013 June 3, 2013 August 1, 2013 November 1, 2013 February 3, 2014 Medication Management Disease Management: Part 1 Immunization / Infection Control MH: Aspirin Therapy and Blood Pressure Control MH: Cholesterol Control and Smoking Cessation X X X X X April 1, 2014 Disease Management: Part 2 X 5
HHQI Data Reports 16 Screen cap of Data Access Site 17 Network & Span tabs 6
UP BPIP Let s Meet EDNA & DEAN EDNA 7
Clinician s findings Medications Diabetes management Family dynamics are poor Transportation Vision impairments Health Literacy EDNA (cont.) DEAN 8
DEAN (cont) Primary caregiver of his wife Independent prior to recent fall (6 wks ago) Weak due to disease process and increased time in bed over past few weeks Feelings of helplessness with new medical conditions as well as no back up for caring for his wife Sound Familiar? How Can HHQI Help EDNA? HHQI Quarterly Best Practice Intervention Packages (BPIP) Free educational material for both leadership & clinical staff Theory, tools, resources & application for day to day implementation Turn key tools to quickly implement 9
HHQI BPIPs Help EDNA Pt. Self Management My Action Plan would allow EDNA to pick a goal that is meaningful to her Are You at Risk for Going to Hospital? tool allows her to explore & learn that she is at risk Pt/Clinician Interaction Level Tips & Motivational Interviewing tool will assist the clinicians to work more effectively with EDNA My Action Plan Patient Risk Assessment 10
Underserved Population (UP) Assistance Network Health Disparities Dual Eligible Small HHA Under served Areas HHQI BPIPs Help EDNA Underserved Population (UP) Network Tools to determine & create a plan for her health literacy issues Evaluate our current patient tools for literacy using guidelines in BPIP Evaluation tools for clinicians to know that she knows (information) Leadership insight to identify, track and improve population diversity & lower outcomes like all the EDNA s in the agency Teach Back 11
Teach-Back Edna, I am glad you picked your sugar pill to talk about today. Let s talk about how to take the pill as the doctor wants you to, so you will feel better and can get to go to church.. Edna, do you have questions?. I would like you to tell me how you are going to take your medications just like your were the teacher. I take 2 of the sugar pills every morning. Great Edna that s right 2 sugar pills every morning. Can you show me how you are going fill the pill boxes? Sure! Every Sunday I am going to refill this box with my pills. I will use this paper you wrote for me in big lettering. I put 2 of the blue sugar pills in every morning slots just like this HHQI BPIPs Help EDNA (cont.) Medication Management Tools & resources to improve EDNA s med management including reconciliation, education strategies Strategies to assist her to safely & consistently adhere to correct medication schedule Collaborative network needs set up for EDNA with physicians & her pharmacist with awareness of financial difficulties and health literacy issues Medication Adherence 12
HHQI BPIPs Help EDNA (cont.) Disease Management Clinician tools to address Diabetes that are 5 th 6 th grade level Resources to write blood glucose monitor instructions that EDNA can follow every time Clinician s can use resources to know the evidence based practices with Diabetes & Hypertension to verify EDNA is prescribed Importance of interdisciplinary case/team conference to ensure comprehensive care plan addresses all of her needs Bulletin Boards & Data 38 Data to monitor agency s outcomes & care to patients including EDNA Possibly underserved data Evaluate trending & clinical educational needs HHQI Data Help EDNA 13
ACH Underserved Populations Network (UP) UP Assistance Networks Multiple network calls will be established Focus on common barriers & issues for agencies with special populations Individual Assistance Smaller HHAs can receive assistance from HHQI team Assistance to implement tools, resources & strategies to overcome barriers HHQI Assistance Helps EDNA Individual assistance to adapt and implement tools and resources into agency level Ability to discuss unique agency barriers/issues Limited resources (staff or equipment) to implement HHQI at agency level 14
Now Back To DEAN How can HHQI help you help DEAN? Screenshot of Data Reports Portal 44 ACH 15
ACH National Hospitalization ber week ACH Monthly 16
Reason(s) for Hospitalization Oral Meds monthly report Oral Meds state and national 17
Report for Oral Meds. Educational Resources - HF 18
Educational Resources - HF Educational Resources - HF Educational Resources - HF 19
Educational Resources - HF Educational Resources - HF Educational Resources - HF 20
Educational Resources: Warfarin Educational Resources: Warfarin Educational Resources: Warfarin 21
Educational Resources: Warfarin Educational Resources: Mobility Educational Resources: Mobility 22
Educational Resources: ACH Educational Resources: ACH Patient Hospitalization Risk Form 23
Educational Resources: ACH SBAR Physician Communication Tool Specific for High Risk Patients Assistance How Can HHQI Help? Difficulties interpreting your Data Reports? Understand your reports but not sure where to start? Wonder what tools are available to help your patients? What s new? Assistance How Can HHQI Help? 24
Assistance How Can HHQI Help? Does your DEAN surf the web? Assistance How Can HHQI Help? Promoting Your Successes through: AOTM Blogs BPIPs e bulletins Assistance How Can HHQI Help? Contact: HHQInfo @ hhqi@wvmi.org 25
Network Live Chats Discussion Forums Learning Action Networks or LANs Network Coordinator Share your success stories QUIZ EDNA DEAN Million Hearts A Aspirin therapy B Blood Pressure measurement C Cholesterol measurement & management S Smoking cessation www.millionhearts.hss.gov 26
Questions?? 79 Thank You! To reach me: csun@wvmi.org And of course, we can always be reached at hhqi@wvmi.org References Hernandez, A.F., Greiner, M.A., Fonarow, G.C., Hammill, B.G., Heidenreich, P.A., Yancy, C.W., Peterson, E.D., and Curtis, L.H. (2010). Relationship Between Early Physician Follow up and 30 Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. The Journal of the American Medical Association, 303,1716 1722. Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Rehospitalizations among Patients in the Medicare Fee for Service Program. The New England Journal of Medicine, 360, 1418 1428. Melnyk, B.M., & Fineout Overholt, E. (2011). Evidence Based Practice in Nursing & Healthcare (2 nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 27
Thank You This material was prepared by the West Virginia Medical Institute, the Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication Number: 10SOW WV HH BKH 062113. Approved 6/2013. 28