Berkshire Medical Center Heart Failure Program

Transcription

1 Berkshire Medical Center Heart Failure Program Reducing Readmissions A Multi Disciplinary Approach 1 Project Goals To improve the overall care of Berkshire County Heart Failure Patients Reduce 30 day readmission for any cause Provide a high level comprehensive program that will meet the needs of this patient population across the continuum Improve patient satisfaction 2 1

2 Background Heart Failure is the leading cause of hospitalization and re hospitalization among U.S. adults over the age of million hospitalizations occur yearly with HF as the primary or secondary cause 3 Heart Failure is a Major and Growing Public Health Problem in the U.S. Approximately 5 million patients in this country have HF Over 550,000 patients are diagnosed with HF for the first time each year Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year In 2001, nearly 53,000 patients died of HF as a primary cause 4 2

3 Heart Failure is Primarily a Condition of the Elderly The incidence of HF approaches 10 per 1000 population after age 65 HF is the most common Medicare diagnosisrelated group More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare 5 Why Is Improving HF Care Important at BMC? Second most common medical reason for BMC admissions (296 admissions 2008) High 30 day readmission volume (53 Readmissions 2008) 6 3

4 Description Advanced practice nurse led multidisciplinary team Early identification Multidisciplinary team meetings 3 times per week Application of scientifically based AHA/ACC guidelines for Heart Failure Aggressive in patient treatment Referral to Outpatient Clinic and Homecare Services 7 Berkshire Medical Center Multidisciplinary Rounds 8 4

5 PATIENT Implementation System: Concurrent Feedback, Rapid-Cycle 9 Improvement, Flexible, Redundant, Efficient, Sustainable Team/Resources In Patient Heart Failure Program Cardiology NP Quality Management Documentation Specialist Case Managers Telemetry Charge Nurse Cardiologists Hospitalists Chairman of the Department of Medicine Pharmacist Gerontologist 10 5

6 Inpatient Process Early identification from Emergency Department, Case Management and Documentation Specialist Team activated Case discussed daily with covering house staff and Hospitalist Review all HF cases 3 times weekly at Multidisciplinary Rounds Cardiology consultation considered Patient, family education begun Day 1 or 2 Aggressive in patient treatment Application of ACC/AHA guidelines Assure adequate documentation. Use of Cardiovascular Disease Management Tool Referral to outpatient Heart Failure Clinic Referral to Homecare Services Time Out at Discharge Follow up phone call 48 hours post discharge 11 Outpatient Process Referrals received from inpatient stay, PCP s, other cardiologists and self referrals Patients seen in full consultation by Dr Mara Slawsky, MD, PhD, Heart Failure Specialist Application of ACC/AHA guidelines Aggressive treatment and workup initiated Frequent follow up visits for up titration of heart failure medications and serial assessments Referral to other specialties if necessary e.g. sleep center, pulmonology, cardiac rehabilitation, homecare Intensive diet, fluid restriction, medication, weight and reportable signs or symptoms education performed at every clinic visit by NP Approximately 100 patients currently enrolled 12 6

7 Home Care Program Heart Failure Team Installation of Telemedicine product if appropriate Monthly and as needed patient case reviews 13 Technology Telemedicine Remote monitoring for geographically isolated patients Aggressive assessment for high risk patients Integrated electronic medical record Available to all in patient providers, most county providers and home care agencies 14 7

8 Telemedicine 15 Electronic Medical Record 16 8

9 17 Berkshire Medical Center Data 18 9

10 BMC HF Performance CHF % Readmits Within 30 Days (All-Cause) CHF % Readmits Within 30 Days Linear Trend Jan 2007 Feb 2007 Mar 2007 Apr 2007 May 2007 Jun 2007 Jul 2007 Aug 2007 Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008 Aug 2008 Sep 2008 Oct 2008 Nov 2008 Dec 2008 Jan 20 Feb 20 Mar 20 Apr 20 May 20 Jun 20 Jul 20 Aug 20 Sep HF Clinic Readmission Rate 3% 3% 3% 2% 2% 2% 2% 2% 1% 1% 1% 1% 1% 0% 0% 0% 1% Jan- 2% Feb- 1% Mar- 0% 0% 0% 0% 0% 0% Apr- May- Jun- Jul- Aug- Sep- HF Clinic Readmission Rate 20 10

11 Berkshire Medical Center Board Scorecard Quarterly Report Q Q2 20 Heart Failure (CHF) Care Qtr Qtr Qtr 1 20 Qtr % 90% 98% 100% Discharge Instructions 100% 100% 100% 100% 100% 100% 100% 100% LVF Assessment ACE-Inhibitor / ARB for LVSD 100% 100% 100% 100% Smoking Cessation 89% 93% 99% 100% Appropriate Care Score Better than expected Expected Worse than expected 21 BMC HF Performance Discharge Instructions 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 99% 99% 83% 78% 77% 73% 69% Nat'l Avg Top 10% Discharge Instructions Num Den Must Meet All Six Instructions to Pass Indicator 1. Activity 2. Diet 3. Follow-up 4. Medications 5. What to do if Symptoms Worsen 6. Weight Monitoring 22 11

12 BMC HF Performance Peer= Premier HF Top Quartile Performer Heart Failure - Inpatient Mortality Rate 10% 9.13% HF Program & Clinic Started 8% 6% 4% 2% 5.33% 2.67% 6.27% 5.23% 2.56% 3.59% 2.30% 1.71% 1.52% 3.82% 2.47% 0% (Jan- June) Mortality Rate for Facility Expected Mortality Rate for Facility Mortality Rate for Peer Year Mortalities for Mortality Rate for Expected Mortality Expected Mortality Rate Mortality Rate Expected Mortality Cases for Facility Facility Facility Rate for Facility Index for Facility for Peer Rate for Peer % 5.33% % 5.13% % 5.23% % 4.65% % 3.59% % 5.07% 20 (Jan- June) % 3.82% % 5.12% 23 BMC HF Performance 25% 20% Heart Failure - 30 Day Readmission Rate (All-Cause) 21.3% 19.1% 19.03% HF Program & Clinic Started 23.6% 21.7% 18.07% 18.5% 21.0% 17.67% Peer= Premier HF Top Quartile Performer 20.3% 21.2% 17.21% 15% 10% 5% 0% (Jan- June) Readmission Rate for Facility Expected Readmission Rate for Facility Readmission Rate for Peer Readmission Rate for Expected Readmission Rate Expected Readmission Rate Index for Year Cases for Facility Facility for Facility Facility Readmission Rate for Peer % 21.27% % % 21.66% % % 21.01% % 20 (Jan- June) % 21.22% % 24 12

13 BMC HF Performance Peer= Premier HF Top Quartile Performer 1.80% 1.60% 1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% 1.24% 1.77% 1.19% Heart Failure - Complication Rate 1.11% HF Program & Clinic Started 1.59% 1.07% 0.34% 1.67% 0.63% 0.00% 0.99% (Jan- June) 0.54% Complication Rate for Facility Expected Complication Rate for Facility Complication Rate for Peer Complications of anesthesia Death in low mortality DRGs Decubitus ulcer Failure to rescue Foreign body left in during procedure Iatrogenic pneumothorax Selected infections due to medical care Postoperative hip fracture Postoperative hemorrhage or hematoma Postoperative physiologic and metabolic derangements Postoperative respiratory failure Postoperative pulmonary embolism or dvt Postoperative sepsis Postoperative wound dehiscence Accidental puncture and laceration Transfusion reaction Birth trauma -- injury to neonate Obstetric trauma -- vaginal delivery with instrument25 Obstetric trauma -- vaginal delivery without instrument Obstetric trauma -- cesarean delivery BMC HF Performance Heart Failure - Average Length of Stay HF Program & Clinic Started Peer= Premier HF Top Quartile Performer (Jan- June) ALOS for Facility Expected ALOS for Facility ALOS for Peer Year Cases for Facility ALOS for Facility Expected ALOS for Facility Expected ALOS Index for Facility ALOS for Peer (Jan- June)

14 CHF Mortality Rate All Ages Jan-Sep Time-out 2007 process at discharge for all HF pts 20 F/up Hire phone HF Nurse calls Practitioner: post discharge Alicia Ferrarin, NP BVNA 2005 Tele-medicine 2006 HF Development Clinic and/or & Cardiologist coordination Ongoing Joined f/up of IP HF Services MD/Resident/ GWTG-HF HF Project focus Nursing at & MDR Community More BVNA aggressive Disease Management diuresis Task Force joins with BMC Services creating BHS HF Program allowing education evidence (2007-present) based MDPI interventions Conference Improved complete continuum AMI care and of care: Mission IP-OP-Home attendance Lifeline monthly inservice at (improved Comprehensive national reperfusion Integration of Medical Records Documentation to Specialist all collaborative new RNs Hospitalist therapy for coding conferences identification Program leads to decreased incidence) Cardiologists increase from Creation of OP HF Clinic 2 Gold to 14 ongoing Achievement between 2005 daily education Award and 2008 with addition of Electrophysi-ologist for via NP rounding device management: Peter Hahn, MD Focus on transitions Hire HF Specialist: RN specific contact hour program scheduled f/up appts in PCP offices Mara Slawsky, MD & Coordinated community Berkshire/ lectures Baystate with HF HF Specialist improved discharge process (med rec) Program 27 Documentation Tools CVD Disease Management Documentation Tool Discharge Time Out Follow up phone call 28 14

15 CVD Disease Management Documentation Tool BerkshireMedical Center 725 North Street, Pittsfield, MA Aspirin Patient is on Aspirin Aspirin Contraindicated because: Beta-blocker Patient is on a Beta-blocker Beta-blocker contraindicated because: ACE-InhibitorORARB Patient is on an ACE-Inhibitor or an ARB ACEI/ARB contraindicated because: Lipid Lowering Drug Patient is on a Lipid Lowering Drug Lipid Lowering Drug contraindicated because: LDL LDL has been measured LDL not measured because: LVF Assessment Left Ventricular Function has been assessed LVF not assessed because: Type of Heart Failure ACUTE HEART FAILURE Systolic EF less than 40% Diastolic EF greater than or = 40% Combination systolic / diastolic Valvular Right-sided Heart Failure EJECTION FRACTION ACUTE / CHRONIC HEART FAILURE Systolic EF less than 40% Diastolic EF greater than or = 40% Combination systolic / diastolic Valvular Right-sided Heart Failure EJECTION FRACTION Smoking Cessation Patient was given advice to quit smoking Patient has not smoked cigarettes within the past 12 months. Diagnosis clarification: National Hospital Quality Measures/JCAHO Core Measures / CMS / AHA Get with the GuidelinesPhysician Name /Signature 29 Discharge Time Out Checklist Physicians Plan discussed with hospitalist/consultant/primary care physician Pt/family aware of discharge & expected time of d/c Patient mobility at baseline Charge nurse/primary nurse notified of discharge Medications reconciled Pt friendly med profile printed, reviewed, signed and copied Prescriptions written NH/homecare referral completed and signed Discharge summary dictated from patient friendly med profile Smoking cessation counseling provided if applicable Disease Specific Considerations Heart Failure Ejection fraction documented ACE I/ARB for EF < 40% Contraindications: β blocker for EF < 40% Contraindications: Signature Nursing Patient education completed including dietary restrictions Medications reconciled Medication profile reviewed with patient and/or family Prescriptions given to patient NH/homecare referral completed, patient given copy for homecare Transportation arranged Pneumovax/flu vaccine if applicable Patient instructed regarding follow up blood work and MD appointments Disease Specific Considerations Heart Failure Heart failure education packet given to patient Follow up appointment with cardiologist/heart Failure Clinic Date Follow up appointment with Primary Care Physician Date 30 Nurse Signature 15

16 Follow Up Phone Call CONGESTIVE HEART FAILURE ROUTINE TELEPHONE Visit / Call Patient s Name: Date of call: ID No.: Date of D/C: Cardiologist: Primary MD: Assessment via telephone 1.Current symptoms Chest pain/discomfort Palpitations Dizziness Shortness of breath Night time SOB Fatigue Edema of legs, ankle, & / or abdomen (? Any change) If any of the above are checked, please page #3050 Weight today: lb Change lb Hospital discharge weight: lb Initial Home weight: lb If patient gains >2lbs/24 hours or 5 lbs in 1 week, please page # mg sodium(salt) restriction compliance? Other (specify) 2.Change in symptoms: Overall, how are your symptoms compared to 2 days ago? Better About the Same Worse (describe) If patient describes symptoms as worse please page # Current treatments Prescriptions filled Any issues with current medications? Discharge medication profile attached 4. Can you tell me the name of your water pill? 5. Can you tell me what amount of weight gain you should report to your doctor? 6. Which doctor would you report those symptoms to? MANAGEMENT RECOMMENDATIONS / Follow-Up (check all that apply) Contacted Alicia Ferrarin, FNP re: CHFissues phone extension 3050 pager #3050 Cardiologist Follow Up Appointment: Primary Care Physician Follow Up Appointment: CLINICAL NOTES 31 Next Steps ED protocol for 1 time intravenous diuretic Standardized electronic order sets Increase referrals to Out Patient Clinic 32 16

17 Thank you! 33 17