HOSPITAL RE-ADMISSION STRATEGIES

Transcription

1 HOSPITAL RE-ADMISSION INTERVENTION STRATEGIES Presented By Robin Seidman, RN, MSN, MBA, LNCC, HCS-D Natalie Kenney RN, Care Transitions Nurse Specialist National Association of Homecare & Hospice ANNUAL MEETING November 1, 2013 INTRODUCTION It s no secret everyone wants to lower hospitalization rates Steps of Implementing a RE-ADMISSION INTERVENTION STRATEGY COUNCIL Tool for data collection & analysis Creating a DASHBOARD Identify Interventions & Strategies to help reduce re-hospitalizations 2 1

2 What does RISC mean? Re-admission Strategy Intervention Council WHEN o Instituted December, 2011 WHY o Responding to increase in acute care hospitalizations WHO o Clinical Managers, Nursing, Rehab, Transitions in Care, Palliative Care 3 RISC Implementation Invite Council Members Set Meeting Schedule o Weekly decrease to monthly Meeting Agenda o Compile reasons for Re-Admissions Need to TREND & ANALYZE o Create Trigger Lists (i.e. case conference, palliative consult o Create written processes Case Conferences Managing the non-compliant patient Front loading visits for STAAR & high-risk patients PCP Appointment follow up 4 2

3 RISC Goals Must have GOALS to be SUCCESSFUL: Use data collection and analysis to identify any trend Use trends to develop programs & resources Increase awareness of patients that return to hospital Use Case Conferences, POC modification & other strategies / interventions to keep patients at home 5 US Women s Soccer WINS 3 rd GOLD Medal IDENTIFY TRENDS In order to identify trends, RISC developed an automated data collection tool using Microsoft Excel. The data is collected for every patient transfer to the hospital. The data collected includes: o Patient Information (ID #, Name) o Start of Care Date for Home Health Services o Transfer Date to Hospital o Reason for Hospitalization o Risk Factors that could impact transfers (i.e. lives alone, complex medication regime) o Patient s Case Manager (RN or PT) o Physician 6 3

4 RISC Data Collection RISC Data Collection Tool (Excel) o Information from All-Calls o Fields of Entry: ID# & Name SOC & Transfer Date REASON for Hospitalization RISK Factors AVOIDABLE or Not Case Manager MD Comments Sort data for analysis & trending 7 Wearetryingtoset to Natalie up for RISC data collection...which line is for OASIS??? User Friendly Data Entry Tool EASY To Use Pull-Down Menus 8 4

5 User Friendly Data Entry Tool Select ALL RISKs that Apply Pull-Down Pull-Down Menu to select AVOIDABLE or Not Enter Case Manager, MD & applicable comments 9 Sample of Tool 10 5

6 RISC Analysis - Dashboard Primary REASON for HOSPITALIZATION (OASIS M2310) 11 RISC Analysis - Dashboard RISK Categories Determined by RISC AVOIDABLE or Not Avoidable & by DIAGNOSIS 12 6

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8 What is the PIRT Alert Patient at Increased Risk for Transfer WHAT type of Patient Transfer o The PIRT alert identifies a patient that has been transferred to the hospital more than once in a 60-day HH Episode. WHO is Responsible o Clinical Managers, Case Managers, all others disciplines involved in the case. Senior Management included on Alerts 15 Frequent Flyers PIRT Alert Process Case conference will review why patient went to the hospital Review current Plan of Care (POC) and all related clinical documentation Modify POC to reduce patient s risk of re-hospitalization. Action plan initiated before resumption of home care services o i.e. management of non-compliant patients 16 8

9 SAMPLE PIRT ALERT Typical PIRT Alert sent via communication: o PIRT Alert for SECOND Transfer in episode starting Dehydration, Adult FTT Fall with Left Clavicle FX. Thanks, RISC 17 SAMPLE PIRT ALERT & AVOIDABLE HOSPITALIZATION PIRT Alert for SECOND Transfer in Episode. SOC o N/V D, Hypokalemia o N/V, Metastatic Prostate CA. o Case Conference thoughts: Why so much Nausea, Abd Ct 10 days ago, no Obstruction. Is He currently getting Chemo/Radiation? Reglan will enhance Motility,? Diarrhea. Does he need something else for Nausea,??Zofran. The Morphine IR is for Break through pain, How often does he use this, and should the Fentanyl patch dose be changed? Palliative Care consult? Thanks, RISC 18 9

10 Case Conference Process Created Case Conference Guidelines specific for PIRT Alert & Avoidable re-hospitalization o Objective To manage the needs of high-risk patients as effectively as possible until discharge back into the community o Trigger List High-risk patients (i.e. STAAR, SHP, OASIS M1032) o Format of Case Conference Identify Facilitator (i.e. Clinical or Rehab Manager) Invite appropriate clinicians Face to face or Conference Call (Agency # set up) Attend meeting with documentation needed (i.e. laptops) 19 Case Conference AGENDA REVIEW & DISCUSS: Plan of Care Medication List Treatments Clinical Notes Visit notes prior to transfer Transfer note Visit Frequency Scheduling & Continuity of caregivers Support services 20 10

11 Expected Outcomes Modify Plan of Care as needed Review FALL RISK TUG > 30 seconds OASIS ADLs difficulty out of chair, commode Benefit from a PT/OT EVAL?? LIFELINE Program Case Conference should occur as soon after Transfer as possible. o Average LOS in hospital = 2.8 days Document Case Conference in the Clinical Notes in Allscripts. 21 STRATEGIES - Resources Patient & Family Guide Tri-Folds CHF COPD Wound Management Catheter Management Bladder Health Dehydration Prevention MI Pneumonia Constipation 22 11

12 STRATEGIES - Programs Programs Advanced Heart Failure Management Advanced COPD Management Wound Care Essentials LIFELINE SBAR Situation Background Assessment Recommendation CALL US FIRST STICKER INITIATIVE 23 Heart Failure & COPD Management Programs Identified at Intake o STAAR on documentation Patient Scheduling o Front-loading (5W1, 3W1, 1-2W7) o Medication Intensive Visit (within 10 days) o Case Manager continuity Program Booklet as Teaching Guide Collect, analyze & report program data to Quality & Safety Council 24 12

13 Wound Management Program Collaborative wound education o Nursing and Therapy PowerPoint presentation Essentials of Wound Management in the HomeCare Setting Booklet o Wound Chart Illustrations for Identification o OASIS Documentation Tip Sheet 1.5 CEUs 25 Strategy - EDUCATION RISC THINK TANK o Specialized education program to introduce RISC initiative to all staff o Provide staff with tools & strategies to reduce avoidable re-hospitalizations o PowerPoint presentation Printed resource Actual Case Conference Examples (3 patients) Informal open discussion to engage staff in sharing of new ideas and/or strategies 26 13

14 Post-Hospital Discharge ALL hospital discharges should be ASKED: Have you made an appointment with your PCP now that you are out of the Hospital? What are YOUR goals now that you are home and out of the hospital? Current data tells us that patients who see their PCP within 7-10 days of hospital D/C have a 30% reduction in under 30-day Rehospitalization Rate ALWAYS ask if MD appointment was made 27 On-Call Strategies Before calling the patient back: oget a quick view picture of the patient oreview: Medication List Note symptom relief meds & high alert meds (i.e. Digoxin, Insulin) Diagnoses Problem List - Read last few Clinical Visit Notes Before sending to ED.Think VISIT or follow-up PHONE call Last straw - ED 28 14

15 Strategies - Resources In-House RESOURCES: Your Peers Clinical Mangers Social Workers Transitions in Care Program Palliative Care Hospice Pain Management 29 PROVEN SUCCESS 30 15

16 AWARD RECOGNITION RISC was awarded the QUALITY PILLAR OF EXCELLENCE in 2012 o Pillar Awards are recognition based on demonstrated commitment to excellence by Achieving a measurable improvement in one or more of the six pillars People, Service, Quality, Growth, Finance, Community o Going above & beyond expectations of all patients, family members, physicians, coworkers and members of the community 31 QUESTIONS? IDEAS? COMMENTS? THANK YOU! 16