Decreasing 30 day Readmissions on a Medical Surgical Telemetry Unit

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1 Decreasing 30 day Readmissions on a Medical Surgical Telemetry Unit Presented By: Dr. Micah Beachy, Rickelle Collins and Nicole Turille Context As part of healthcare reform, hospitals are being challenged to improve the quality of care we provide patients. This includes the patient s transition from one phase of care to another. In 2012, Medicare began withholding 1 percent of their payment to hospitals with excessive readmission rates. This percentage will increase over time. 1

2 Context From July 2011 through June 2012, The Nebraska Medical Center (TNMC) had 3,402 readmissions. (13.8%) Per United Healthcare Consortium (UHC) data, in 2012, TNMC ranked 113 out of 119 academic medical centers in our 30 day all cause readmission rate. Beginnings are always messy. John Galsworthy English lih Novelist lit 2

3 Continuous Quality Improvement Operational Improvement Methodologies DMAIC: To improve any existing product or process Define Measure Analyze Improve Control Who are the customers and what are their priorities? What are the most important causes of the defects? How can we maintain the improvements? How is the process performing and how is it measured? How do we remove the causes of the defects? D001.5 Problem Statement: Define & Measure From July 2011 through December 2011, 8 Telemetry experienced a cumulative 30 day readmission i rate of 18.2%. This contributes to 9% of TNMC s 30 day readmissions. The goal for our pilot was to decrease the 30 day readmission rate by 25% of baseline, or to 13.7%. 30 Day Readmission Definition 30 Day Readmission Definition Includes only those patients discharged from 8 Tele and readmitted to TNMC within 30 days of discharge. It excludes readmissions for chemo, radiation therapy, deliveries and psychiatric transfers. 3

4 Case Manager Concurrent Review Analyze Root Cause Analyses Medical Call Center Post Dc Calls Frequently Readmitted Pt Retrospective Review 87% of readmissions were unplanned 44% of pts returned for the condition that brought the patient in for the initial hospitalization 46% of readmissions occurred w/in 7 days & 75% w/in 14 days Only 51% readmitted patients completed a physician visit between the initial admission and the readmission Key Issues for Patients after Discharge Medications (what to take, how to get refills, etc) Access to MDs for follow up & questions Unclear about education provided while an inpatient Decreasing 30 day Readmissions on a Medical Surgical Telemetry Unit In an effort to decrease readmission rates, a community partnership was created between TNMC and the Visiting Nurse Association (VNA). This multidisciplinary, cross organizational group worked toward implementing a modified version of the Coleman model. 4

5 Leadership Sponsor: Physician Sponsor: Owner: 8 Tele VNA Care Transitions Pilot Project Leader: Sue Nuss, TNMC Bridget Young, VNA Dr. Micah Beachy Med Dir, 8Tele Kim Acosta, VNA Jane Stier, TNMC Jen Wemhoff, TNMC Nicole Turille, TNMC Team Members TNMC Jane Stier, Sue Stensland, Jen Wemhoff, Dara Schlecht, Kimi Clark, VNA Kim Acosta Liz Anderson Rikki Collins Manager, 8 Tele Manager, Social Work Manager, Case & Utilization Management Associate Nurse Manager, Clinical Educator Nurse Case Manager Clinical Manager Clinical Liaison Care Transitions Coach Improve Pilot Details Why the Coleman Model? Patient centered approach Encourage patients to take an active role in their own care Specifically focusing on: Med Management Patient Centered Health Record (PHR) Follow up with PCP and specialists Recognition of early warning signs and red flags Recognition of early warning signs and red flags Cost effective utilizing registered nurses and/or social workers versus other models which utilize advance practice nurses 5

6 Participant Inclusion Criteria Improve Lives within the VNA service Area Inpatient on 8 Tele Participant i Exclusion Admitted d for Discharging i with ihhome Criteria ETOH/Substance Abuse Health Care or CHF Modifications to Original Coleman Model TNMC Coach provides support to patients transferring to SNF TNMC Coach completes a minimum of a home visit and one follow up call. Based on patient needs additional follow up calls will be completed per the Coach s discretion Coach is non nursing personnel Coaching Intervention Hospital Visit Offer Intervention Visit with patient regarding why they were admitted Discuss the patient s medical history Review "DC plan" to pt's knowledge and discuss perceived support system Home Visit Discuss DC instructions and possible barriers to adherence. Empower pt to demonstrate medication reconciliation and proper medication management Review pt's knowledge about conditions, medications, and "red flags" Encourage patient to use a "PHR" Personal Health Record Facilitate connection to community resources where appropriate Encourage patient to provider communication (especially regarding medication changes) Telephone Follow Up Ensure all home visit content and priorities are completed Ensure follow through Determine new or review outstanding priorities for the Assist patient with issues/problems 6

7 Improve Pilot Details Process Measures 1. Eligibility Rate 2. Acceptance Rate 3. Preventive Measures by Coach (Qualitative) 4. Additional Level of Care Need Identified 5. Post DC Follow up Appointments Made 6. Follow Thru (Completion of Intervention) 7. ED visits by participants Process Measures Sample Data obtained from January 1, 2012 thru June 16, Tele s Population (738 patients were discharged) 40% were eligible for an intervention (293 of the 738 discharged) 225 eligible pts were offered an intervention (77%) 152 Agreed to participate 7

8 Improve Outcome Measure 30 Day Readmission Rates Baseline Period July 2011 through December 2011 Pilot Period = January 2012 through May 2012 Pt s Eligible for Pilot (N =293) Baseline Pilot 18.2% 15.0% Coach 100% Complete (N=36) Baseline Pilot N/A 0% Single Home RN Visit (N=32) Baseline Pilot N/A 13% 8 Tele: All Dc s (N=738) Baseline Post Pilot 18.4% 17.2% Coach Partial (N=78) Baseline Pilot N/A 3% Refused OR Not Offered (N=183) Baseline Pilot N/A 18% 8Tele VNA Care Transition Pilot (1/1/12 6/31/12): Putting Results in Context Tele Unit The Nebraska Medical Center is Ranked 113 th out of 119 AMC s in 30 Day All Cause Readmission Rate 620 = # of readmissions we need to reduce to move performance to 50%tile (Source: UHC Imperatives for Quality Report, Q1 11 Q readm s/23,040dc s) 8Tele 6% = % of all FY11 TNMC Dc s (1594) 9% = % of all FY11 TNMC 30 Day All Cause Readmissions (294) 8 Tele: All Dc s (N=738) Baseline Post Pilot 18.4% 17.2% How many prevented readmissions does this translate to? A 1.2% lower Readm Rate for a pt population of 738dc s (5mo) = 9 Prevented Readm s (5mo) OR 21 Prevented Readm s (12mo) 8

9 Road Blocks Identified with our Process During Pilot Period New Process One department has patients that are eligible for the Care Transitions Intervention Staff unaware of the benefit to the organization or to the patient Road Blocks Identified with Our Patients During Pilot Period Unaware of the benefit of having a Coach Overwhelmed by the discharge process Concerned about having someone in their home Unfamiliar with Coach 9

10 Process Measures Qualitative Data on the Impact of the Coach Interventions completed by coach to prevent re admissions Empower patient To communicate with all providers about recent condition/hospital stay To assist in own care at SNF To make f/u appt, additional appts Encourage patient To create and maintain a PHR to bring with them to all f/u appts To establish and/or follow up with PCP To recognize Medication Discrepancies Assist illiterate pt with f/u and discharge instructions Provide patient financial/social assistance and resources Ensure SNF/Caregiver is aware of necessary f/u appts Control Plan Control Continue to provide patients with the coaching intervention Continue to Monitor/Measure 8 Tele 30 day readmission rates Offer and acceptance rate Completion of Coaching intervention Next Steps The coaching intervention has been translated to a similar unit within the organization 10

11 Road Blocks We Currently Face Eligibility Flag Two departments of 13 possible that have patients that are eligible for the Care Transitions Intervention. New process for some of our Case Managers Issues with patients that are admitted to a non eligible unit and then are transferred to 5 West or 8 Tele Offering Coach not in house at all times Not enough coaches for the number of patients that are eligible Acceptance Patient s unaware of the benefit Follow Through h Overwhelmed by the discharge process Concerned about having someone in their home Unfamiliar with Coach Inability to reach the patient after discharge Improve Outcome Measures Post Pilot Period 30 Day Readmission Rates Year To Date= Jan through Nov Tele: All Dc s (N=209 of 1274) Pilot Phase Post Pilot 17.2% 16.4% Coach 100% Complete (N=2 of 78) Pilot Phase Post Pilot 0% 2.6% Pt s Eligible for Pilot (N = 90 of 611) Pilot Phase Post Pilot 15% 14.7% 11

12 Questions? Continuous Quality Improvement DMAIC In English What is the problem? How do we know this is a problem? What makes this a problem? What is considered good and what is considered bad? Do we have a way to measure our performance? Is it a reliable measurement system? How often do we meet the expectation today? We know how well we meet that expectation today. Does anyone else deal with this same issue? Looking in depth at the process, what happens within the process that affects our ability to meet the patients expectation? What can we control? Of the factors we can control, which ones really affect the performance of the process? If we have accomplished our goals, then let s put some controls in place to make sure that our goals stay accomplished. We don t want things to change for no good reason; we want to have the customers satisfied by the performance of this process long after our project is completed. Who else could benefit from our findings? D

13 Single Home Health Intervention Single visit from a VNA Nurse: Review Medications Reviews Patient Centered Health Record Reviews/confirms/schedules follow up appointments Reviews Red Flags Completes Comprehensive Assessment 13

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