A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

NYSPFP Preventable Readmissions Initiative:

Pilot Review and Post Hospital Care

June 17, 2014

NYS PARTNERSHIP FOR PATIENTS

Agenda Topic Speaker

I. Welcome Elaina Heagerty, Project Manager NYSPFP Staff

II. Readmission Pilot Project • Revisiting goals and objectives • Where are we now?

NYSPFP Staff

III. Hospital Experiences • Successes • Challenges • Lessons Learned

St. Barnabas Hospital St. Joseph’s Hospital Health Center

V. Question and Answer Session Maria Stala Sacco, Project Manager NYSPFP Staff

VI. Next Steps • Fall Regional In-person Sessions • Hospital Story Board Preparation

NYSPFP Staff

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Review of Pilot Objectives o Phase 1 – Admission

o Identify patients on admission who are at risk for readmission using an “any risk” approach.

o Assemble a multidisciplinary team to address interventions that will mitigate risks for readmission.

o Phase 2 – Hospital Stay o Prepare patient and caregiver for discharge, beginning at admission. o Conduct ongoing patient reassessment to identify new or changing risk factors. o Ensure systems for multidisciplinary communication, coordination, planning, and

evaluation.

o Phase 3 - Discharge o Ensure patient and family/caregiver are fully prepared for post hospital care. o Provide timely and thorough communication to post hospital providers.

Background

SBH is a not-for-profit, nonsectarian, 435-bed, acute care, 911-receiving hospital that holds state designations as a regional trauma center, stroke center and AIDS center.

The hospital’s emergency department has nearly 100,000 visits annually.

Preventable Readmission Initiative - Phase 1

Risk assessment for hospital readmission – 2 week pilot project

Implementation of a tool to identify potential readmissions

• The modified LACE tool was utilized

Unit identified – 3 North

Team identified – geographic to 3N

Communication between teams during daily multidisciplinary rounds

Team Members

Name Title

Manisha Kulshreshtha Hospitalist Director

Mohammad Azam Hospitalist Attending Physician – 3N

Abdurhman Ahmed Hospitalist Attending Physician – 3N

Ricardo Velasquez Medical Resident – Lead Resident 3N

Naldeen Hector Case Manager – RN – 3N

Sally Lebron Medical Social Worker – 3N

Wanda Kelly Director – Case Management

Grace Ortiz Associate Director–Case Management

Lorraine Barnett Associate Director – Social Work

Marie BonTemps Nurse Manager – 3N

Rachel Sussman Clinical Pharmacist

Rebecca Ditkoff Nutrition

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Referrals/ Interventions Risk Factor Category Referral/ Intervention

Medications Clinical Pharmacist Referral

Psycho-social Barriers/ Clinically Complex Social Work Department Nursing/Clinicians

Financial Barriers Credit Department

Nutritional Limitations Nutrition Department

Limited Patient Understanding/ Health Literacy

Nursing/Clinicians

Mental Health/ Substance Abuse Psychiatry/ Addiction Medicine Referral

Palliative Care Palliative Care Referral

Calculate LACE score for all patients on 3N on admission

Share LACE score with team during WhiteBoard (WB) Multidisciplinary Rounds

High Risk (HR) magnets placed on WB if score greater than 11

Interventions according to issues identified by physicians/ social worker/ case manager/ nutrition/nursing

Appropriate referrals made

Interventions put in place

Checklist completed Patients tracked for readmission 30 days after discharge

Results

Total of 76 patients reviewed over a 2 week period

9 patients were identified as high risk for readmission

67

9

Patients at Risk for Readmission

Low Risk

High Risk

tool for

risk classifica

tion

Length of stay Number of patients

Less 1 day 0

1 day 4

2 days 2

3 days 1

4-6 days 2

7-13 days 0

14 or more days 0

Acute Admission In patient 9

Observation 0

Comorbidity No prior History 0

DM no complications, Cerebrovascular disease, Hx of MI, PVD, PUD 2

Mild liver disease, DM with end organ damage, CHF, COPD, cancer, leukemia, lymphoma, any tumor, cancer, moderate to

severe renal disease 3

Dementia or connective tissue disease 0

Moderate to severe liver disease or HIV infection 7

Metastatic cancer 0

ER visits during previous 6 months 0 0

1 1

2 3

3 1

4 or more 4

Results

Specific Risk Factors

5

1 1 0

2 2

1

3

2

3 3

2

0 0 0 1 1

0 1 1 1

2

1 1

0

1

2

3

4

5

6

Referrals Given

100%

0%

Referrals Given

Yes No

Disciplines Involved

1

1

6

4

2

2

1

1

1

1

0 1 2 3 4 5 6 7

GI

ID

Medicine

Social Worker

PMD

Addiction Medicine

Dietician

Heme/Onc

Palliative care

Surgery

Disciplines Involved

High Risk Patients – ED Visits/ Readmissions in 30 Days

4

1

7

2

0

1

2

3

4

5

6

7

8

Readmitted Against Medical Advice ED visits No ED visits

Follow Up of High Risk Group

0

1

2

3

4

5

6

7

8

Yes No

Clinic Follow Up - High Risk Group (n=9)

Number of Patients

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Yes No

Clinic Follow Up - High Risk Readmitted Group (n=4)

Number of Patients

Next steps - Sustainability

High risk(HR) magnets as part of all whiteboard rounds on all units

LACE tool auto-calculation being incorporated into the EMR

Ongoing communication with Allscripts (EMR) to have the LACE score available on the header of the patient medical record based on the previous visit

Admission/Discharge reconciliation – clinical pharmacist interventions; clinician education

Preventable Readmission Initiative- Phase 3

Identify PCP (on admission) – completed

Identify Pharmacy – eRx, map of local pharmacies – in progress

Contact PCP – Resources: little blue book, community physician list; training and education of clinicians; CCDA

Patient Portal

Pilot on 3N – phone calls post discharge

Identifying PCP on Admission

e-Prescribe

Patient’s preferred pharmacy identified

Interdisciplinary Discharge Summary

Medications electronically prescribed and indicated on the interdisciplinary discharge summary

Map of Local Pharmacies

Map of local pharmacies to be provided to patients

Communication with PCP

Clinician education on communication with PCP ongoing

Dispense history on Allscripts EMR

The Little Blue Book app

Contact numbers of community (out of network) physicians available on all medical units

In-network physicians contacted using secure health messaging in the Allscripts EMR for communication regarding patient follow up care

Patient Post-Discharge Call - Pilot

In progress on 3N - initiated 2 weeks ago

Unit nurse manager responsible for calling all discharged patients within 24-72 hours of discharge

Script and a list of questions provided

Important information regarding gaps in transitions of care being obtained

Algorithm for taking care of issues arising from the follow up phone calls in progress

Meaningful Use 2 (MU2)

Meaningful Use 2 (MU2) incorporates many elements of post discharge care coordination

Patient Portal

E-Prescribe

Patient Education (Info Button)

CCDA – Consolidated Clinical Document Architecture

o Planning Goal, Goal Instructions, Plan of Care Goal types incorporated into the discharge summary

SBH –Care Coordination

Preventable Hospital Readmission Initiative (PHRI) – 11.5% reduction in all cause readmissions in 2013 compared to 2012

Readmission alerts, teach back, transmitting discharge summaries to PCPs, ED case management, interdisciplinary discharge summary, intensive patient education on CHF & glucose monitoring

Readmission Committee; Transitions of Care Committee

Incorporating Meaningful Use 2 (MU2) in the post hospital care coordination process

Summary: What are Readmissions

“Readmissions are not primarily about people being re-hospitalized because of mistakes made in the hospital.”

“Reducing readmissions is about making transitions of care more effectively.”

“When transitions of care are not done well,.. evidence suggests they wind up back in the hospital.”

Prevention of Readmissions

What we were doing…

• Multidisciplinary daily rounds. Physical therapy, case- management, nursing, attending physician, pharmacy and third year resident discuss discharge barriers and patient condition.

• As an organization we recognized that our readmission rates proved an area of opportunity.

How we were doing… All Cause 30-Day Readmissions to Same Facility –Green, Orange & Red Hospitalist Attending at Discharge

Initial Encounters Discharged 1/1/13-3/31/14, Readmissions through 4/30/14 - data shown by initial discharge date

Making the change…

• Agreed to participate in NYSPFP Preventable Readmissions pilot program.

• Developed the initial committee to discuss implementation. Team consists of physicians, nursing, nutrition, pharmacy, physical therapy, performance improvement team member, director of medical surgical nursing, social work, and case management.

Making the change… • It was crucial to have nurse buy-in. Maria Stala Sacco

from NYSPFP initially met with the nursing staff discuss the pilot and to explore the feelings of this group.

• Nurses identified early on that there were key indicators that were present on admission that could impact readmission. Agree that focus would need to be on early intervention

• Utilizing the input from the nursing staff, the committee developed a plan for implementation.

Perceived Barriers

• The nursing staff identified several potential barriers. – Implementation of the new EMR (EPIC) network

wide during the same time frame as the pilot. – Staffing ratios. – Patient acuity. – Nurse work load.

Making the change…Phase 1

• We selected to utilize the NYSPFP Readmission Any Risk Assessment tool at the time of admission to identify potential readmission risks.

• We placed a flowchart and a breakdown of identified risks with possible interventions as a reference for the health care team.

• In addition this guide listed the drivers of specific interventions according to their scope of practice.

Implementation of risk identification tool

• Nursing was initially slow to incorporate the tool into their admission process workflow. They gradually adapted their routine to include the tool just as the EPIC EMR was launched.

• EPIC implementation started, which required all staff to focus on the EMR.

• To keep the pilot going each unit educator took responsibility of the process while nursing focused on EPIC.

• Now that EPIC has been assimilated into the nurse workflow, we are reengaging the nursing staff to utilize the readmission risk tool during the admission process.

Phase I Recap • The initial plan was to have nursing drive the risk tool. There was a

need based on competing priorities to incorporate other resources to support Pilot.

• Prior to the implementation of EPIC the majority of nursing staff identified readmission risks per the admission process these aligned with what we were seeing in early audits; medications and psychosocial barriers.

• Referrals for specialties were made by the nurse at the time of admission and on identification of specific risks.

• Weekends and nights referrals were delayed. • Identified that a risk assessment tool is built in new electronic

medical record system for case management. Plan is to expand the tool, create automatic referrals when physician order is not required and make it risk assessment score available to all disciplines.

Phase II: Teach-Back

• A teaching action plan was developed to implement the Teach-Back method for all disciplines. – Reviewed NYSPFP website and current literature for teach back

information. – A power point was developed for use by all disciplines to educate on

the Teach-Back method. Utilized video’s displaying correct and incorrect forms on teach-back.

– Developed education plans for nursing, pharmacy, residents and Physical Medical rehabilitation.

– Audit teach-back method at the bedside with immediate coaching if needed.

Next Steps

• The committee continues to meet to review the process and to identify areas of opportunity for improvement and sustainability.

• Work with Business Analysis unit to review readmission data and drill down on opportunities.

• Implement a more robust pharmacy consult process. • Implement Phase III- Evaluate and Refine discharge process

including current use of D/C phone-calls. • The committee will develop strategies for hospital wide

implementation.

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Next Steps o June – September, 2014:

o Continue pilot activities and one-on-one work with NYSPFP project manager

o Begin developing your team’s Story Board for the Fall 2014 sessions o NYSPFP to provide template for hospitals to use o Project managers available to assist with Story Board

development

June 16, 2014 4

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NYSPFP Resources and Support o NYSPFP Project Managers

o Address questions from the team and assist with identifying next steps o Participate in team meetings and discussion of outcomes o Clarify the use of tools and resources o Convene regional in-person meetings and/or calls to facilitate sharing of

ideas, practices, challenges, and successes

o NYSPFP Tools and Resources

o NYSPFP Website Preventable Readmission Initiative Page o Pilot Phases 1, 2, and 3 Tracking Tools o Preventable Readmissions Action Planning Resource Guide

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Preventable Readmissions In-Person Sessions – Fall 2014: Upstate sessions: o October 21 –Batavia o October 22 – Syracuse Downstate sessions: o October 29 – New York City o October 30 – Long Island

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