04/24/13 1 SKILLED NURSING FACILITY HOSPITAL COLLABORATION: ANTIOCH & LONE TREE CONVALESCENT Phylene Sunga, NHA Wednesday, April 24, 2013
Change is NOW and NOT Tomorrow "If I am interested in change I need three things: the will to change; ideas and alternatives to the status quo; and the management of change as an on going process" Don Berwick, MD* * http://www.cfmc.org/integratingcare/ (third slide on QIO home page)
Readmissions in Contra Costa County Hospital Name Hospital Ownership FY 2013 Readmission Payment Adjustment Factor Excess Readmission Ratio for Pneumonia Excess Readmission Ratio for Heart Failure Acute Myocardial Infarction Excess Readmission Ratio SUTTER DELTA MEDICAL CENTER Voluntary non-profit - Private 0.9956 1.1005 0.9130 1.0534 JOHN MUIR MEDICAL CENTER - CONCORD CAMPUS Voluntary non-profit - Private 1.0000 0.9877 0.8990 0.9357 KAISER FOUNDATION HOSPITAL - ANTIOCH Voluntary non-profit - Private 1.0000 0.0000 0.0000 0.0000 CONTRA COSTA REGIONAL MEDICAL CENTER Government - Local 0.9990 1.0245 1.0038 0.0000 SAN RAMON REGIONAL MEDICAL CTR Proprietary 0.9962 1.0603 1.0487 1.0060 KAISER FOUNDATION HOSPITAL - WALNUT CREEK Voluntary non-profit - Other 1.0000 0.0000 0.0000 0.0000 JOHN MUIR MEDICAL CENTER - WALNUT CREEK CAMPUS Voluntary non-profit - Private 1.0000 0.9369 0.8509 0.9391 DOCTORS MEDICAL CENTER-SAN PABLO Government - Hospital District or Authority 0.9989 1.0392 0.9771 0.9172 Payment adjustment is percent of Medicare Discharge Reimbursement Withheld NOTE: Penalty Doubles 10/1/2013 What do you think the Hospitals might do to reduce avoidable readmissions?
How Important is Performance Improvement? 31 SNFs in Contra Costa County Total Number Of Residents Percent Of Occupied Beds Special Focus Facility Over-all Star Rating Health Inspections Stars Nurse Staffing Stars RN Only Stars Quality Measures Stars Totals / Averages 2557 86.3 0 3.8 3.0 3.9 3.9 3.8 Does your facility have an above average rating that the hospitals will see? Does your facility need to explain its rating?
04/24/13 5 Causes of Re-Admission Hospitals will say: Pneumonia Fracture-Hip Stroke Heart Failure UTI COPD Dementia-Altered Mental Cellulitis Urosepsis SNF s will say: Pneumonia Shortness of Breath GI Bleed, Coughing Blood Resp. Failure No Urine Output/Renal Failure Change in Mental Status Chest Pain, Severe Pain UTI Febrile Illness
04/24/13 6 Building a Common Vision Hospital Too many readmissions are reducing $ payment SNF Readmissions will eventually have a $ impact admission growth Inter-facility handoffs are messy Inter-facility handoffs are messy High quality care and reputation matter High quality care and reputation matter
04/24/13 7 Lean Six Sigma Improvement Strategy (RCA) Methods Manpower Materials Lack of info SNF reports Type of transport Pt supplies, O2, Wound Vac, Walkers Accurate pt info Machines/equip ment Can SNF s Have more serv 24/7? Family/pt Understanding Expectation education Notification of pt DC d from SNF To home What can SNF s Handle? Tech, Care, Procedures, Monitoring Levels of Care Acute v. Chronic Mode (processes) Nursing staff/ Anc staff ED physicians Attending physicians Liability, care Rendered outside Of hospital Management support For project Management EMS Patients/ Families Unplanned readmissions Hospital View Financial challenges
04/24/13 8 SNF s Are a Solution For Acute Care Want short term care alternative Treatment and stabilization of acute problem Management of secondary diagnosis or co-morbidity What is not being addressed Rehab Patient education Eventual patient discharge to home
4/24/13 9 How Do We Begin?
04/24/13 10 Grass Roots Effort There was a dilemma between 1 SNF and 1 Acute SNF s are required to have an informed consent for the use of psychotropic drugs SNF s in need of a triplicate for narcotics Acute not understanding why
4/24/13 11 Meet the Neighbors Create a Committee 1 Acute /5 SNF s Roles/ Responsibilities Identify areas for improvement between healthcare entities i.e. communication, forms, electronic health records access, best clinical practices Develop strategies Share and provide education i.e. Heart Failure, Pneumonia, Urinary Tract Infections Review agreed upon outcomes No marketing of programs during Committee meetings
4/24/13 12 Meet the Neighbors Committee Members At least two members from each participating entity Committee Structure and Operations 2 co-chair: Director of Case Management and an Administrator from the SNF
4/24/13 13 Discerning Common Concerns Prioritization of Issues Missing/poor documentation at handoff Patient needs unclear No planning for potential decline in patient health Medication reactions, inability to obtain meds Physician involvement at SNF Complexity of patient monitoring
4/24/13 14 Key Issue Agreement Communication must strengthen Patients and Families need to understand why re-admission is not always the best action SNF Physicians are a key factor in preventing re-admissions Early Identification of impending patient decline is vital
4/29/2013 15 SNF Tools INTERACT Tools Stop & Watch SBAR Best Practice Care Paths SNF Skill Sets POLST
4/29/2013 16 interact2 Stop and Watch (Early Warning Tool) Seems different Talks less Overall need more help Pain Ate less No Bowel movement Drank less Weight change Agitated or Nervous Tired, weak, confused Change in skin Help more than usual
4/29/2013 17 interact2 SBAR (Communication Form) Situation Background Assessment Request
4/29/2013 18 interact2 Nursing Home Capabilities List (SNF Skill Set)
4/29/2013 19 Interact2 Care Paths (Best Practice) Acute Mental Status Change Change in Behavior Dehydration Fever GI Symptoms Shortness of Breath Symptoms of CHF Symptoms of Lower Respiratory Illness Symptoms of UTI
4/29/2013 20 Interact2 POLST
4/29/2013 21 What We ve Done First Meeting-Kick Off March 2012 Training on Heart Failure July 2012 Meeting with SNF Medical Director September 2012 Started Nursing Home Capabilities List October 2012 Meeting with SNF Directors, Case Managers, February 2013 and Hospitalists Team Spoke at Senior Care Link March 2013 SNF invite to Surgical Committee April 2013 SDMC Heart Failure 30 day all cause readmission rates from SNF 2010 31.9% 2011 29.7% 2012 17.9% TRENDING DOWN with largest decrease in 2012 Cautiously optimistic that collaborative efforts may have assisted in this trend
% Readmit 4/29/2013 22 70.0 Trending Reduction in Readmissions From SNF s Sutter Delta 30 Day All Cause Heart Failure Readmissions from SNF *Numerator includes those patients readmitted w/in 30 days for any cause with an admit origin of SNF/ Denominator includes all patients discharged to SNF with a principal diagnosis of Heart HF Readmissions from SNF Linear (HF Readmissions from SNF ) 60.0 60.0 50.0 2010: 31.9% 2011: 29.7% 2012: 17.9% 40.0 30.0 38.5 23.1 30.0 33.3 25.0 SNF/Sutter Delta Collaborative Started 36.4 20.0 10.0 9.1 16.7 7.1 16.7 12.5 0.0 1Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 2Q12 3Q12 4Q12
4/29/2013 23 Carry On Invitation to speak at ARC April 2013 Invitation to speak at Commons at Dallas Ranch May 2013 Collaboration to begin with: Emergency Department and Home Health May 2013 Dialysis/Ambulance/Transportation June 2013 Assisted Living, Board & Care, Cancer Centers,..and so on (Re-admission SNF s immunization rates, facility acquired pressure ulcers, physical restraints under 3%, Nursing hours 3.2 or higher,
Why It Matters
4/29/2013 25 Shout Out Lisa Stroud, RN Director of Case Mgt Sutter Delta Medical Center Beth Guo, RN, MSN, CCNS Sutter Care at Home Gwenmarie Hilleary, NHA, FACHE Hospital Association of San Diego and Imperial Counties Brion S. Pearson MD Sutter Delta Medical Center Derek Johnson DO Sutter Delta Medical Center John Sheridan e Health Data Solutions
4/24/13 26 HELPFUL REFERENCE www.noplacelikehomeaz.com http://www.interact2.net/ TrendTrachttp://www.ahcancal.org/research_data/trendtracker/Pages/default.aspxker.com http://www.nhqualitycampaign.org