Southern California Patient Safety Collaborative

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1 Southern California Patient Safety Collaborative Track II: Care Transitions March 6 th, 2012 Markus Mettler, NHA, PT : REDUCING SNF TO ACUTE RE-HOSPITALIZATIONS Markus Mettler, NHA, PT 20 years in Healthcare Physical Therapist and Nursing Home Administrator Experience in: Hospital Acute Care, Hospital Acute Rehab, Hospital TCU Home Health Home based and ALF based Long Term Care, Sub-Acute Care, Post-Acute Care Rehab Vice President of Operations HMS, LLC Operational Support to SNFs and ALFs Supervise Clinical Support Services to SNFs 1

2 Healthcare Management Services Private - Family owned healthcare provider 32 years in business 8 SNFs and 1 RCFE Geographically spread throughout CA San Diego Sacramento Los Angeles (East LA, Hollywood, Long Beach, Glendale) Priority 1: Clinical Care & Clinical Outcomes Priority 2: See Priority 1 and ALL things will come SNF to Acute Re-Hospitalization Did you know.. What % of Medi A pts admitted to a SNF are sent back to the hospital within 30 days? 25%, 1 in 4 Med A pts admitted to a SNF from a hospital are readmitted to the hospital within 30 days What % of SNF to Hospital transfers are consider Potentially Avoidable? Up to 66% of SNF to Hospital transfers are considered potentially avoidable? SNF to Acute Re-Hospitalization Did you know.. When will CMS begin penalizing Hospitals for Re-Hospitalizations? Oct 2012 CMS will implement $$ incentives/penalties for hospitals to decrease re-hospitalizations? When will CMS begin penalizing SNFs for Re-Hospitalizations? 2016 CMS is proposing a 3% payment reduction to SNFs for re-hospitalization? 2

3 SNF to Acute Re-Hospitalization At HMS We realized that we were be contributing to the issue We realized that we did not fully understand the issue We realized that we did not have a tool to address the issue We valued quality of care and understood we could improve HMS committed to implementing 1 st Qtr 2011 initial education on the issue and 2 nd Qtr 2011 initiated roll out of SBAR Communication and Progress Notes Change in Condition File Cards SNF to Acute Re-Hospitalization implementation (cont) 3 rd Qtr 2011 roll out of additional tools STOP and WATCH 4 th Quarter 2011 re-educate, re-enforce, re-visit 1 st Quarter 2012 roll out of Quality Improvement Tools Acute Care Transfer Log Quality Review of Acute Care Transfers 2 nd Quarter 2012 roll out of community Tools Resident Transfer Form and Transfer Checklist/Envelope INTER = Interventions to R = Reduce A = Acute C = Care T = Transfers Developed by Joseph Ouslander, MD, Mary Perloe, MS, GNP, Alice Bonner, PhD, RN, Ruth Tappen, EdD, Laurie Herndon, GNP, Gerri Lamb, PhD, RN 3

4 What is? Quality Improvement program focused on managing the acute changes in a SNF resident Goal is to improve quality that results in a reduction of avoidable SNF to Hospital transfers Program focuses on: Early Identification Assessment Documentation Communication What is? 3 types of tools: Communication Tools Care Paths Advanced Care Planning Tools Quality Improvement Review and Tracking/Trending Tools Re-Hospitalization - Internal Does work? What was the reduction in SNF to Hospital transfers? 50% Reduction in overall transfers from SNF to Hospital! What was the reduction in Potentially Avoidable SNF to Hospital transfers? Potentially Avoidable SNF to Hospital transfers decreased from 77% to 49%. A 36% reduction! Study published in JAMDA Nov 09 4

5 Communication Tools SBAR: Situation/Background/Assessment/Recommendation Licensed Nurse formal communication tool with MDs & NPs Improved License Nurse assessment and communication skills Decrease MD s When in doubt, send them out scenarios Documentation of assessment, evaluation, and recommendations Change in Condition File Cards Licensed Nurse resource tool: A Z COC Signs & Symptoms Improve License Nurse actions and responses to COCs Improve License Nurse decision making and communication Communication Tools STOP and WATCH Early Warning tool for CNAs to alert License Nurse of change Improve CNA observation skills of subtle changes Improve CNA-LVN/RN communication to initiate action BEFORE hospital transfer is un-avoidable Resident Transfer Form & Envelope with Checklist SNF to Emergency Department communication Improve communication of needs and reason for transfer Improve communication and ability to transfer back to SNF Care Paths Care Paths Educational resource for evaluation of common COCs: Mental Status Change Fever Symptoms of Lower Respiratory Infections Symptoms of CHF Symptoms of UTI Dehydration Improve License Nursing evaluation skills Increase consistency of evaluating common symptoms 5

6 Advanced Care Planning Tools Palliative Care / Hospice Identification Pocket Cards to assist all staff to identify residents that may be appropriate for palliative care or hospice Improve in identifying early signs that palliative or hospice care may be indicate Advanced Care Planning Communication File Cards for staff communicating with resident and family regarding levels of care options Improve communication between staff and resident/family to understand options and decisions Advanced Care Planning Tools Comfort Care Order Set File Cards for MDs, NPs/PAs, and License Staff on appropriate orders for comfort, palliative, and hospice care Improve understanding of how orders can be different for various approaches to care Improve resident/family understanding of options Quality Improvement Tools Acute Care Transfer Log Monthly Tracking Log of all Acute Care Transfers Tracking / Trending data for Re-Hospitalization Quality Improvement Review Tool Formatted guide to complete a critical review of Acute Care Transfers Determine opportunities for improvement in clinical management of resident that resulted in a transfer 6

7 Guides to Success ~ Helpful Hints Obtain Administrator and DON Support Educate IDT on issues of Re-Hospitalization Clinical Understanding vs Financial Understanding Obtain consensus and support that ACTION is required Identify a facility clinical champion to lead Implement / Educate in parts ~ DO NOT Rush! Schedule time to re-review and re-educate Provide LOTS of positive feedback and kudos Obstacles to BE AWARE of: Perception that the Nursing Home and MD are less likely to be sued if a patient is sent to acute who does not need vs keeping the res at the SNF treatment who has an unfortunate unavoidable outcome. For LTC custodial residents, if the Acute Care hospitalization is for at least 3 days the patient may return to SNF as a Medi A patient. Nurses may lack the ability/knowledge or time to review the risks vs benefits of a transfer to the hospital with resident and families Nurses may prefer to transfer the resident to the acute care hospital if they perceive the resident s COC will result in more nursing care that they lack the time for. Nurse may lack the confidence in evaluating an acutely ill resident and may encourage res/family and MD to transfer to the hospital Obstacles to BE AWARE of: Nurse may have personal values that would encourage them to recommend hospital transfer instead of palliative care at SNF Nurse may call On-Call MD who is not familiar with res and prefers to have res checked at Acute Care. Resident or family may have been identified as a problem and staff would prefer to transfer to Acute to avoid continued issues with resident. MD may not have confidence in COC report given on the phone that MD decides that it s safer to transfer. Facility may lack equipment or staff to provide necessary care at SNF to avoid acute care transfer 7

8 Re-Hospitalization Concerns Perception. Hospital Transfers = Poor Quality of Care Hospitals will NOT refer patients to SNFs that: Provide poor quality of care that result in Re-Hospitalizations Reduce their revenue due to Re-Hospitalizations Hospitals are more likely to refer patients to SNFs that: Have lower rates of Re-Hospitalizations than other SNFs Understand the Qualitative & Economic issues impacting the hopsital regarding Re-Hospitalizations Have systems and actions to reduce Re-Hospitalizations Re-Hospitalization Post SNF BE ALERT to. SNF DC to community and returns to Hospital Causes that result in Community Re-Hospitalization: Medically unstable at time of SNF discharge Pt failure to comply with Medication orders Pt failure to follow up timely with Primary Care provider Pt failure to properly transition to Home Environment Inadequate support or supervision at home or B&C Re-Hospitalization Post SNF Possible solutions: Medically unstable at time of discharge Properly asses res prior to SNF discharge Assure all Labs / Tests are completed and normal prior to DC Monitor all new medications ordered 3-5 days prior to DC to assure they are effective and free of side effects Failure to comply with Medication orders Provide res with easy to use/understand medication education Provide res with 1-2 weeks of medications when discharging Provide res with a in-home medication alert system Call res at home 5-7 days post discharge to check-in and confirm that meds are being complied with 8

9 Re-Hospitalization Post SNF Possible solutions: Failure to follow up timely with Primary Care provider Pre-schedule Primary Care provider appointment prior to discharge Pre-arrange transportation to Primary Care provider s office Provide res at time of discharge with envelope of pertinent medical information to be brought to Primary Care provider s office Failure to properly transition to Home within 24-72hrs Refer all discharges for Home Health Use Home Health agency that provides visit same day of discharge Re-Hospitalization Post SNF Possible solutions: Inadequate support or supervision at home Family conference prior to discharge home Family and home caregiver training prior to discharge home Arrange community support services ie Meals on Wheels, In Home Supportive Services Consider SNF Re-Admission vs Re-Hospitalization SNF can direct admit from home with MD order If within 30days of a Medicare stay can readmit as skilled Questions / Comments Open Forum 9

10 Case Study #1 Mr Tee 88yo male Alert and Oriented to self and place, moderate dementia, admitted to SNF 16days ago Lived at home with caregiver, had fall at night, admitted to hospital, no new fractures, but had respiratory complications, after 4 days transferred to SNF for rehab and possible LTC placement Medical Hx includes: CHF, COPD, DJD, Depression, Hip Fx with ORIF 1yr ago Physical Condition: Extensive assist with transfers, bed mobility, and bathing, independent with w/c mobility, participates with PT and OT 6x/week. Change of Condition Case Study #2 Ms Sweetie female Alert and Oriented person, place and time, mild dementia, loves bingo Lives at SNF for 2 years, was hospitalized 4months ago for 7days post fall from wheelchair resulting in a L5 compression fracture. Received 45days of PT and OT and returned to prior level of function. Medical Hx includes: hx of UTI, COPD, Osteo, Anxiety, Insomnia, L4 Compression Fx, Dysphagia Physical Condition: Extensive assist with transfers, bed mobility, and bathing, independent with w/c mobility, RNA ROM Change of Condition 10

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