Eddy VNA Care Transitions Program

Transcription

1 Eddy VNA Care Transitions Program Patrick Archambeault RN, MS, CRNI Director of Clinical Specialties

2 About Eddy VNA Large not for profit home care agency based in upstate New York CHHA, LTHHCP, Licensed Agency DME Company and Home Infusion Pharmacy Serves a 6 County area (Albany, Renssealer, Saratoga, Schenectady, Columbia and Greene Counties) Has an average daily census of approx patients

3 Capital Region Partners in Care Transitions Eddy Visiting Nurse Association CBO St. Peters Hospital Albany Memorial Hospital Seton/St. Mary s Hospital Samaritan Hospital Columbia Memorial Hospital Office of the Aging A+ Meditrans

4 Coach Team Bob Baldwin Program Assistant Suzanne Defruscio Samaritan Hospital Hospital lead Val McMahon Barbara Cupp Albany Memorial Hospital Hospital lead Karen Julian Amy Potter Seton/St. Mary s Hospital Hospital lead Val McMahon Dot Millar-Cole St. Peter s Hospital Hospital lead Nora Baratto Eileen Beare Columbia Memorial Hospital Hospital lead Barb Brady and Bev Turner

5 Based on Dr. Coleman s Model Transition of patients from hospital to home can be dangerous The hospital is not the best environment for the patient to learn It is important to involve caregivers in the discharge plan Patients should be discharged with clear discharge instructions

6 Operations Coaches are in the hospitals in the morning and home visits in the afternoon Daily census report and Mercury MD report Work with Case Management dept. to identify patients at high risk for re-admission Meet with patient and care givers to introduce the program and get patient s consent

7 Key Hospital Data Patient Diagnosis: HF, AMI, Pneumonia, COPD and Diabetes (CMS covered dx) Seen by coach in hospital within 24 hours prior to hospital discharge Seen by Coach at home within 3 days of hospital discharge Follow up phone call within 1 week of hospital discharge.

8 Home Visit 1. Completion of a Personal Health Record 2. Medication Reconciliation 3. Ensure f/u PCP or specialist appointment within 7 days of discharge 4. Provide self management support tools: Zone sheets Scale Incentive Spirometer Education material Medication boxes

9 Zone Sheet

10 30-Day Intervention Patient is followed for a total of 30 days Phone calls are made once weekly Pillars of the program are reviewed Med review Teach back r/t identification of s/sx Feedback from MD f/u appt. Q&A

11 Miscellaneous 1. Patients can receive Coach services once every 180 days and must be admitted to the hospital (not observation) 2. If outside the covered dx, we will bill under Eddy Foundation Grant 3. Contracts with 2 major payers

12 25% refusal rate Patient Refusals Patients worried about co-pays Worried about the condition of their home Worried we have an ulterior motive Patients feel they do not need the help

13 What we ve learned This will not work for every patient Need PCP support and hospitalists as well as support from senior management Some patients require more intense Coaching based on literacy and cognitive issues Medication reconciliation is a major issue Need to follow patients to SNFs

14 Home Environment Care givers are not as available as we thought Patients cannot afford medication Patients do not realize they have a chronic condition Medications in several locations Patients typically eat foods high in sodium and do not pay attention to food labels Sometimes it s the caregiver that is calling 911

15 Tracking Outcomes Data tracking spreadsheet Creates monthly reports shared with hospital leads Rehospitalized patient review with hospital lead and others

16 Patient Outcomes 11% readmission rate (prior year rates for these diagnoses range from 20-25%) Over half of the patients served had medication reconciliation issues. 781 med discrepancies in 9 months (3.51/pt) Follow up appointments are at 7 days accomplished through persistence. Now have a process to speak to hospital lead directly with any issues r/t patients discharge.

17 Rehospitalizations Some avoidable: Patient did not refer to Zone sheet Patient did not call their physician or Coach prior to going to ER Patient called Physician s office and was told to go to the ER Patients with respiratory related diagnosis often go to ER with Anxiety related issues

18 Closing Well received by our patients, physician groups and hospitals Gets to those patients who would have otherwise fallen through the cracks Most patients DO NOT know how to correctly take their meds. This program does make a difference!

19 Contact Information Patrick Archambeault RN, MS, CRNI 433 River Street Troy, NY