Care Coordination: Focus on Rural Access and Underserved Populations

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1 Care Coordination: Focus on Rural Access and Underserved Populations Sarah Plante, MSN RN CNL Lawrence General Hospital & Lisa Adams, MSN RN CNL Texas Health Presbyterian Hospital Kaufman Sarah Plante, RN, MS, CNL Lawrence, Massachusetts 1

2 OBJECTIVES After viewing this presentation the audience should be able to: Summarize the national concern for readmission reduction and how interagency collaboration can effectively impact disease-specific readmission rates Summarize the role of the CNL in providing care coordination for underserved populations Describe the importance of interagency teams in streamlining care delivery process for high-risk patients WHO WE ARE 189-bed, urban, disproportionate share community hospital 10,861 Hospital Admissions 2,144 Inpatient Surgeries Commercial 19% 222,623 Outpatient Visits 73,107 Emergency Room Visits 1,513 Births Uninsured 7% Low-Income Public Payers 36% Public Payers 38% 2

3 WHO WE ARE CONT 90.0% Lawrence, MA Demographics 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% Lawrence State of MA 20.0% 21.8% 10.0% 0.0% % of Population Hispanic/ Latino 10.5% 11.4% % of Population Below Poverty Level Obesity Rate 12.0% Poor Mental Health Status 8.9% Report 15+ Days Poor Mental Health 3

4 THE PROBLEM ATTENTION! IMPORTANT MESSAGE FROM THE CENTERS FOR MEDICARE AND MEDICAID SERVICES 1. Readmission reduction pays- inaction hurts 2. Hospitals MUST update and standardize transitional processes 3. Readmissions reduction MUST be a cross-continuum effort 4. Attention to non-clinical needs is critical post-hospitalization PARTNERS IN WELLNESS 4

5 Lesson Learned ROLE OF THE CNL IN CARE COORDINATION PATIENT CARE EXCELLENCE INFORMATION MANAGEMENT OUTCOMES MANAGEMENT INNOVATION 5

6 WHERE TO BEGIN Start local Start small Recognize your weaknesses Set achievable goals Let the data speak for itself FUNDING THE INITIATIVES Delivery Systems Transformation Initiative (DSTI) Waiver CMS funded initiative Disproportionate share hospitals Goals: Maintain near-universal health coverage Episodic to preventative care Patient-centered care planning Improve care coordination Enhance services for chronic disease management Alternative payment structures 6

7 BRINGING THE PCMH TO THE BEDSIDE HOW WE GOT THERE Created a joint team Job shadowing Identified barriers Identified roles 7

8 THE IMPROVEMENT PLAN Care Mapping Patient Identification Risk Stratification Hand-Off Follow-Up SAMPLE CARE MAP FOR DIABETES Risk Level Criteria Level 1a. DKA (Diabetic Ketoacidosis) Diabetic HHS or HHS (Diabetic Hyperglycemic Hyperosmolar Syndrome) Newly diagnosed Type 1DM Initiation of Insulin for home; or change in home insulin regimen from once daily insulin injection to multiple daily insulin injections Gestational Diabetes: new diagnosis or change in treatment regime Recurrent Hypoglycemic events, hypoglycemic unawareness or patient needed glucagon to treat Level 1b. Uncontrolled DM with one or more of the following: A. A1C 11 B. Complex medical needs requiring close supervision (such as status post surgery, initiation of corticosteroids, and other conditions) Newly diagnosed Type 2 DM (NOT on insulin) Patient who meets high risk criteria as above but is discharged with VNA services other than HHVNA TOC Recommendations: 1a. STAT DSME w/in 4 days of discharge if d/c d to home without VNA services 1b. DSME on same day as f/u hosp w/pcp if possible, but w/in 10 days of discharge unless receiving DSME through Home Health VNA Level 2 DM w/a1c 9* but <11 DSME Referral in Centricity or No referral in Centricity Patient who meets high risk criteria as above but is discharged to Long Term Care Hospital, Skilled Nursing Facility, Rehab, Inpatient Psychiatric or other temporary care facility Patients who are d/c d from HHVNA and who received DSME support at home Level 3 DM w/a1c < 9 * DSME Referral in Centricity or No referral in Centricity *A1C level 9 was chosen based on CMS s Accountable Care Organization 2013 Program Analysis criteria for inadequate or poorly controlled diabetes and GLFHC s Clinical Outcome measures for diabetes Next Available DSME; for patients discharged from LGH to temporary facility, recommend next available DSME following discharge from temporary facility and/or HHVNA service DSME at discretion of PCP at time of f/u for hospitalization 8

9 IMPACT Hospital Specific Measures 30 Day All- Cause Diabetes Readmission Rate* 30 Day All- Cause Heart Failure Readmission Rate* 6/1/11-5/31/12 6/1/12-5/31/13 6/1/13-5/31/ % % % % % % *CMS IQR Definition Custom Report LESSONS LEARNED Focus on social health determinants in conjunction with medical complexity Engagement of community providers is critical Early identification of high-risk patients Move care beyond the bedside Without the proper infrastructure, change is not sustainable 9

10 References: Agency for Healthcare Research and Quality. (2014). Project RED Training Program. Retrieved from: Centers of Disease Control (2010). FastStats. Retrieved from: City-Data.com. (2014). Lawrence, Massachusetts. Retrieved from: Centers for Medicare and Medicaid Services (2013). Accountable Care Organization 2013 Program Analysis Quality Performance Standards Narrative Measure Specifications. EOHHS. (2007). Facts about diabetes in Massachusetts. Retrieved from: INTERAT2.net (2011). Interventions to Reduce Acute Care Transfers. Retrieved from: Medicare.gov Hospital Compare (2010). Hospital Readmissions Reduction Program Data. Retrieved from: /readmission-reduction-program.html Society of Hospital Medicine (2015). Project BOOST Implementation Toolkit. Retrieved from: Innovation/Implementat ion_toolkit/boost/overview.aspx United States Census Bureau. (2013). State & County QuickFacts: Massachusetts. Retrieved from: PHOTOS: Meanwhile in Texas 10

11 Lisa I. Adams MSN RN CNL Kaufman, Texas Healing Hands. Caring Hearts. Objectives Describe care coordination, interdisciplinary care planning, and interagency connectivity in a rural setting for underserved populations Describe collaboration opportunities between inpatient and emergency department (ED) clinical nurse leaders (CNLs) Describe strategies to improve care outcomes for chronic disease management 11

12 Texas Health Resources Texas Health Resources (THR) is one of the largest faith-based, nonprofit health care delivery systems in the United States Largest in North Texas in terms of patients served THR has 25 acute-care and short-stay hospitals Serves 16 counties, home to more than 6.2 million people THR 12

13 Texas Health Kaufman Texas Health Presbyterian Hospital of Kaufman (THK) is a 91-bed acute-care, full-service medical center Initially opened in 1979 Serving Kaufman and Henderson counties and the southern part of Dallas County Level IV Trauma Center Challenges Identified Communication between units/floors Readmissions Lack of discharge planning/care coordination Large population of uninsured/underserved utilizing the ED for a PCP 13

14 60% of the patient population at THK are Medicare or uninsured Texas Health Resources [2]. (2014). Care Coordination According to the Agency for Healthcare Research and Quality (AHRQ) care coordination is the deliberate organization of patient care activities between two or more participants involved in a patient s care to facilitate the appropriate delivery of health care services to achieve safer and more effective care. Main goals Meet patient needs and preferences Deliver high-quality, high-value healthcare Increase communication between healthcare providers regarding patient Increase collaboration regarding delivery of healthcare Agency for Healthcare Research and Quality [AHRQ]. (2014). 14

15 Care Coordination Photo compliments of Caremerge.com. (2015). ED Navigator Program 1 CNL and 2 Nurse Navigators Focus on care coordination Identification of in need patients Improve care outcomes for chronic disease management Reduce the use of the ED as a PCP office 15

16 ED Navigator Program Needs assessment Medical Home Kaufman Community Health Clinic Still Waters St. Luke s Hospital medication charity program Delivery System Reform Incentive Payment (DSRIP)Program Texas Health Resources [2]. (2014). DSRIP Program Incentive payments made to providers that participate in health care quality and delivery system reforms this is referred to as the Delivery System Reform Incentive Payment (DSRIP) program. Providers will participate in developing a plan for their region that is a result of collaboration through a Regional Healthcare Partnership. After the plan is approved and in place, the regional partnership will measure and report the outcomes of the region s reform initiatives as the basis for DSRIP payment to qualifying hospitals. Texas Health and Human Services Commission. (2011). 16

17 Goals DSRIP Program Develop a program that supports hospitals efforts to enhance access to healthcare, the quality of care, and the health of patients and families they serve Develop a program rooted in intensive learning and sharing that will accelerate meaningful improvement Ensure individual hospital DSRIP plans are consistent with their mission and quality goals, as well as, CMS overarching approach for significantly improving health care through the concurrent pursuit of three aims Better care for individuals Better health for the population Lower cost through improvement Texas Health and Human Services Commission. (2011). Care Transition Management Improve outcomes by reliably applying medical science to each patient. Acute Care Coordination Nurse Manager Charge Nurse CNL/PCF Direct Care Nurse Denials & Appeals Management Clinical Review Denials & Appeals RNs Clinical Review Specialists Care Management Care Transition Management CTM RN CTM SW Post-acute Care Managers Texas Health Resources [1]. (2014) Utilization Management Clinical Review Utilization Management RNs Clinical Review Specialists 17

18 CTM Critical Roles and Functions Clinical Nurse Leader and Patient Care Facilitator Coordinates care across multiples disciplines in the acute setting for all patients to achieve optimal patient / population outcomes. Care Transition Manager (RN / Social Worker) Identifies and arranges transition and post-acute patient follow-up needs for referred patients to support patient well-being across the continuum of care. Clinical Review Utilization Management RN Completes Admission and Concurrent Reviews to ensure patients are assigned the appropriate status based on medical necessity and are responsible for payor communications. CTM Critical Roles and Functions Clinical Review Denials and Appeals RN Processes retrospective Clinical Denials by reviewing denial and patient record to determine the merit to appeal, write-off or recommend legal action. Clinical Review Specialist and Care Transition Specialist Clerical support for the Clinical Review and Care Transition Manager functions. Physician Advisor Serves through teaching, consulting and advising both the Care Transition Management department and the hospital on matters regarding physician practice patterns, over/under-utilization of resources, patient flow, medical necessity, and compliance. 18

19 CTM Daily Care Briefings Purpose: The Right Patient Meets Medical Necessity for Admission In the Right Bed Correct Level of Care Outcomes: Appropriate length of stay Decreased readmission rates Improved outcomes through delivery of quality patient care Increase patient and caregiver satisfaction For the Right Amount of Time Length of Stay Texas Health Resources [1]. (2014) CTM Daily Care Briefings Objective Daily communication between the interdisciplinary team (IDT) to discuss each patient s plan of care, estimated transition date (ETD), barriers and/or risks to transition (if applicable), readmission risk, and post acute care needs. Logistics When: Initiated daily on each unit between 8:00 AM & 11:00 AM What: Review all patients to identify action items and accountable party How: 1 minute per patient (every patient); facilitated by Clinical Nurse Leader/Patient Care Facilitator Where: Nursing station or conference room. Who attends: CNL/PCF, Care Transition Manager (CTM), Charge Nurse/Nursing Supervisor, Direct Care Nurses, and other members of the IDT as able (Physician/APRN/PA, Ancillary Services, Pastoral Care, Palliative Care CNS). If unable to attend briefings, interdisciplinary team members are responsible for either following up with the CNL/PCF and/or reviewing their documentation in the electronic medical record on a daily basis for their assigned patients to understand the patient progression. Action Item Follow-up Formal: 5 minute afternoon recap each day to identify which action items have been accomplished and any escalation needs OR Informal: CNL/PCF follow up with responsible parties throughout day, or responsible parties tasked with reconnecting with CNL/PCF when they complete an action item Documentation of Progression Care Coordination Plan Care Plan Transition Plan Texas Health Resources [1]. (2014) 19

20 Although the readmission rate is often presented as a measure of the performance of hospitals; it is also an indicator of the performance of an integrated health care system. Texas Health Resources [1]. (2014) Readmission Rates Centers for Medicare & Medicaid Services [CMS]. (2014) 20

21 CNL impacts at THK Core measures Safe Zone/MRSA PCR Medication Side-Effect Information Sheet Case Study #1 Ms. G - Fragmented Care 58 year old female with 15-year history of Type 2 diabetes, HTN, obesity, and major depression BMI 37, HbA1c 9.7%, BP 190/106, PHQ-9 score suggesting major depression (despite SSRI) Recent PCP visit referral to mental health center before adjusting medications further, then follow up Difficulties with scheduling appointment at the mental health center took two months New psychiatrist noted Ms. G s BP at 220/124, c/o headache and fatigue he received no info from PCP sent her to ED ED changed current BP medications but did not give clear instructions regarding previous prescriptions patient took all the prescriptions 21

22 Case Study #1 Ms. G - Fragmented Care One week later daughter called 911 when finding mother on floor of bathroom last known well 48 hours prior daughter visits every other day Symptoms included lethargy, altered mental status, slurred speech admitted for possible stroke, BP 146/71 lost dose of anti-hypertensive was 18 hours prior Medications adjusted in hospital, BP remained stable and neurological deficits cleared Discharged with an appointment at the mental health center for the management of the worsening depression exhibited in the hospital Depression symptoms increased after discharge she became forgetful, dysfunctional, unable to get self out of bed or to any appointment Case Study #1 Ms. G Fragmented Care Increased depression symptoms led to non-compliance with medications Three weeks later daughter became concerned as Ms. G had not answered the phone in two days found her in her bed, hemi-paretic She was readmitted to the hospital with a complete stroke PCP was contacted by daughter during hospitalization he had not been made aware of the events that followed the last appointment to current date Daughter angered by the course of events and her perception of ignorance by the PCP 22

23 Case Study #2 Mrs. O Readmissions 34 year old with history of DM, CHF, obesity, and ARF 24 visits to the ED within a one year span, 18 of those resulted in admission to the hospital HbA1C 11.6%, EF >20%, pacemaker placed 4 years prior. Per patient she is on a transplant list and is awaiting a new heart Patient has chronic diabetic ulcers on bilateral feet, frequently requires long term antibiotics, follows at an outpatient wound care clinic Case Study #2 Mrs. O Readmissions Collaboration with ED CNL when arrived back in the ED after discharge from hospital previous week Interdisciplinary care coordination with CM and SW (CTMs) Contacted cardiologist patient had not followed up with appointments scheduled Had been removed from the transplant list six months prior due to noncompliance with follow up and medications MD willing to reinitiate care and determine if patients prognosis and program constitute eligibility for transplant 23

24 References Agency for Healthcare Research and Quality [AHRQ]. (2014). Care Coordination. Retrieved from Caremerge.com. (2015). Care Coordination Photo. Centers for Medicare & Medicaid Services [CMS]. (2014). Hospital Compare Report for years Retrieved from Texas Health and Human Services Commission. (2011) Waiver, DSRIP. Retrieved from Texas Health Resources [1]. (2014). Care Transition Management. (Internal Documentation) Texas Health Resources [2]. (2014). DSRIP. (Internal Documentation). THK Contact information Lisa Adams, MSN RN CNL inpatient CNL Claire Crossland, MSN RN CNL ED CNL 24

25 Questions??? 25

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