CAH CMS definition History Numbers OBJECTIVES 4/3/2013

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1 Crossing Over: A Critical Access Hospital & Academic Medical Center Collaborating in Emergency Education and Care A Critical Access Hospital & an Academic Medical Center? A Journey to Collaboration Leigh Anne Schmidt, MSN, RN & Chris Costello, BS, RN, CEN 4 OBJECTIVES Compare and contrast resources between Critical Access Hospitals and Academic Medical Centers Identify potential opportunities for collaboration and facility enrichment afforded both hospitals during a collaboration List tactics to facilitate RN exchange between hospitals in different states Recall staff exchange highlighting professional growth through learning and teaching opportunities State outcomes garnered during the collaboration between a CAH and a AMC and consider potential opportunities for one s own facility 2 Critical Access Hospital (CAH) 5 A conversation in the bike shop CAH CMS definition History Numbers 3 6 1

2 7 map/maine.shtml 10 CAH Challenges & Benefits Physical isolation Population differences Reliance on outpatient services for revenue Increased overhead Aging facilities Flexibility Community familiarity Flat hierarchy Patient satisfaction Where is Mount Desert Island Hospital? 9 Mount Desert Island Hospital (MDI) Bar Harbor, Mount Desert Island, Maine Population 10,

3 AMC Challenges Academic Medical Center (AMC) Decrease costs Create a community network Quality Metrics Restructure to move quickly in a rapidly changing environment Align research into clinical and business strategies AMC Accredited 119 in United States New Joint Commission International Guideline for Academic Medical Centers effective January 1, 2013 Where is the Hospital of the University of Pennsylvania? Academic Medical Center Provides patients with health care for everyday needs and specialized services for complex diseases Offers regional care Teaches health care professionals for the future for medicine Innovates technology & research that improves lives map/pennsylvania.shtml Pricewaterhouse Cooper The future of academic medical centers: Strategies to avoid a margin meltdown. January 17, 2012 from industries/publications/the future of academic medical centers.jhtml

4 management software blog/wpcontent/uploads/2010/09/greater Philadelphia.jpg 19 Clinical Resources CAHs (n=1268) No. (%) Non CAHs (n=3470) No. (%) Member of hospital system 374 (29.5) 1653 (47.6) Medical intensive care unit 380 (30.0) 2581 (74.4) Cardiac intensive care unit a 120 (11.1) 1301 (44.0) Cardiac catheterization 6 (0.5) 1654 (47.7) PET Scanner a 26 (2.4) 632 (21.4) Surgical capability 1104 (87.1) 3386 (97.6) Nurse to census ratio, median (IQR) 6.9 ( ) 6.4 ( ) County level per 100,000 population, mean (SD) b Total physicians 92.6 (94.6) (210.3) Generalists 50.0 (36.1) 52.2 (29.0) Cardiologists 1.0 (3.3) 7.0 (7.2) Pulmonologists 0.4 (1.4) 3.3 (3.3) Joynt, K., Harris, Y. O., & Jha, A. (2011, July 6). Quality of Care and Patient Outcomes in Critical Access Rural Hospitals. Journal of the American Medical Association, 306(1), MDI vs HUP Resources Emergency Department Hospital of the University of Pennsylvania (HUP) Philadelphia, Pennsylvania Population 1,526, Hospital MDI HUP Hospital type CAH AMC Total number of beds ICU beds ED Beds 6 48 Total # ED Staff Ratio ED staff: ED bed 4.3 staff: 1 bed 6.7 staff:1 bed Mix of disciplines RN, NUA, CNA, PA/NP RN, ED Techs, Residents, PA, NP, MD RN max/min 1 / 2or 3 (seasonal) 19/12 Volume/month , Resource Comparison Comparative Outcomes CMS Quality Indicators HUP MDI National Avg and still dazzling/ 21 Joynt, K., Harris, Y. O., & Jha, A. (2011, July 6). Quality of Care and Patient Outcomes in Critical Access Rural Hospitals. Journal of the American Medical Association, 306(1), ACE inhibitor CAP blood cultures CAP appropriate abx 24 4

5 CAH Outcomes Risk Adjusted 30 Day Mortality Rates Among CAHs and Non CAHs for Common Medical Conditions Model Specifications CAHs AMI CHF Pneumonia Patients % Patients % Patients % Non Non Non CAHs CAHs CAHs CAHs CAHs Raw Mortality Rates How did we get from Bar Harbor to Philadelphia? 600 miles Adjusted for age, sex, race, and medical co morbidities Joynt, K., Harris, Y. O., & Jha, A. (2011, July 6). Quality of Care and Patient Outcomes in Critical Access Rural Hospitals. Journal of the American Medical Association, 306(1), Where does everyone fit? Bringing it back to the bike shop Why collaborate? First Steps Donors Rural/mid level model Emergency & critical care focus Feasibility study

6 Feasibility Study Facilitator Internal vs external Interviews Brainstorming Team visits Brainstorming Paring down plan Planning & Implementation Institutional commitment Philanthropy Case statement Donor presentation Donor commitments Budget Legalities Contracts Memorandum of understanding and unusual bike designs/ 31 Competencies & annual requirements 34 How would your facility benefit from a partnership? Goal Setting Initial Goals Taking the plunge Goals set out by initial collaborators Interdisciplinary case statement Pulled from feasibility interviews Increase patient care, create education and increase outcomes

7 Nurse Leaders Role In Goal Setting Translation of overarching goals to SMART goals Lead in implementation of projects Staff development for better patient outcomes Involved front line staff in planning Applying Evidence Based Practice Therapeutic hypothermia Treatment of acute hypothermia Rapid long board removal Ultrasound guided d IV Sepsis management Cooling/warming device Cardiac evaluation & treatment Airway management Mutual Goals Increase clinical outcomes Apply evidence based practice Provide professional continuing education & growth opportunities Develop critical thinking skills of the clinician in an environment outside of norm 38 Professional Continuing Education & Growth Opportunities Interdisciplinary training sessions Presenters Attendees Staff exchange Clinical & didactic Major presentations Exchange site in services Post exchange education & experience sharing 41 Increased Clinical Outcomes Clinical outcome measures Managed projects to outcomes within our control Therapeutic Hypothermia Sepsis Airway Develop Critical Thinking Skills Rests on knowing the patient and the situation Influences by context in which situations occur Reflection on practice is critical Blogging/journaling Experience sharing writing

8 Project Roadmap Year One Development Planning Phone conferences What, who, when Communication Inter facility & intra facility MDIstaff education & preparation Roles & responsibilities Application Process Credentialing Preparation Goals large.jpg 46 Actual Roadmap Roadmap = Budget Overall Budget $2,000,000/3 Years Staff Exchange HUP MDI $56,000/week Staff Exchange MDI HUP $90,000 / 3 years Educational Days $61,000/Year Backfill $45,000/Year PA vs Board certified physician $50/hr vs $150+/hr Electronic ICU/ telemedicine $500, Leadership Development NOVICE ADVANCED BEGINNER COMPETENT PROFICIENT EXPERT YEAR 1 BEGINNING YEAR 1 END 47 Year One Two 2 week Emergency Department education sessions (staff exchange) Two educational course presentations by Penn Medicine faculty & staff at MDI Hospital Educational/research funds for two Penn Medicine faculty Training at Penn Medicine for MDI Hospital clinical staff Coverage for MDI Hospital clinical staff while at training Consulting services Administrative overhead 45 Year One Two 2 week Emergency Department education sessions (staff exchange) HUP team working at MDI 48 8

9 RN Staff Exchange My trip to MDI was amazing. To work with such a talented, diverse team, with challenging gresources was a great experience. It makes me realize what you have. Robin W Year One Two educational course presentations by Penn Medicine faculty and staff at MDI Hospital Therapeutic hypothermia Rapid sequence intubation Year One Training at Penn Medicine for MDI Hospital clinical staff Staff exchange staff choice MDI RN at HUP responsibilities MDI RN staff exchange feedback Year One Miscellaneous Educational/research funds for two Penn Medicine faculty Coverage for MDI Hospital clinical i l staff tff while at training Administrative overhead content/uploads/2012/06/basil Pimp your bike.jpeg Vicky Year One Progress Need for more academic specialties Educational session results Interdisciplinary MDI staff survey 96.4% 64.9% Do you feel the collaborative has helped patient care & outcomes? Have you utilized previous learning from the collaboration into practice? 4.6% 0.7% 1.4% 30.5% 1.4% 0.0% 51 yes/ planning to no n/a I don't know 54 9

10 Year Two Year Two Educational/research funds for two Penn Medicine faculty Telemedicine pilot study for cardiac arrest and severe sepsis Safe Prescription Drug Prescribing and Enhanced use of the Maine Prescription Drug Monitoring Program Year Two Four 2 week Emergency Department education sessions (staff exchange) Two educational course presentations by Penn Medicine faculty & staff at MDI Hospital Educational/research funds for two Penn Medicine faculty Training at Penn Medicine for MDI Hospital clinical staff Coverage for MDI Hospital clinical staff while at training Consulting services Administrative overhead Introduction of behavioral health 56 Leadership Development NOVICE ADVANCED BEGINNER COMPETENT PROFICIENT EXPERT YEAR 2 BEGINNING YEAR 2 END 59 Year Two Two, 2 day educational course presentations by Penn Medicine faculty and staff at MDI Hospital Sepsis Pediatric respiratory emergencies & airway management 57 Year Three Six 2 week Emergency Department education sessions (staff exchange) Two 2 day educational course presentations by Penn Medicine faculty & staff at MDI Hospital Educational/research funds for two Penn Medicine faculty Training at Penn Medicine for MDI Hospital clinical staff Coverage for MDI Hospital clinical staff while at training Consulting services Administrative overhead Behavioral health 60 10

11 CAH Takeaways Equipment Rapid sequence intubation protocols Research grants Sepsis protocol Asthma protocol Alternative perspectives Critical care skills Confidence Change agent Teamwork AMC Takeaways CAH Takeaways Don t light a fire under someone's feet, light the fire within Jeanne Venella DNP, MS, RN, CEN, CPEN AMC Takeaways Overall Lessons Learned Validation of practices Shared patient care Just in time culture Relationship building Teamwork

12 How could you develop a collaboration at your hospital? 67 Questions? miles has never felt so close Thank you! 69 12