NYSPFP Preventable Readmissions Initiative: Pilot Review and Post Hospital Care

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1 NYSPFP Preventable Readmissions Initiative: Pilot Review and Post Hospital Care June 17, 2014 A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

2 NYS PARTNERSHIP FOR PATIENTS Agenda Topic Speaker I. Welcome Elaina Heagerty, Project Manager NYSPFP Staff II. Readmission Pilot Project Revisiting goals and objectives Where are we now? III. Hospital Experiences Successes Challenges Lessons Learned NYSPFP Staff St. Barnabas Hospital St. Joseph s Hospital Health Center V. Question and Answer Session Maria Stala Sacco, Project Manager NYSPFP Staff VI. Next Steps Fall Regional In-person Sessions Hospital Story Board Preparation 2 NYSPFP Staff

3 NYS PARTNERSHIP FOR PATIENTS Review of Pilot Objectives o o o Phase 1 Admission o o Identify patients on admission who are at risk for readmission using an any risk approach. Assemble a multidisciplinary team to address interventions that will mitigate risks for readmission. Phase 2 Hospital Stay o o o Prepare patient and caregiver for discharge, beginning at admission. Conduct ongoing patient reassessment to identify new or changing risk factors. Ensure systems for multidisciplinary communication, coordination, planning, and evaluation. Phase 3 - Discharge o o Ensure patient and family/caregiver are fully prepared for post hospital care. Provide timely and thorough communication to post hospital providers.

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5 SBH is a not-for-profit, nonsectarian, 435-bed, acute care, 911-receiving hospital that holds state designations as a regional trauma center, stroke center and AIDS center. The hospital s emergency department has nearly 100,000 visits annually. Background

6 Risk assessment for hospital readmission 2 week pilot project Implementation of a tool to identify potential readmissions The modified LACE tool was utilized Unit identified 3 North Team identified geographic to 3N Communication between teams during daily multidisciplinary rounds Preventable Readmission Initiative - Phase 1

7 Name Manisha Kulshreshtha Mohammad Azam Abdurhman Ahmed Ricardo Velasquez Naldeen Hector Sally Lebron Wanda Kelly Grace Ortiz Lorraine Barnett Marie BonTemps Rachel Sussman Rebecca Ditkoff Title Hospitalist Director Hospitalist Attending Physician 3N Hospitalist Attending Physician 3N Medical Resident Lead Resident 3N Case Manager RN 3N Medical Social Worker 3N Director Case Management Associate Director Case Management Associate Director Social Work Nurse Manager 3N Clinical Pharmacist Nutrition Team Members

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9 Risk Factor Category Medications Referral/ Intervention Referrals/ Interventions Clinical Pharmacist Referral Psycho-social Barriers/ Clinically Complex Social Work Department Nursing/Clinicians Financial Barriers Credit Department Nutritional Limitations Nutrition Department Limited Patient Understanding/ Health Literacy Mental Health/ Substance Abuse Nursing/Clinicians Psychiatry/ Addiction Medicine Referral Palliative Care Palliative Care Referral

10 Calculate LACE score for all patients on 3N on admission Share LACE score with team during WhiteBoard (WB) Multidisciplinary Rounds High Risk (HR) magnets placed on WB if score greater than 11 Interventions according to issues identified by physicians/ social worker/ case manager/ nutrition/nursing Appropriate referrals made Interventions put in place Checklist completed Patients tracked for readmission 30 days after discharge

11 Total of 76 patients reviewed over a 2 week period 9 patients were identified as high risk for readmission Patients at Risk for Readmission 9 Low Risk High Risk 67 Results

12 Length of stay Number of patients Less 1 day 0 1 day 4 2 days 2 3 days days days 0 14 or more days 0 Acute Admission In patient 9 Observation 0 tool for Comorbidity No prior History 0 risk severe renal disease 3 classifica DM no complications, Cerebrovascular disease, Hx of MI, PVD, PUD 2 Mild liver disease, DM with end organ damage, CHF, COPD, cancer, leukemia, lymphoma, any tumor, cancer, moderate to Dementia or connective tissue disease 0 Moderate to severe liver disease or HIV infection 7 Metastatic cancer 0 tion ER visits during previous 6 months or more 4 Results

13 Specific Risk Factors

14 Referrals Given 0% 100% Yes No Referrals Given

15 Disciplines Involved Surgery 1 Palliative care 1 Heme/Onc 1 Dietician 1 Addiction Medicine 2 PMD 2 Social Worker 4 Medicine 6 ID 1 GI Disciplines Involved

16 Readmitted Against Medical Advice ED visits No ED visits High Risk Patients ED Visits/ Readmissions in 30 Days

17 Clinic Follow Up - High Risk Group (n=9) Clinic Follow Up - High Risk Readmitted Group (n=4) Number of Patients 2.5 Number of Patients Yes No 0 Yes No Follow Up of High Risk Group

18 High risk(hr) magnets as part of all whiteboard rounds on all units LACE tool auto-calculation being incorporated into the EMR Ongoing communication with Allscripts (EMR) to have the LACE score available on the header of the patient medical record based on the previous visit Admission/Discharge reconciliation clinical pharmacist interventions; clinician education Next steps - Sustainability

19 Identify PCP (on admission) completed Identify Pharmacy erx, map of local pharmacies in progress Contact PCP Resources: little blue book, community physician list; training and education of clinicians; CCDA Patient Portal Pilot on 3N phone calls post discharge Preventable Readmission Initiative- Phase 3

20 Identifying PCP on Admission

21 Patient s preferred pharmacy identified e-prescribe

22 Medications electronically prescribed and indicated on the interdisciplinary discharge summary Interdisciplinary Discharge Summary

23 Map of local pharmacies to be provided to patients Map of Local Pharmacies

24 Clinician education on communication with PCP ongoing Dispense history on Allscripts EMR The Little Blue Book app Contact numbers of community (out of network) physicians available on all medical units In-network physicians contacted using secure health messaging in the Allscripts EMR for communication regarding patient follow up care Communication with PCP

25 In progress on 3N - initiated 2 weeks ago Unit nurse manager responsible for calling all discharged patients within hours of discharge Script and a list of questions provided Important information regarding gaps in transitions of care being obtained Algorithm for taking care of issues arising from the follow up phone calls in progress Patient Post-Discharge Call - Pilot

26 Meaningful Use 2 (MU2) incorporates many elements of post discharge care coordination Patient Portal E-Prescribe Patient Education (Info Button) CCDA Consolidated Clinical Document Architecture o Planning Goal, Goal Instructions, Plan of Care Goal types incorporated into the discharge summary Meaningful Use 2 (MU2)

27 Preventable Hospital Readmission Initiative (PHRI) 11.5% reduction in all cause readmissions in 2013 compared to 2012 Readmission alerts, teach back, transmitting discharge summaries to PCPs, ED case management, interdisciplinary discharge summary, intensive patient education on CHF & glucose monitoring Readmission Committee; Transitions of Care Committee Incorporating Meaningful Use 2 (MU2) in the post hospital care coordination process SBH Care Coordination

28 Readmissions are not primarily about people being re-hospitalized because of mistakes made in the hospital. Reducing readmissions is about making transitions of care more effectively. When transitions of care are not done well,.. evidence suggests they wind up back in the hospital. Summary: What are Readmissions

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30 Prevention of Readmissions

31 What we were doing Multidisciplinary daily rounds. Physical therapy, casemanagement, nursing, attending physician, pharmacy and third year resident discuss discharge barriers and patient condition. As an organization we recognized that our readmission rates proved an area of opportunity.

32 How we were doing All Cause 30-Day Readmissions to Same Facility Green, Orange & Red Hospitalist Attending at Discharge Initial Encounters Discharged 1/1/13-3/31/14, Readmissions through 4/30/14 - data shown by initial discharge date

33 Making the change Agreed to participate in NYSPFP Preventable Readmissions pilot program. Developed the initial committee to discuss implementation. Team consists of physicians, nursing, nutrition, pharmacy, physical therapy, performance improvement team member, director of medical surgical nursing, social work, and case management.

34 Making the change It was crucial to have nurse buy-in. Maria Stala Sacco from NYSPFP initially met with the nursing staff discuss the pilot and to explore the feelings of this group. Nurses identified early on that there were key indicators that were present on admission that could impact readmission. Agree that focus would need to be on early intervention Utilizing the input from the nursing staff, the committee developed a plan for implementation.

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36 Perceived Barriers The nursing staff identified several potential barriers. Implementation of the new EMR (EPIC) network wide during the same time frame as the pilot. Staffing ratios. Patient acuity. Nurse work load.

37 Making the change Phase 1 We selected to utilize the NYSPFP Readmission Any Risk Assessment tool at the time of admission to identify potential readmission risks. We placed a flowchart and a breakdown of identified risks with possible interventions as a reference for the health care team. In addition this guide listed the drivers of specific interventions according to their scope of practice.

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40 Implementation of risk identification tool Nursing was initially slow to incorporate the tool into their admission process workflow. They gradually adapted their routine to include the tool just as the EPIC EMR was launched. EPIC implementation started, which required all staff to focus on the EMR. To keep the pilot going each unit educator took responsibility of the process while nursing focused on EPIC. Now that EPIC has been assimilated into the nurse workflow, we are reengaging the nursing staff to utilize the readmission risk tool during the admission process.

41 Phase I Recap The initial plan was to have nursing drive the risk tool. There was a need based on competing priorities to incorporate other resources to support Pilot. Prior to the implementation of EPIC the majority of nursing staff identified readmission risks per the admission process these aligned with what we were seeing in early audits; medications and psychosocial barriers. Referrals for specialties were made by the nurse at the time of admission and on identification of specific risks. Weekends and nights referrals were delayed. Identified that a risk assessment tool is built in new electronic medical record system for case management. Plan is to expand the tool, create automatic referrals when physician order is not required and make it risk assessment score available to all disciplines.

42 Phase II: Teach-Back A teaching action plan was developed to implement the Teach-Back method for all disciplines. Reviewed NYSPFP website and current literature for teach back information. A power point was developed for use by all disciplines to educate on the Teach-Back method. Utilized video s displaying correct and incorrect forms on teach-back. Developed education plans for nursing, pharmacy, residents and Physical Medical rehabilitation. Audit teach-back method at the bedside with immediate coaching if needed.

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44 Next Steps The committee continues to meet to review the process and to identify areas of opportunity for improvement and sustainability. Work with Business Analysis unit to review readmission data and drill down on opportunities. Implement a more robust pharmacy consult process. Implement Phase III- Evaluate and Refine discharge process including current use of D/C phone-calls. The committee will develop strategies for hospital wide implementation.

45 NYS PARTNERSHIP FOR PATIENTS Next Steps o June September, 2014: o Continue pilot activities and one-on-one work with NYSPFP project manager o Begin developing your team s Story Board for the Fall 2014 sessions o NYSPFP to provide template for hospitals to use o Project managers available to assist with Story Board development 4 June 16, 2014

46 NYS PARTNERSHIP FOR PATIENTS NYSPFP Resources and Support o NYSPFP Project Managers o o o o Address questions from the team and assist with identifying next steps Participate in team meetings and discussion of outcomes Clarify the use of tools and resources Convene regional in-person meetings and/or calls to facilitate sharing of ideas, practices, challenges, and successes o NYSPFP Tools and Resources o o o NYSPFP Website Preventable Readmission Initiative Page Pilot Phases 1, 2, and 3 Tracking Tools Preventable Readmissions Action Planning Resource Guide 5

47 NYS PARTNERSHIP FOR PATIENTS Preventable Readmissions In-Person Sessions Fall 2014: Upstate sessions: o October 21 Batavia o October 22 Syracuse Downstate sessions: o October 29 New York City o October 30 Long Island 6

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