M7: Improving Transitions and Reducing Avoidable

11/16/2011
M7: Improving Transitions and
Reducing Avoidable
Rehospitalizations
Peg M. Bradke, RN, MA
St. Luke’s Hospital, Cedar Rapids, Iowa
This presenter has nothing to disclose.
St. Luke’s Hospital
Member, Iowa Health System
• Private hospital – Cedar Rapids, Iowa
• Affiliate in the Iowa Health System
• Licensed for 500 Beds with more
than 17,000 admissions
• Thomson-Reuters Top 100 Heart
Hospital – 3 years
• Iowa Recognition for Performance
Excellence Gold Award - 2010
• Magnet Designation - 2009
• The Joint Commission DiseaseSpecific Certification for Heart
Failure since 2008; Stroke since
2006; Chest Pain Accreditation 2010
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Why is Reducing Avoidable Rehospitalizations
Strategic for St. Luke’s Hospital?
• It is part of our mission: “To give the care we
would like our loved ones to receive.”
• It represents goals that are aligned with health
care reform: providing better value for
decreased costs.
Heart Failure Team
• Formed in 2001
• In February 2006, St. Luke’s joined the RWJF/IHI TCAB
Collaborative with a focus on improving discharge
processes and reducing avoidable rehospitalizations
• Initial focus was on the heart failure population with
the goal of creating an “ideal” transition to home”
• In 2010, changed focus to all Core Measure patients to
develop reliable processes to ensure smooth transitions
and compliance with CMS Core Measures
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Heart Failure Team Members
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Peg Bradke, Chair, Heart Care Svcs.
Robinn Bardell, PI
Ann Beem, PCC-3C
Alexis Benion, Living Center West
Christy Charkowski, STL Hospitalists
Krissy Elder, PCC-5C
Karen Forster, Pharm
Terri Grantham, Card Outcomes
Renee Grummer-Miller, OP Pal. Care
Barb Haeder, Card Outcomes
Sue Halter, Card Outcomes
Lesley Haro, Ortho
Sherrie Justice, Dir-PI
Carmen Kinrade, Dir-Med/Surg
Shirley McCloy, Resp Ther
Sandi McIntosh, Dir-ED
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Signe Munson, VNA
Jennifer Owens, Med Soc Svcs
Julie Peterson, Mgr-Card Rehab
Diane Pfeiler, Mgr-5E
Kelly Pottebaum, PCC-5E
Nikki Robson, Pal Care
Amy Schweer, CLC - #944
Aimee Traugh, Mgr-3C
Jean Vorwald, VNA
Jean Westerbeck, Living Center West
Pam Williams, JRMC Resp Care
Sharon Zimmerman, Resp Care
• AD HOC:
• Doralyn Benson, Mgr-Med Soc Svcs
• Dena Fisher, STL Hospitalists
Cross-Continuum Team
• Meets every other week
• Reviews readmission to assess causes and
opportunities for improvement
• Reviews process and outcome measures
• Continually makes improvements, aggregating
the experiences of patients, families and
caregivers.
• Provides oversight for CMS Core Measures
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Heart Failure Continuum of Care
• Standardized care through order sets
• Patients identified via BNP daily reports
• Teaching
Utilizing Universal Health Literacy Concepts
Enhanced teaching materials
Teach Back
• Touch points
Home Care - care coordination visit 24 to 48 hours post
discharge
Hospital Based Heart Failure Clinic visit in 3-5 days with
subsequent visits established with clinic and PCP based on
needs of each individual
Follow-up phone call on post discharge at 5-9 days
Outpatient Heart Failure class
Enhanced Admission Assessment
• During Admission Assessment, the patient and family
are asked, “Who would you like to have present when
we provide your discharge information?”
• Information added to the whiteboard.
• RN and physician do medication reconciliation. At
times, the pharmacy or physician offices need to be
called to get additional information. If the patient is a
home care patient, the home care agency is called to get
the current list of medications.
• Automatic referral to Respiratory Care for all new
inhaler orders for inhaler education.
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Enhanced Admission Assessment (2)
• Referral to Palliative Care for patient with advanced
stages of disease - The referrals have increased from less
than 5% to over 20%.
• Bedside report to involve the patient and family
caregivers as partners in their care. Daily discharge
huddle is facilitated daily with the RN caring for the
patient, the charge nurse, and unit-based case manager.
• Daily goals are reviewed and written on the whiteboards
in each room, providing the opportunity to review the
plan for the day, anticipate discharge needs, and
determine what it will take to get the patient home
safely.
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Whiteboard Update
New Section: Goal to Go Home
• Current State: We have the “anticipated d/c date” in the upper left box.
This is an area that has not been filled out for a variety of reasons. Often,
there was a discrepancy in the date among the HCT or uneasiness in
putting an exact date in for fear the date would change and patient and
family would lose some trust.
• Test of Change: 3C and 5E trialed a new entry on the whiteboard. A
small additional magnet has been added to address “Goal to Go Home”. It
is put in the Plan and Goal for the Day box.
• Feedback from the staff was positive. They found this provided a more
tangible step that the patient and family must achieve to be sent home.
It can aid in engaging the patient and family more in working towards
the time to discharge which is part of our CARE MODEL. We hear over
and over again how much our patients/ families and the healthcare team
rely on the whiteboards for information. This new way to address goals
towards discharge seems to meet our patient/family needs better.
Whiteboard Update (2)
New Section: Goal to Go Home
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Outcome: We will now be adding this item to all the standard
whiteboards. The Daily Goals will continue to be changed daily. The
Goal to Go Home for the most part will probably not change. Below is an
example for a Heart Failure patient.
Plan/Goal for the Day
• Walk to Nurse’s Station and back 2
times today
• Eat all meals out of bed.
Goal to Go Home
• Learn Heart Failure diet plan to go
home
• Weigh self and monitor changes in
weight
• Identify Warning Signs and
Symptoms to report to doctor
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Enhanced Teaching and Learning
• The patient education materials facilitate the use of teach-back, and
the same materials are used across the continuum: in the hospital,
with home care, long-term care settings and the clinic.
• Teach-back - the process of asking patients to recall and restate in
their own words what they have been taught - was incorporated at
the patient’s bedside during the 24-48 hour post-discharge followup visit by Home Health and in the seventh day post-discharge
phone call to the patient.
• Short, succinct material developed for each Core Measure DRG
• Teach-back question part of packet for staff and patient reference
• Patients and families are given a 12-month calendar for Heart
Failure
• Patient teaching flowsheets are set up to address teach-back and
assure the documentation and utilization of the technique.
Lung Packet Contents
Cover page
Inside
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Heart Failure Magnet
Heart Failure Zones
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Teach-back with Discharge
Instructions
• Can you show me on these instructions:
How you find your doctors’ office appointment?
What other tests you have scheduled and when?
• Is there anything on these instructions that could be
difficult for you to do?
• Have we missed anything?
Successful Teach-back Rate
Aug 06 – Aug11
VNA teachback initiated
Follow-up
phone calls
initiated
Nurse competency evaluations
in health literacy started
Updated 9/26/11
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Post-Acute Care Follow-Up
• Home Care Visit set up for 3-5 days. Home Care liaison in-house.
• At 5-10 days, a hospital nurse conducts a follow-up phone call. During this
call, the RN uses the same teachback questions used in the hospital to
determine the patient and/or caregiver understanding of the critical self-care
instructions.
• HF patients called through Clinic, Hospitalist program calls their patients
after discharge.
• Partnership with physicians’ offices resulted in redesign of scheduling HF
visits to allow office visits within 3 to 5 days for all patients with HF in HF
Clinic. Subsequent appointments established with Clinic, PCP or specialist
based on patient’s assessment and need.
• The Cross Continuum Team continually makes improvements by aggregating
the experiences of the patients, families and caregivers. Readmissions are
monitored, and failures are reviewed by the Cross Continuum Team to assess
opportunities for improvement.
Attending MD during Hospitalization
(11/07 – 10/11)
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Discharge Status (11/07 – 10/11)
Real-time Handover Communications
• Medication Reconciliation is a joint physician and nurse accountability.
The physician is provided a report at discharge to reconcile home
medication list with those in hospital. The nurse puts the reconciled list in
the patient’s discharge instructions. All patients going home are offered a
care coordination visit with Home Care in the first 24-48 hours after
discharge. The home care does a certified content visit including
medication reconciliation.
• St. Luke’s partnered with the hospital’s home care agency (VNA) and two
long-term care facilities to standardize and enhance the quality of the
handoff communication process. Standardized form. Warm handover
with those patients with complex issues.
• Provided education for home care and long-term and skilled care RNs and
CNAs on HF and continuity process. CNAs often observe symptoms.
• Provided the receiving nursing home facilities with the patient education
packet.
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Number of Days after Discharge Patients are
Readmitted
25
# of patients readmitted
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
# of days between discharge and readmission
Three to Five-Day Follow-up
(Nov 07 – Aug 11)
Updated 9/26/11
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Heart Failure Readmissions (for Any Cause) within 30 Days
35%
30%
Percent
25%
20%
15%
10%
5%
0%
2006
2007
2008
%HF to Any Reason
2009
2010
2011 YTD
Median
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Heart Failure Readmissions (for Any Cause) within 30 Days
45%
40%
Percent
35%
30%
25%
20%
15%
10%
5%
%HF to Any Reason
2011 Q2
2011 Q1
2010 Q4
2010 Q3
2010 Q2
2010 Q1
2009 Q4
2009 Q3
2009 Q2
2009 Q1
2008 Q4
2008 Q3
2008 Q2
2008 Q1
2007 Q4
2007 Q3
2007 Q2
2007 Q1
2006 Q4
2006 Q3
2006 Q2
0%
Median
HCAHPS RESULTS
DISCHARGE INFORMATION (% Yes)
90
88
86
84
82
80
78
76
74
89
89
88
87
85
83
82
80
Dec-07
82
82
82
80
Apr-08
2009
St. Luke's
Jun-10
Sep-10
Dec-10
National
#19 During hospital stay, did doctors, nurses or other hospital staff
talk about whether you would have the help you needed when you
left the hospital?
#20 During the hospital stay, did you get the information in writing
about what symptoms or health problems to look out for after you
left the hospital?
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Leadership Activities and Learning
• Executive Leader facilitates reports to Senior Leaders
and Board
• Day-to-Day Leader manages bi-weekly Transition to
Home meetings and assures ongoing testing and
implementation of changes and monitors results
Barriers and Breakthroughs
• Limitations of the electronic medical record to
capture and transmit information.
• Access to physician offices for follow-up visits.
• Complexity of patients with multiple comorbidities.
• Challenges to completing reliable medication
reconciliation.
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Lessons Learned
• Importance of engaged executive leaders
• Explicit focus on patient and family-centered work
• Front-line clinicians and staff involvement in developing
process improvements
• Physician engagement
• Cross Continuum Team – power of relationship building and
collaboration
• Importance of understanding patients’ home environment
• Impact of Information Technology
• Stories are as important as the data
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