Readmissions as an Enterprise Priority. Presenters 4/17/2014

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1 Readmissions as an Enterprise Priority April 24, 2014 Presenters Vincent A. Maniscalco, MPA, LNHA Administrator Middletown Park Rehabilitation and Health Care Center Eileen Masterson, RN-C, LNHA Director of Nursing Middletown Park Rehabilitation and Health Care Center Patricia Metzger, MLSW, CCM Director of Case Management Orange Regional Medical Center Mary Ellen Crittenden, RN, MS, CPHQ Administrator of Quality/ Patient Safety Officer Orange Regional Medical Center Objectives for Today Brief overview of the current CMS quality initiative spotlighting why hospital readmissions have become a priority Identify contributing factors related to readmissions Identify key stakeholders - important players at the SNF and Hospital level for collaboration Review key elements of success and identify hospital and SNF strategies for collaboration for reducing 30-day readmissions 1

2 Middletown Park Rehabilitation & HCC 230-Bed Skilled Nursing Facility Middletown, NY (Orange County) Approx. 72 miles NW of Manhattan 4 - LTC Units 1 - Dementia Unit 1-40-Bed Sub Acute Rehabilitation Unit 4 Orange Regional Medical Center 374 Bed Acute Care Regional Hospital State-of-the-art hospital combines high-tech healthcare with a patientcentered approach utilizing innovations such as wireless technology, electronic health records and the latest in diagnostic and lifesaving equipment Mission Statement Improve the health of our community by providing exceptional healthcare. Vision Statement We are caring professionals driven by standards of excellence who go above and beyond to provide an exceptional patient care experience. 5 Readmissions - a National Priority! Readmissions- an important indicator of quality care Traumatic to the Resident/Patient Often result in Polypharmacy Increase risk of deconditioning and infection while in the hospital Account for billions of dollars in annual Medicare Spending Targeted by Legislators and Policymakers to reduce healthcare costs & improve quality and patient outcomes The Affordable Care Act Penalties to facilities with high rates of readmission Health Care Reform: Triple Aim Improving Care, Improving Health, Making care Affordable 2014 NYS Quality Pool (Potential Avoidable Hospitalizations: 20 Pts) 6 2

3 Hospital Readmissions Reduction Program Almost one of five hospitalized Medicare beneficiaries are readmitted within 30 days; more than one-third are readmitted within 90 days. Research suggests that a substantial proportion of readmissions can be prevented with evidence-based care in the hospital combined with comprehensive discharge planning, supportive transitions in care, and timely primary care. With reduced readmissions, experts estimate the nation can save $12 billion annually in the Medicare program alone. Medicare Payment Advisory Commission, Payment Policy for Inpatient Readmissions, in Report to the Congress: Promoting Greater Efficiency in Medicare (Washington, D.C.: MedPAC, June 2010). 7 How Well Does NYS Compare? New York s Place: 2010: 4 th Quintile! 8 NYS Re-hospitalization Rate All SNF (2011 Q Q3) NYS 2011 Q4 Baseline= 18.4% NYS 2013 Q3= 17.7% -NYSHFA,

4 Factors & Incentives that Influence the Decision to Hospitalize a LTC Patient Medicare Reimbursement Policies for Hospitals, Nursing Homes, HHA s & Physicians Concerns about Legal Liability & Regulatory Sanctions for Attempting to Manage Acute Illnesses in a Non Hospital Setting Resident & Family Preferences HOSPITALIZATION Emergency Dept (ED) Time Pressures & Availability of Care Options After ED Discharge Availability of Individual Patient Advance Care Plans and Physician Orders for Palliative or Hospice Care Availability of Diagnostic & Pharmacy Services in Home & LTC Settings Clinical Competencies Maslow, K and, Ouslander, JG: Measurement of Potentially Preventable Hospitalizations. White Paper prepared for the 10 Long Term Quality Alliance, Measuring and reporting readmission rates will create incentives for hospitals and health systems to: Evaluate the entire spectrum of care that they and their affiliated providers furnish to patients Identify systemic or condition-specific changes that will make care safer and more effective Invest in interventions that reduce complications of care Better assess the readiness of patients for discharge Improve discharge instructions Reconcile medications More carefully transition patients to outpatient care, Post Acute Rehabilitation, or other institutional care settings 11 What Are Some Contributing Factors to 30-Day Readmissions: Ineffective communication/patient handoffs and/or coordination of care at the point of discharge/transfer from the SNF to the Hospital Lack of educational competencies and opportunities for learning and modeling best practices Lack of appropriate end of life care planning (end stage diseases i.e. Dementia, CHF, Renal, ) The Nursing Home/Hospital Fallacy Lack of timely post-discharge physician visit; Primary care physician unaware of hospitalization; Patient has no transportation; Patient has no primary care physician 12 4

5 Reducing Readmissions Hospital ACO SNF Care Manager Trans. Coordinator Telemonitoring Home Visit 13 Middletown Park Orange Regional Medical Center Collaboration December 31, 2012 Formal Affiliation Agreement Signed Improving the continuum of care and transitions in care related to SNF to Hospital Readmissions, Overarching Goal Decrease 30-day Readmissions by 20% from 2012 to Middletown Park Director of Nursing Director of Admissions Admissions Nurse Liaison Post-Acute Unit Manager Administrator Crystal Run Healthcare Care Team Coordinator Chief Clinical Transformation Officer Physicians Quality Key Players- The Team Orange Regional Medical Center Director of Case Management Administrator of Quality ED Nurse Administrator ED Medical Director Staff Development Unit Manager 5 South Director of Nursing Pharmacy 15 5

6 Universal Transfer Form Modeled from NJ Clinical Information SNF Contact Information Nursing Home Capabilities 16 MD Communication Tool-SNF to Hospital 17 Improving Patient Handoffs SNF to ED Workflow Algorithm Education by SNF and Hospital to ED staff Facilitates Nurse to Nurse call with all transfers prior to patient arrival in ED Prompts MD to SNF call for follow up Prompts Medication Reconciliation 18 6

7 Improving Patient Handoffs Post-Acute Discharge Protocol Ensure safe transitions to home post discharge Patient contacted within 24 hours of discharge Medication reconciliation and optimization Scheduled visit with PCP/Specialist within 3-5 days Appropriate services in place Home visit within hours Tele-monitoring Heart Failure Clinic DME 19 Safe to be home 2013 Multidisciplinary/ Cross Continuum Partnership Focus Sub-Teams ED---SNF Focus Share patient chart- all can access EPIC Readmission Flag to alert providers Patient flow algorithm- facility to facility & MD to MD communication/ collaboration; focus to treat & release Inpatient Hospitalization/ Discharge Focus Educate patient/ caregiver using teach back Created universal transfer form CR Care Manager role to transition patients To SNFtreatment plan, physician followup SNF Focus SNF hospital admission liaison role created Created universal transfer form Patient flow algorithm- processes to manage patients i.e. change in condition- protocols for sending patients to the hospital ED Pharmacist medication reconciliation Review challenging medication reconciliation process Education provided on managing challenging treatment/ chronic disease ED visit call backs Discharge call backs Engaging family in care Tracking data i.e. SNF specific readmission data Tracking data i.e. Use of transfer form Tracking data i.e. Success when patients return from ED 20 Team Success 2012 vs % Decrease! 21 7

8 Quality behind the Scenes Model for Improvement The DMAI 2 C Model Right Team Work-out Session Funnel the Data Root Cause Analysis Idea Generation Action Plans Align with others- New York State Partnership for Patients Define What is the problem? What is the scope of the effort? Control Measure the effectiveness Act on outliers Implement Launch ideas for change Improve Generate ideas for change Measure Look for the Pareto Analyze Why does the problem ex Readmissions ORMC Data Overall Key Findings Expected Practice/ Condition Readmitted in 30 Days D/C to Home Not Readmitted in 30 Days D/C to Nursing Home Readmitted in 30 Days Not Readmitted in 30 Days Evidence of patient/family 60% 64.29% 20% 33.33% teaching? Evidence of teach back? 40% 14.29% 10% 5.56% Evidence of patient/family 40% 50% 30% 18.75% understanding (of teaching)? Evidence of family support? 100% 90.82% 88.89% 87.5% Evidence of (need for) Follow-up 80% 92.86% 90.91% 94.44% MD appointment on d/c instructions Evidence that follow-up appointment was made prior to d/c 0% 0% 0% 0% 23 Be Innovative Hot Spotters The Hospital- Dependent Patient Palliative Care 8

9 INTERACT Program for SNFs Program available online at Overall Quality Improvement System Improve the Quality of Care to Your Residents Strengthen Your Clinical Staff s Skill Levels Fulfill the SNF s goal to initiate QAPI Creates Opportunity for Improved Relationships with your Hospitals and Physicians Requires a Change/Enhancement in Thinking and Actions Calculating your Hospitalization Rate Four basic hospitalization rates can be calculated: Unplanned hospitalization rate 30 Day Readmission rate Emergency Room visit only Transfers resulting in Observation stays 27 9

10 Strategies for Implementation Communication within the nursing home Stop and Watch: Direct caregiver, family, ancillary staff SBAR: Nurse-Physician Communication between the NH and Hospital Engaging the Hospitals Transfer Forms 28 Interact III Stop & Watch All Hands Approach Education to Front Line Staff Forms Kept on Each Nursing Unit 29 Interact III SBAR 30 10

11 Improving Patient Handoffs Post-Acute Discharge Protocol Community And Residential Extenders for Transitions, Evaluation And Management Goal to Reduce Admissions, Readmissions, and LOS Integration Care Manager Infrastructure, Telemetry, and home visits 31 Conclusion Multi-disciplinary approach to transitional health across the continuum of care is key to success Care Management, Nurse Practitioner home visits, and telehealth are effective methods of delivering critical components of transitional care, in particular to high risk and elderly populations. Improving Transitions provides opportunity to lower total cost of care 32 Keys to successful implementation: Prepare for change Select a champion Involve staff at all levels Talk it up Pilot on one unit The Power of One Integrate into your QAPI program/organizational culture 33 11

12 Next Steps: Spread the Improvement and Conquer Expand Collaborative Partnership to other High Volume Skilled Nursing Facilities Focus on Transitions in Care for Heart Failure & Pneumonia Drill down on the data Improve the Medication Reconciliation Process and Transitional Care 34 Thank You! To our partners in care for their assistance and vision in preparation of this initiative and presentation

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