Support for Presentation

Transcription

1 Purpose of Activity The purpose of this presentation is to demonstrate how Athens Regional Home Health successfully implemented remote telemonitoring as a part of a comprehensive disease management program for heart failure patients. The initial goals were to reduce hospital readmits and emergency department returns but benefits realized extended well beyond these goals. The purpose 1

2 Faculty Biography Pamela Hall, RN, MBA, Executive Director of Athens Regional Home Health Services is responsible for leadership of the home care agency and home infusion pharmacy. Responsibilities include establishing the mission and vision for the agencies, strategic planning, oversight of budget preparation, monitoring revenues and expenses, assuring compliance with all applicable regulations, laws and accreditation requirements, implementation of standards of care and best practices, patient outcomes and the integration of home health and home infusion services into the hospital system. Mrs. Hall has held a variety of positions in acute care and home care settings ranging from staff nurse to Administrative positions. She has also taught in public schools, technical college and at the college level. Publications include articles to State and local newsletters and contributions to a book authored by Roey Kirk (1997, Managing Outcomes, Process, and Cost in a Managed Care Environment (pp ). Maryland: Aspen Publication.) 2

3 Support for Presentation Support of this presentation has been provided by: Manufacturer of ZOE The telemonitoring equipment utilized by Athens Regional Home Health is provided through a rental contract with Philips. The ZOE bioimpedance monitor is manufactured by Noninvasive Medical Technologies and is provided to Athens Regional Home Health through the Philips contract. Philips and Noninvasive Medical Technologies paid travel expenses for the presenter s attendance at this conference. The content of this presentation is controlled solely by Pamela Hall and is copyrighted by Pamela Hall. Permission to use any of the materials or information may be obtained from the presenter. 3

4 Objectives Identify how remote telemonitoring (vital signs, chest fluid impedance and subjective patient assessment data via surveys) in combination with a chronic disease management protocol were used to reduce emergency department returns, hospital readmission and improve patient outcomes for heart failure patients. Compare and contrast how patient behaviors and home care service delivery changed for heart failure patients pre and post telemonitoring program implementation. Identify and use leadership best practices to develop and implement an innovative approach to care delivery. 4

5 About Athens Regional Home Health Service area: 5 county area of Northeast Georgia covering 1094 square miles; offices located in Athens, GA Joint Commission Accredited Medicare Certified Began operations in 1998 Average Daily Census 145; associated Home Infusion Pharmacy, average daily census of 50 All disciplines provided 5

6 Agency Demographics Payer Mix - FY YTD January 2010 Commercial 27% Self Pay 4% Medicaid 4% Medicare 65% FY09 ARHH Primary Diagnosis N=965 Respiratory diseases Diabetes 5% 5% Wounds 11% Cardiac related 16% Other 27% Rehab related 36% 0% 5% 10% 15% 20% 25% 30% 35% 40% Percent of Total 6

7 The Problem After a dramatic decline in the agency s Acute Hospitalization rate in early 2007, the 12 month rate increased 23% by December 2007 (note red line). A similar picture of Returns for Emergent Care occurred.) 7

8 Drill Down Reasons for Hospital Readmission During Home Care Episode 6/07-12/07 (N=89) 25% 21% Percent of Total 20% 15% 10% 5% 16% 13% 8% 8% 6% 4% 3% 0% respiratory problems wound deterioration uncontrolled pain other scheduled surgery DM fall GI bleed, obstruction Of the 89 patients who were readmitted from June 2007 through December 2007, 21% or 19 of those patients were readmitted due to respiratory problems. 8

9 Drill Down Cause of Respiratory Hospitalizations During Home Care Episode 6/07-12/07 (n=19) other 11% CHF 63% COPD 26% Analysis of these 19 patients revealed that 12 (63%) of these patients were readmitted due to heart failure related causes, 5 (26%) were readmitted due to chronic obstructive pulmonary disease and 2 (11%) for other reasons. 9

10 Analysis Records of the 12 heart failure patients who were readmitted were reviewed: Nine (9) or 75% of these patients, were admitted to the emergency department where IV diuretics for fluid overload were administered. Subsequently, these patients were admitted to the hospital for treatment of heart failure exacerbation. Agency Leadership hypothesized these readmits could be prevented with earlier intervention on the part of home care. 10

11 Program Development A team of managers & interdisciplinary clinicians met to develop a plan of action. What the team did: Researched best practices & evidence based guidelines: Heart Failure Society of America Guidelines Institute for Healthcare Improvement Transitional Care Colorado model Participatory Care Patient sets goal Telemonitoring to identify patient status changes Developed chronic disease management protocol, incorporating telemonitoring. 11

12 Program Components Disease Management Evidence based best practices Participatory care by patient In-home Telemonitoring Devices to measure BP, P, weight & bioimpedance Transitional Care Palliative Care Telephonic Program post home care discharge Disease management program implemented 9/1/08; Telemonitoring implemented 12/9/08. 12

13 Metrics for Success Given that heart failure related readmits were the number one reason driving increased agency acute hospitalization and emergent care rates, the following metrics were established: Reduce overall acute hospitalization rate Reduce overall emergent care rate Prevent hospital readmission for at least 30 days post hospital discharge 13

14 Evidence Based Best Practices Goals: Patient will establish a goal for home care episode Patient will utilize the HF Zones of Management to better manage disease Patient or caregiver will complete daily telemonitoring activities Implement Diuretic Protocol per MD orders Patient will adhere to dietary & fluid restrictions Physical Therapy or Occupational Therapy to assess and develop plan of care Copyrighted by Athens Regional Home Health

15 Evidence Based Best Practices Goals, continued: Patient will adhere to plan for activity level & utilize energy conservation techniques Patient will verbalize wishes regarding tobacco use & follow plan established Assess need for pneumococcal or influenza vaccines Patient will adhere to medication regimen Arrange appropriate community referrals prior to home care discharge Copyrighted by Athens Regional Home Health

16 Telemonitoring Integration Daily weight, BP & P, along with chest fluid bioimpedance measurements allows the clinician to intervene before the patient gets into difficulty. 16

17 Telemonitoring Integration This is a partial example of a patient assessment survey triggered automatically when the preset patient parameters are exceeded. Survey questions mirror nursing assessment questions, while reinforcing key teaching concepts. Patient answers provide additional information for determining the type of intervention needed such as teaching via phone, extra dose of oral diuretic or nursing visit. 17

18 Benefits of Bioimpedance Chest fluid increases detected up to 2 weeks prior to weight gain on scales Patients learn to associate behavior with consequences Nurses able to provide more relevant assessment & teaching based on patient needs & goals Extra doses of oral diuretics can be administered to prevent exacerbation Patients feel better physically & emotionally Improves patient compliance 18

19 How Home Care Delivery Changed Before Routine planned visits without knowledge of patient compliance or symptom history. Clinician goal directed teaching focused more on general disease concepts. No routine phone contact with patient. After Visits provided based on patient signs and symptoms. Patient s stated goals drive care. Teaching focus is on symptom control, diet and med management. Frequent phone contact with patient. Signs and symptoms caught much later resulting in ED visit for IV diuretic or hospital readmit for exacerbation. Short home care length of stay (LOS) of 30 days. Symptoms detected much earlier, preventing emergent care and hospital readmits. Extra oral diuretics often given in the home. LOS - 46 days. Visits spread throughout LOS. Visit utilization - 17 visits. Visits frontloaded. Visit utilization - 22 visits. 19

20 The Patient s Perspective According to Celim Lee, a patient who previously had two cardiac arrests and had been on hospices services for a period of time: It taught me how to change my life, how to manage my diet, how to build myself up. Before, I could hardly walk across the floor. Now I can walk to the doctor s office. I played all night at our little Christmas party and wasn t tired. 20

21 Outcomes Average Rate 35% 30% 25% 20% 15% 10% 5% ARHH Acute Care Readm its in HF Telem onitoring & Disease Mgm t Patients for HF Exacerbation During Hom e Care Episode 32% TM program implemented 12/08 (baseline N=158; average quarterly n=25) 27% 13% 19% 20% 0% CY 08* CY Q1/09 CY Q2/09 CY Q3/09 CY Q4/09 * Baseline Data Source: SHP (baseline) and ARHH (quarterly data) Following program implementation, the readmit rate began a steady decline to a low of 13% in Quarter 2, An increase in the 3rd and 4th quarters raised concerns. Analysis indicated an unintended expansion of the program to populations more appropriate for palliative care largely due to patient and physician demand for telemonitoring services. Several non-compliant patients were also kept on service longer than desirable in order to provide opportunity for improved compliance. 21

22 Outcomes ARHH HF Acute Care Hospitalization All Reasons/All Payer Sources FY08 n=164; FY09 n=167 Rate 40.0% 30.0% 20.0% 10.0% 0.0% -10.0% -20.0% 36.6% 33.5% -8% FY 9/08 FY 9/09 % change Data Source: Strategic Healthcare Programs The previous graph depicted the rate of readmits for heart failure exacerbation during the home care episode for those patients on the telemonitoring & chronic disease management program. This graph shows the impact of this program to the readmit rate for all heart failure patients, regardless of reason. The rate decreased 8% from the 2008 baseline. 22

23 Outcomes Athens Regional Home Health Acute Care Hospitalizaton: All Diagnoses All Payer Sources FY 08 N=763; FY 09 N=775 40% 30% 20% 10% 22% 19% 29% 29% 17% 9% FY 9/08 FY 9/09 % FY08-09 change 0% Rate -10% -20% ARHH Actual CMS Risk Adjusted CMS Percentile Rank -30% -40% -50% -60% -47% Data Source: SHP/Home Health Compare Performance Reports This graph displays the readmit rate for all patients. The impact of reducing readmits for heart failure patients by 8% resulted in the agency s overall rate decreasing to 19% between 2008 & The emergent care rate decreased 20% in the same time frame. Of greater significance, the agency s percentile ranking improved by 47% over The agency s National ranking for Emergent Care improved by 39%. 23

24 Outcomes Athens Regional Home Health (ARHH) 30 Day Hospital Readmit Rate Telemonitoring and HF Disease Management Patients average n=21 30 Day Readmit Rate 25% 20% 15% 10% 5% 0% 19.6% 8.5% 8.7% 7% 5% 8% 8% Jul-09 Nov-09 CY Q1 09 CY Q2 09 CY Q3 09 CY Q4 09 ARHH Running average 5% 7% 8.5% 8.7% 8% 8% National avg 19.6% 19.6% 19.6% 19.6% 19.6% 19.6% Data Source: ARHH internal data And the benefit to our parent hospital (or other referral source hospitals) is unquestionable in helping reduce costs associated with preventing these readmissions. 24

25 Other Results Dyspnea Improvement in HF Patients All Payer Sources ARHH FY08 N=88; FY09 N=100 Percent (higher is better) 70% 60% 50% 40% 30% 20% 10% 0% -10% 43% 61% ARHH 41% 58% 58% 0% SHP Benchmark FY08 FY09 % change Although the agency did not set out with the goal of improving dyspnea in these patients, the results were impressive. A similar picture was noted with other outcomes such as ambulation, bathing, toileting, and confusion frequency. 25

26 Leadership Role With the implementation of any new program or service, particularly one that changes the way care is delivered, Leadership is vital to ensuring the success of the program. Although telemonitoring and chronic disease management are not new concepts, they were new for Athens Regional Home Health. Previous slides have shown the best practices implemented for care of the patient. The following slides demonstrate Leadership Best Practices utilized with program implementation & the steps taken by the agency to assure success of the program. Of note, Philips awarded Athens Regional Home Health the Easiest Go Live award, June

27 Leadership Best Practices Strong leadership engagement: Created the vision for the program Created buy-in for the program Identified how patient outcomes will improve Involved all stakeholders early & often Link strategy to operations: Developed strategic plan to target change needed Planned budget for increased program costs as well as projected increased referrals Linked home care plan to that of parent hospital Planned operational support into daily routines Developed realistic timeline for implementation to maximize success 27

28 Leadership Best Practices Engage in moral leadership: Addressed competing interests of multiple stakeholders: Patients asked to do something outside their comfort zone Staff asked to work differently Doctors asked to use bioimpedence reading as a predictor System asked to spend money with no reimbursement, but prediction of increased referrals & improved outcomes 28

29 Leadership Best Practices Create sense of urgency: Identified negative impacts to the agency of doing nothing Identified negative impacts on patient outcomes of doing nothing Educated staff on need for change Design a program to deliver superior value: Used evidence based best practices Established metrics of success & monitor progress 29

30 Leadership Best Practices Sustain improvement: Shared data & outcomes routinely with staff Constant & frequent education to staff Held routine staff focus groups to brainstorm improvements Conducted periodic continued drill downs when metrics trend toward undesirable performance 30

31 Summary The agency recognized an unacceptable trend in patient outcomes. Through integration of chronic disease management with best practices and telemonitoring, the outcomes of this patient population improved dramatically. Patients report an improved understanding of their disease process and how to prevent exacerbations. Compliance has improved. Hospital referral sources and emergency departments report a noticeable decrease in the number of Athens Regional Home Health patient returns. (Please take the quiz to measure successful completion of the objectives.) 31