Redesigning Care for the BPCI Initiative

Transcription

1 Redesigning Care for the BPCI Initiative September 26, 2012

2 Before Care Redesign Patient responsible for coordinating: Joint Replacement Class Complete Lengthy Paperwork Pre- op testing Physical Therapy Hospital Discharge Plans Doctor s Appointments Short Term Rehab Facility Homecare Services

3 Decision Making Appointment Pre Care Redesign MD & Pt commit to surgery Patient prompted to begin preparations MD mentions Joint Class Post Care Redesign MD & Pt shared decision making for surgery Patient referred to nurse navigator Prehab appointment scheduled Patient scheduled for joint class Patient/NN begin to explore preferred STR/HC options

4 Surgery and Pretesting Scheduling Pre Care Redesign Each individual MD surgical packet with doctor specific info mailed to patient Content and information varies by surgeon Post Care Redesign Standardized and consistent surgical packet for all MD s mailed to patient Surgery letter provides specifics to patient regarding: Surgery Clearances Joint class appointment Information about nurse navigator assigned specifically to him/her

5 Preadmission Processes Pre Care Redesign Patient completes huge packet of forms for all potential discharge dispositions at PAT appointment Preop visit with surgeon; he asks patient if all plans made Post Care Redesign Nurse navigator contacts patient at least 2 weeks preop In- depth assessment completed with patient and/or family member Patient specific, individualized care plan created for continuum of care Navigator serves as single point of contact for all patient/family needs Care plan transmitted to hospital, short term rehab facility, and/or homecare agency, as needed STR and HC agencies advised of anticipated discharge date Patient participates in prehab program in preparation for surgery and postop PT Postop outpatient physical therapy encouraged as part of education process

6 Surgery Pre Care Redesign Hospital discharge planners review packet of info patient completed in pretesting and visit patient after surgery Hospital discharge planners begin discussion with patient/family regarding discharge disposition/plan Facility or agency notified of patient at time cleared for discharge No opportunity presented for discharge to home with OP Therapy Post Care Redesign Nurse navigator communicates with patient in hospital to assess progress Care plan and intended discharge disposition reinforced with hospital care team, patient, and family Facilitates with hospital team, discharge to intended post acute destination/services or assists to amend plan based on progress in hospital

7 Post Discharge Pre Care Redesign If discharge to STR, facility drives plan of care, scope of services, and LOS 2013 LOS for DRG 469 = 34 days 2013 LOS for DRG 470 = 17.7 days If discharge home with homecare services, agency drives plan of care, scope of services, and length of service 2013 length of services for DRG 469 = 24.9 days 2013 length of services for DRG 470 = 17.7 days Post op visit with patient occurs between 10 and 30 days (surgeon specific); MD learns of patient s progress at that time Homecare agency sends order for care to office for authentication based on their own plan of care STR notifies surgeon office when patient discharged from STR Post Care Redesign Postop visit with patient occurs between 10 and 14 days for all surgeons Nurse navigator maintains contact with patient and any relevant agencies to manage care and apprise surgeon of progress (plan may be changed or expedited based on patient) Maintains communication with patient throughout the 90 day post surgery period of time to deal with issues and prevent readmission

8 Relationships Identify the key partners necessary to assist in pre and post care redesign care coordination processes Hospital Case Mangers Skilled Nursing Facilities Home Care Agencies Outpatient PT Necessary to take ownership of our patient s care pre and post op. Although we had standardized our internal process, we still had to reinforce our plans of care with our community partners. Nurses have worked hard to continually improve the relationships we have with all of our care partners

9 Barriers Facilities continued to want to do things the old way Care plans were changed without notification to Nurse Navigators LOS of stay was dictated by length of time services covered rather than by actual medical necessity Facilities had programs and protocols in place

10 Hospital Case Management Care plans were being changed in the hospital without our knowledge Frequent meetings held with all members of the hospital team that would be part of patient care (including SOS hospital based midlevels) Protocol was developed Nurse Navigators to be notified prior to the change being made Physical therapy to identify barriers to going home SOS PT involved to discuss these issues; serves as expert to liaise with hospital PT SOS Surgeons getting more involved in the D/C process at the hospital level SOS hospital PA s intervening on behalf of and communicating with NN (participation in daily discharge rounds)

11 Positive Engagement from Hospital Identified one central point person to receive patient care plans Created a spreadsheet identifying the BPCI patient, assigned NN, and the intended discharge disposition. Educated clinical staff on the floors to new protocols. Result: Huge impact on patient satisfaction with the hospital as well as the care coordination program. Patients now view us as a team working together on their behalf.

12 Skilled Nursing Facilities Care plans were not being acknowledged as guide for DC planning Identified 4 preferred providers; all with 3+ star ratings with CMS Elderwood Syracuse Home Iroquois Finger Lakes Center for Living Improved our communication processes Created a questionnaire that gave the facility an opportunity to collect the information we needed from them.

13 Positive Engagement from SNF Identified one central person to receive care plans Social worker and director of PT use our LOS stay target as the goal for discharge Do not change discharge date without discussion with NN and input from SOS PT Transitioned from facility goal oriented care planning to following the milestones for care as a guide HC, as a bridge level of care, was eliminated as part of the discharge plan unless medically necessary and appropriate Patient engagement and awareness of the LOS goal and positive messaging that everyone was collaborating to get them home safely as soon as possible were key strategies contributing to success

14 Home Care Agency LOS was being determined by insurance coverage not by necessity Identified 2 home care agencies that were willing to adhere to our care plans St. Joseph s Hospital Home Care HCR Developed protocol that the NN would be the point of contact Advised that they could not go directly to the PCP and circumvent Ortho doctor for orders LOS was shortened to 5-7 visits if they did not have a SNF stay; if transitioned from SNF 2-3 visits.

15 Positive Engagement from the HC Agency Identified one contact person for referrals and issues Used SOS care plan as the guide for number of visits Communicated barriers to discharge with NN Did not provide any unnecessary services, ie: nursing, home health aid

16 Outcomes Each facility/agency wanted to ensure that they were getting our referrals LOS for SNF has dropped Number of HC visits shortened Patients more satisfied with their care. Readmissions decreased because of improved relationships and communication Continues to be further opportunity to reduce readmissions from STR to Hospital Total Joint doctor and Nurse Manager providing on- site education relative to patient assessment prior to transfer to hospital

17 DRG 469/470 Hip/Knee Replacement Baseline st 6 Months of TJR Patients % Ave LOS IP Rehab 0.30% Ave LOS % Ave LOS STR 46.10% Ave LOS % Ave LOS Homecare 49% Ave LOS Readmit Rate 3.70% (full 90 days not yet released) 9.40%

18 What we ve learned Increased physician involvement has resulted in greater accountability and a more positive patient experience Direct contact with community partners provides ease of access for patients to the highest quality programs

19 What we ve learned Monitoring progress of patients Keeps patients on track Motivates patients Assists post- acute partners to adhere to the intended plan of care. Increases patient satisfaction Standardized care processes- The Joint Council The foundation for successful redesign

20 Other Outcomes BPCI Hospital Gainsharing 2 hospitals engaged Implant negotiating = SOS led and driven Identifying numerous opportunities Feeling of SOS Leading in Bundle Discussions with Hospital Partners SOS discussing merging with Other Groups BPCI opportunity is discussed Presented to hospitals as positive