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Optimizing Transitions of Care: Redesigning Nursing Roles to
Improve Quality and Reduce CostSuneela Nayak, MS, RN,
Clinical Quality Improvement Specialist, Center for Quality and Safety
David Bachman, MD Senior Medical Director, Clinical Integration
Learning Points
• Preventable Readmissions in the context of Transitions of Care
• Why now? Where to Start?
• MaineHealth Transitions of Care Program
• Leading with Innovation: Redesigning Roles, Competencies
Case Study : Mr. S
• 76 year old male, living independently, limited social supports
• Past Medical History– Congestive heart failure– 6 routine medications including Coumadin
• Admitted for evaluation of syncopal episode
Mr. S: Hospital Course
• Cardiac monitoring and diagnostic testing• Developed urinary retention
– Urology consultation– Urologic procedure performed
• Discharged on Coumadin, new antibiotic, with urinary catheter
Mr. S: One week later
• Developed hematuria, urinary retention• ED Visit
– Dramatic hematuria with catheter obstruction– INR 9.6 (ideal range 2 –3)– More urological intervention
• Readmitted– Reversal of anticoagulation
• Transfused 6 units of blood
Questions to Consider
• Was this readmission predictable?
• Was this readmission preventable?
• What went wrong with the transitions of care?
• How can we do better?
Why now?
2007 MedPac Report
• Medicare Payment Advisory Committee• Readmissions
– “sometimes indicators of poor care or missed opportunities to better coordinate care”
– 17.6% of Medicare patients readmitted within 30 days– $15 billion in annual spending– 76% of readmissions potentially avoidable
• Recommended public reporting, payment reform
Jencks S et al. N Engl J Med 2009;360:1418-1428
Rates of Rehospitalization within 30 Days after Hospital Discharge
Health Care Reform: Hospitals
• Reduce reimbursement for hospitals with high risk-adjusted rates of readmission by 1% a year beginning in 2012 (up to 5% total)– 2012 : CHF, pneumonia, AMI– 2013: Add COPD, CABG, PTCA, Other vascular
procedures, potentially global readmission rate
• Reduce reimbursement to SNF, Home Health when patient under their care readmitted
Health Care Reform: Physicians
• Create new payment code for patient visit within one week of discharge
• Apply payment reductions for physicians who treat a patient during an admission that results in a readmission
Payment Reform: MaineCare
• Reimburse for only one hospitalization when MaineCare patient readmitted to same hospital within 72 hours for the same diagnosis.
Why Now?
• Frequent & costly
• Issue of quality of care and patient safety
• Source of patient & provider dissatisfaction
• Waste increasingly scarce clinical resources such as nursing care
• Integral to movement towards Accountable Care Organizations
Where to start?
Lots of Data and Toolsat your fingertips
MaineHealth: Efforts to Date
Transitions of Care Pilots
• Supported by funding from the Cardinal Health Foundation
• Three pilot sites selected from MaineHealth hospitals
Transitions of Care Pilots Key Outcomes
MaineHealth Transition of Care Bundle
Implications for Role Redesign
MaineHealth Transitions of Care Bundle
1. Risk stratification for readmission
2. Transition Checklist
3. Medication reconciliation
4. Patient/family health education
5. Timely communication among hospital and post-hospital providers
6.Timely follow-up of patients
Leading with Innovation:
What are implications for
Redesigning
Nursing Roles and Competencies?
National Summit of Advancing Health Through Nursing..
Key Messages from Institute of Medicine and the Robert Wood Johnson Foundation
Nurses should practice to the full extent of their education and training.
Nurses should be full partners with physicians and other professionals in redesigning health care
Washington DC, October 2010
Focus on Reduced Readmissions
Findings from MaineHealth Pilots:
1. Advocacy for patient’s agenda for care
2. Focus on safety, improved outcomes
3. Fully engage clinical skills, scope of practice
4. Develop ability to network across continuum
…Offers Abundant Opportunities for Clinicians, Educators, & Leaders to Redesign Roles and Competencies
Roles and CompetenciesKey Roles Clinicians Educators Leaders
1. Advocacy for patient’s agenda for care
2. Focus on safety, improved outcomes
Skilled Patient Centered Care Practices
Skilled Hand-Off
Communication all levels of care
Instill: Patient/ Family
as central members of the care team
Comfort with transparent Communication
Innovate for improved outcomes and reduced costs
Sustain an environment of knowledge sharing(translate knowledge from individual to system)
Roles and CompetenciesKey Roles Clinicians Educators Leaders 3. Fully
engage clinical skills, scope of practice
Assessment skills & related actions
Develop comfort with “Teach back”
Knowledge access : -continuum networks -electronic media
Quality through measured outcomes
Assessment & related actions
Focus on what is learned; skilled use of “teach back”
Refine networking skills
Operationalize roles to optimize practice and scope
Sustain the gain through visible and engaged continuum leadership.
Facilitate knowledge exchange across continuum
•Facilitate knowledge exchange between providers (Teach back)•Sustain the gain through visible engaged leadership.
Roles and CompetenciesKey Roles Clinicians Educators Leaders
4. Develop ability to network across continuum
Establish networks with -continuum
-payers -patient groups Develop
transition plans that ensure right care, at the right level.
“Admit to home”
Instill Continuum
Navigation skills
Optimal use of EMR to enhance hand-offs
Shape pressing agenda of reimbursement reform
-Lead early ACO work
-Build and sustain networks to reduce downstream spending
Mr. S, revisited
Admitted for syncopal episode
Hospital Course:- Cardiac evaluation
- urologic procedure - Discharged on Coumadin, new antibiotic, with catheter
One week later: - ED Visit - Dramatic hematuria, obstruction
- INR = 9.6 - Readmitted
- Reversal of anticoagulation - 6 units of blood transfused
Mr S: Risk for Readmission (8P‘s)
• Prior hospitalization: in last 6 monthsProblem medications: anticoagulantsPolypharmacy: > 5 routine medications Principal diagnosis: heart failure• Psychological: PHQ2 screen• Poor health literacy: unable to Teach BackPatient support: lives alone• Palliative care: advanced illness
Case Study: The New Post Hospital Scenario
• Home support services– Monitoring of
anticoagulant status
• Follow-up phone call
• Office visit within 5 to 7 days
* No ED visit
* No readmission
* Decreased morbidity
* Decreased cost
* Increased patient satisfaction
Summary
Focus on Reduced Readmissions offers Abundant Opportunities for Nurse Educators, Clinicians and Leaders
Innovative redesign of roles, competencies to- Improve clinical outcomes, quality,
satisfaction- reduce cost
Questions?
Thank-you!