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1 RT AS PROJECT MANAGER: IMPROVING CARE TRANSITIONS DECREASES UNPLANNED READMISSIONS TAMMY JARNAGIN, BHS, RRT DIRECTOR CARDIOPULMONARY SERVICES, NEURODIAGNOSTICS, HOME MEDICAL EQUIPMENT

2 Objectives Recognize leadership opportunities for a Respiratory Therapist Key process improvement techniques to include during project management. Share our journey and how we incorporated evidence-based, best practice components into the MGMC transition care program Importance of Networking (don t reinvent)

3 Project Management

4 MGMC s Improvement Model FOCUS PDCA Find a Process to Improve Organize a Team that Knows the Process Clarify Current Knowledge of the Process Understand Causes of Process Variation Select the Process Improvement Act To Hold Gain To Continue Improvement Plan Process Improvement Check Data from Improvement Do Implement Plan Data Collection

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8 Value Based Purchasing

9 Additional Incentives Improve HCAHPS Care Transitions Questions During this hospital say, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications Improve HCAHPS Discharge Information Questions During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

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11 COPD Readmissions 700,000 hospitalizations in US with principal dx of COPD Only 50% received guideline treatment. How to use their medications ie inhaler, oxygen Arrange a post discharge appointment for follow-up Including Pulmonary Rehab and Smoking Cessation 1 in 5 (23%) readmitted within 30 days Contributing access, quality, coordination of care post-discharge, socioeconomic Half of the estimated $50 billion in health care expenditures for COPD attributed to costs associated with hospitalizations for COPD exacerbations. We can do better!!! Journal of the COPD Foundation. October, National COPD Readmission Summit 2013:

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13 Evidence-based Resources COPD Foundation VA research and articles Dr. Eric Coleman, Div. of Healthcare Policy & Research, Univ. of Colorado, Director of Care Transitions Evidence-Based Programs Society of Hospital Medicine s (SHM) Program BOOST Better Outcomes through Optimizing Safe Transitions RED Project Re-engineering Discharge Care Transitions Intervention Transitional Care Model

14 Development of Transition Care Program at MGMC Purpose: Reduce avoidable readmissions by improving transitions in care (care coordination) Targeted Patient Populations: Pilot (test of change): Chronic Obstructive Pulmonary Disease (COPD) Integration: Heart Failure (CHF) Acute Myocardial Infarction (AMI) Pneumonia

15 Key Components of Transition Care Program Patient Identification --- Transition Care Patient Daily Multidisciplinary Discharge Planning Meetings Bedside Multidisciplinary Team includes family Standardized Educational Materials & Self Management Plan Follow-Up with Physician Within 3 5 Days of Discharge Free Transition Homecare Visit : Hours of Discharge Follow-Up Phone Calls by First Nurse Referrals to Continuum of Care Programs Pulmonary Rehab, Cardiac Rehab, etc Palliative Care Program

16 COPD checklist COPD Transition Care Checklist: Patient Education Completed (RN & IDT) Video: Channel 4 COPD: Take Control (RN) Booklet Living Life to the Fullest with COPD (RN & IDT) Stoplight Self-Management Plan (RN & IDT) Transition Care program (RN give letter to patient/family & review) All educational materials in Discharge Folder (RN) Discharge Instruction including medication reconciliation (RN) Schedule physician follow-up appointment scheduled within 3-5 days of discharge - Appointment made by patient s nurse (M-F 8-5pm). For discharges on weekends, patient directed to make PCP appointment in 3-5 days. HOMEWARD will validate or arrange appointment during visit and validate transportation arrangements. Call HOMEWARD for Free Transition Care Home visit (RN) HOMEWARD referral line Transition Homecare Coordinator will visit patient while they are in the hospital - (HOMEWARD Transition Coordinator)

17 COPD Self-Management Home Plan Symptoms or health problems to look out for after you leave the hospital HOME-MANAGEMENT PLAN FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Green Zone = All Clear Your Normal Weight I am breathing normally for me I can do my usual activities My mucus (phlegm) is usual color and amount I do not have a fever or chills I can think clearly Yellow Zone = Caution If you have any of the following signs or symptoms: I am having increased shortness of breath or wheezing My cough is worse or mucus (phlegm) increases or changes in color I am tired and can t do regular activities I have a fever or chills I have diarrhea or rash I am not thinking clearly RED ZONE= Medical Alert I have more trouble breathing I have more trouble coughing up mucus (phlegm) I can t do my usual activities I am sleepy, difficult to wake up, or confused I have slurred speech or feel faint Change in the color of my skin,my nail beds or lips are gray or blue Green Zone Means: Taking your medications Continue daily activities and regular exercise Wash hands often, avoid people with a cold Stop smoking, avoid second-hand smoke Eat healthy foods and drink clear fluids Keep doctor appointments Yellow Zone Means Limit activities, get plenty of rest Continue with all prescribed medications, including breathing treatments (if ordered) Call your primary doctor or First Nurse First Nurse: Ames: Marshalltown: Anywhere in Iowa: Primary Doctor/Number: Red Zone Means: Call 911 or go to the emergency room. These changes indicate that you need to be evaluated by a doctor right away.

18 Date Daily Symptom Tracker COPD Symptom Tracker Breathing My Normal More short of breath In trouble My Normal Mucus Phlegm More mucus, worse cough Can't coughup mucus Activity My Normal More tired with regular activity Can't do regular activity Temperature Fever Thinking My Normal I have chills or fever I have a Fever ( ) My Normal I'm not thinking clearly I'm confused or hard to wake up I have a Rash Other Action I have diarrhea I have slurred speech I have blue lips, nails I called First Nurse I called my Primary Doctor

19 Key to Decreasing Readmissions Early + Early = Reduction in Detection Intervention Emergent Care

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21 Mary Greeley Transition Care Program

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26 Future Focus / Initiatives Nursing Home Collaboration Patients with 4 key diagnoses going to LTC Facilities LTC RN attend Bedside Care Conferences PCP awareness of skilled services available at LTC Emergency Department Plan Readmission Multi-D Assessment Committee Root-cause analysis of readmissions Individualized care Look for trends modify program, add resources, etc Identification of insufficient resources Chronic Care Clinic (my dream!!)

27 Newer Research Pittsburgh Regional Health Initiative in Pennsylvania Collaboration of medical, business, and civic leaders organized to address health care safety and quality improvements Addresses co- morbidities Multi-D Team: pharmacist for medication reconciliation, motivational interviewing, high-hazard medication focus and phone calls within 72 hours of discharge, and nurse care managers to engage and educate Decreased 180 readmissions (~45% relative reduction )

28 New Research Jesse Brown Veterans affairs Hospital In Chicago, Il Recovering Obstructive Lung Disease (ROLD) post-discharge clinic Multidisciplinary, first visit within 1 week post-discharge, includes a physician, MSS, palliative care specialist, nurse, pharmacist Standardized H & P exam, COPD Assessment Test, Spirometry to classify COPD severity, evaluation of supplemental O2 (sleep, rest, activity), literacy appropriate education, optimization of therapy with medication reconciliation, smoking cessation, referral to Pulmonary Rehab programs, Decreased 30 Day Readmissions from 19% readmission to 14% (26% relative reduction)

29 Telehealth

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32 New Opportunities 3 New Expanding Roles in Healthcare Management: Predictions for 2015 A reflection of the transition to value-based care, new leadership opportunities are emerging These include: Chief Population Health Officer (previously, Chief Medical Officer) Chief Experience Officer Chief Transformation Officer

33 Key Take-Aways Respiratory Therapists can be the key innovators and lead important organizational initiatives It is important to use key Project Management steps when improving processes or developing programs: Plan, Do, and don t forget to Analyze and Evaluate!!!!! Our patients deserve quality care when they are in the hospital, as well as, coordinated care when they transition to their home. Don t reinvent the wheel share within the respiratory community Your opportunities for improving patient care, for improving the success of your organizations, and for professional growth are unlimited!!!!

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5/10/13 HEALTH CARE REFORM LONGITUDINAL CARE COORDINATION HEALTH CARE REFORM WHY = VALUE WHY WHAT HOW WHEN WHO WHY WHAT HOW WHEN WHO

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