Continue the Impact ISSUE 3

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1 Transition the Care Submitted by: Janice Faehnrich, RN, MSN, MBA Stacey Hodgman, MS, RN-BC, CMAC Pam Zanes, RN, BSN, Ed.M Senior Directors of Care Transitions Improving care transitions for our patients is not just the right thing to do; it is a critical component of a successful healthcare delivery system. Kindred s Care Transitions Program has successfully launched in our Boston, Cleveland and Indianapolis markets. Under the clinical leadership of the Senior Directors of Care Transitions, Care Transitions Managers (CTMs) have been deployed in the field across the entire Kindred post-acute continuum, including the patient s home, improving the quality of transitions of care. Hospital readmission rates, poor patient outcomes and avoidable returns to the ER are often a result of imperfect transitions from one healthcare setting to another. Factors that contribute to gaps in care transitions frequently include: lack of availability of health care records such as the discharge summary, poor communication between hospitals and post-acute settings or between healthcare providers and the patient/caregiver, the patient s misunderstanding of their care plan, low health literacy and failure to engage the patient in their plan of care. Our Care Transitions Managers follow patients with specific diagnoses and/or risk factors that vary by market. These may include diagnoses such as CHF or COPD or risk factors such as low health literacy, polypharmacy or frequent hospitalizations. Once identified as eligible for the program, the CTM meets with the patient within the first few days of admission to any Kindred site of care, introduces and explains the program and its benefits, and if the patient elects to participate, obtains signed consent. The CTM follows the patient throughout his or her stay at a Kindred Transitional Care Hospital, Skilled Nursing Facility or at home with Kindred at Home until 35 days post-discharge. The fundamental responsibilities of the CTMs include: 1. Patient/caregiver engagement and education across the continuum 2. Transition plan of care support and collaboration 3. Supporting communication with the patient s healthcare provider 4. Medication management and 5. Supporting the follow-up plan of care Kindred s commitment to improving care coordination was designed using evidence-based research and carefully defined interventions. CTMs collaborate with the care teams at each site Health Education Advocacy Communication Empowerment Outcomes Improvement Collaboration Patient and Care Transitions Manager of care, helping to ensure patient engagement and empowerment in their individual patient-centered care plan, goals and transition plan. Throughout the patient s stay, the CTM works closely with the patient and/ or the caregiver to provide specific disease management education including Teach Back and skills transfer to help improve the likelihood of successful outcomes and reduced hospital readmissions. The CTM works closely with the care team, ensuring that the patient and the IDT s goals are

2 in alignment and may make recommendations to support the patient s identified goals and desired outcomes while ensuring that the transition plan is safe, timely and appropriate to meet the patient s care needs. The CTM communicates with the patient s primary physician upon admission to a Kindred site of care and with each transition thereafter. By keeping the physician looped in and updated about the patient s current health status and care needs, continuity of care upon transition back to the community greatly improves, including a follow-up appointment scheduled within seven days of transition to home (early data showed that 98% of patients in the program had done this). Prior to transition between settings, the CTM reviews the patient s prescribed medications with the patient and the primary caregiver, engages the patient and ensures the patient/caregiver understands his/her medications and the reason for taking each. The CTM further supports accuracy in the medication regime by assisting the patient in completing a Personal Health Record which includes the right medication schedule. A warm handoff is provided to the receiving provider as the patient transitions from one setting to another. This is supported by the completion of a written handoff tool. The CTM assumes full responsibility for the thoroughness of the transition until the receiving provider has confirmed that all required documentation has been received. While each of our integrated markets share these core fundamentals, each also has its own unique elements such as Boston s implementation of a transitional care pharmacist, Cleveland s bundled payment project with the Cleveland Clinic and Indianapolis s use of advanced practice nurses. Early data has shown that by improving transitions of care, Kindred has improved the patient experience and reduced length of stay and unplanned hospital readmissions. But perhaps more important is the difference our program has made in the lives of the patients we serve as they feel empowered, engaged and supported during the most difficult times when they are ill, dependent and relying on others to care for them while transitioning from one site of care to another. Despite current funding challenges, Kindred invests in this program because we believe that relationships matter and that we are providing our patients and their caregivers with exceptional person-centered care as they continue their care with Kindred.

3 Kindred Healthcare s Glycemic Initiative Maintaining glycemic control in patients with or without prior history of diabetes reduces morbidity and mortality and is an essential aspect of patient safety. The Joint Commission and the Institute for Healthcare Improvement (IHI) have identified insulin as a high alert medication. The American Association of Clinical Endocrinologists (AACE), the American Medical Directors Association (AMDA), and the American Diabetes Associates (ADA) recommend replacing sliding scale insulin (SSI) use with efforts to maintain normal glycemic levels through use of basal bolus insulin therapy. Additionally, SSI is included on the American Geriatric Society s BEERS Criteria for potentially inappropriate medications in older adults. Evidence supports keeping blood glucose levels within a desirable zone for better health and outcomes. Both the Kindred Hospital and Nursing Center divisions have worked collaboratively over the past several years to develop an interdisciplinary performance improvement initiative to support improving glycemic outcomes and ensure our patients get the best of evidence based care. Some key strategies of the glycemic performance improvement initiative were implementation of a reliable point of care (POC) finger-stick glucose monitoring system; standardized policies, procedures, and order sets; educational resources, pocket guides, patient education, and professional continuing education.

4 Continued Kindred Healthcare s Glycemic Initiative Both the hospitals and nursing centers have been making progress toward achieving established goals. In the hospitals, the number of blood glucose fingersticks in the ZONE has increased by 6% in 1 year. In 2013 in the Nursing Centers, the proportion of patients using sliding scale insulin decreased by 9%. Although progress has been made in both divisions, there is still opportunity for continued improvement. Check out the Glycemic Initiative Resources in KNECT to help you implement this important initiative in your facility. Hospital Division: > KNECT > Hospital Division > Clinical Operations > Clinical Programs > Glycemic Control > Cis Diabetes Resource Tool doc Nursing Center Division: > KNECT > Nursing Center Division > Clinical Operations > Glycemic Management (middle column) > 01 Kindred NCD Glycemic Control Initiative > 05 Glycemic Control Key Resources.doc Glycemic Initiative Resources can be found in KNECT Kindred Hospital and Nursing Center Model of Collaboration Glycemic Performance Improvement Initiative Both the Kindred Hospital and Nursing Center divisions have worked collaboratively over the past several years to develop an interdisciplinary performance improvement initiative to support improving glycemic outcomes and ensure our patients get the best of evidenced based care.

5 Continued Kindred Healthcare s Glycemic Initiative NCD Glycemic Control Key Resources Glycemic Initiative Materials, Articles, Weblinks, Insulin Information, Patient Education Resources KNECT > Nursing Center > Clinical Operations > Glycemic Management (middle column) Name 01 Kindred NCD Glycemic Control Initiative 02 Kindred Keys to Good Glycemic Control 03 Staff Education Resources 04 Carbohydrate Reference Tools 05 Key Websites (Including websites with Patient Education) 06 Patient Education Resources (see also folder 5-Key Websites) 07 Misc Recorded Diabetes Webinars 08 Insulin and Oral Medication Product Information 09 Articles & Research Studies 10 Sanofi Representatives & Resources 11 Pharmerica Glycemic Mgmt Case Studies 11a Omnicare Info 12 Glycemic Control Initiative E-Blasts 13 Glycemic Control Initiative Division Data Policies and Procedures Find Diabetes in the Great 8 Policies and Procedures Resident Care I Procedure Manual PRO Diabetes Mellitus, Guidelines for Management PRO Blood Glucose Monitoring PRO Blood Glucose Monitoring using the Nova StatStrip Glucometer PRO Hyperglycemia and Diabetic Coma (Ketoacidosis) PRO Hypoglycemia PRO Hyperosmolar Hyperglycemic Nonketotic Syndrom (HHNS) TL 6221 SNF Physician OVERVIEW for Gradual Conversion to Long-Acting Insulin and Taper of Regular Insulin Sliding Scale (RISS) Nutrition Kindred Diet Manual, Section 7: Modifications for Diabetes and Calorie Control Academy of Nutrition and Dietetics Nutrition Care Manual: KNECT>Nursing Center>Nutrition Services>ADA Nutrition Care Manual>Conditions>Diabetes (also search under Nutrition Care and Meal Plans ) Video Training Resources KNECT > Human Resources > Training and Development > RIC > RIC Program > Reserve a Video > #216 Title: Help Enhance Your Staff s Understanding of Diabetes in Elderly Residents Description: This DVD includes 2 chapters Chapter 1: Treating Hyperglycemia and Hypoglycemia in Elderly Residents; and Chapter 2: Medication Options for Blood Glucose Control Diabetes Management in the Long Term Care Setting, Clinical Practice Guidelines Order from American Medical Directors Association (AMDA): > Resources & Tools > Clinical Practice Guidelines Sanofi Representatives KNECT > Nursing Center > Clinical Operations > Glycemic Management (middle column)

6 Continued Kindred Healthcare s Glycemic Initiative Hospital Division Glycemic Initiative Resources Materials for the Glycemic Control Program may be found in the Clinical Programs folder. Policies and procedures are located in the Medication Management Policy Manual on KNECT. KNECT > Hospital Division > Clinical Operations > Clinical Programs > Glycemic Control Policies: Glycemic Control Management (H-MM ) Management of Hypoglycemia (H-MM ) Patient Receiving Subcutaneous Insulin (H-MM ) Managing Patient on IV Insulin Infusion (H-MM ) Self-Management of Insulin Pump (H-MM ) Program Tools: Facility Charter Facility Program Tracker and Work Plan Glycemic Initiative Flyer Process Charts for Subcutaneous PO Feeder, Subcutaneous Tube Feeder, Continuous IV Insulin Infusion and Transition from IV to Subcutaneous Insulin Get in the Zone General Education PowerPoint Presentation Hypoglycemia Questionnaire (H-MM C) Self Management Insulin Pump Log (H-MM A) Self Management Insulin Pump Agreement (H-MM B) Self Management Insulin Pump Standard Order (H-mm C) Available from Standard Register: Standard Order Sets Hypoglycemia Subcutaneous Insulin PO Feeder Subcutaneous Insulin Tube Feeder IV Insulin Infusion Transition from IV to Subcutaneous Insulin Glycemic Management Log (for paper facilities or downtime form for Protouch facilities) Available from Shop Kindred: Pocket Guide for Glycemic Management Food Drug Interactions (contains information about oral hypoglycemic agents and insulin) Education Materials: (see Glycemic Control Folder for more education) Recorded Webexes Diabetes in the Inpatient Setting Hypoglycemia Basal Insulin Bolus Insulin Consistent Carbohydrate Diets One Pagers education sheets Basal Bolus Insulin Translated into Practice Hypoglycemia Basal Bolus Insulin Therapy Carbohydrate Counting Oral Hypoglycemic Agents Insulins Insulin Pump User Guides Insulin Pump patient education sheets Get in the Zone Education PowerPoint for CNAs Carbohydrate Counting for CNAs and Foodservice Workers handout (PDF) The Role of Pharmacy in Improving Glycemic Control in the Acute Care Setting PowerPoint Presentation (AACE)

7 Cognitive Capable Care As part of the Continue the Impact project, we are excited to announce that a pilot project is planned for the Dallas/Fort Worth market involving all clinical lines of business. The purpose of this project is to create a care transitions model to be known as Cognitive Capable Care which includes cognitive assessments and strategies for interventions. The establishment of a care transitions model known as Cognitive Capable Care includes cognitive assessments and strategies for interventions shared across Kindred sites of service. As part of the implementation of this model we will be conducting workshops for caregivers and rehab staff in the Dallas/Fort Worth integrated market. Dementia Care Specialists will conduct the workshop training which will consist of three types of training, each with a specified target audience. Attendees will be from Kindred s Hospital Division, Nursing Center Division, Kindred at Home and RehabCare. We want to hear from you! Do you have a process that focuses on the patient in the care planning process and prioritizes patient goals? Share your practice by contacting continuetheimpact@kindred.com and a member of the team will call you Kindred Healthcare Operating, Inc. CSR , EOE