Senior Centered CareSenior Centered CareProgramming for Older AdultsProgramming for Older Adults

ExcellusAugust 13, 2009

Adult Volume (Seniors = 65+)Adult Volume (Seniors = 65+)

540520

505

580.3

254

304

354

404

454

504

554

604

654

704

Jan-

06Fe

b-06

Mar

-06

Apr

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May

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Jun-

06Ju

l-06

Aug

-06

Sep

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Oct

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Nov

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Dec

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Jan-

07Fe

b-07

Mar

-07

Apr

-07

May

-07

Jun-

07Ju

l-07

Aug

-07

Sep

-07

Oct

-07

Nov

-07

Dec

-07

Jan-

08Fe

b-08

Mar

-08

Apr

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May

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l-08

Aug

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Sep

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09Fe

b-09

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09

Seni

or V

olum

e 65

+

Senior Volume 65+ UCL +2 Sigma +1 SigmaAverage -1 Sigma -2 Sigma LCLMean Volume Age 19-64 (Excluding Maternal/Child)

91.31

82.2784.93

59.89

69.89

79.89

89.89

99.89

109.89

119.89

Jan-

06Fe

b-06

Mar

-06

Apr

-06

May

-06

Jun-

06Ju

l-06

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07Fe

b-07

Mar

-07

Apr

-07

May

-07

Jun-

07Ju

l-07

Aug

-07

Sep

-07

Oct

-07

Nov

-07

Dec

-07

Jan-

08Fe

b-08

Mar

-08

Apr

-08

May

-08

Jun-

08Ju

l-08

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09Fe

b-09

Mar

-09

Apr

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May

-09

Jun-

09

Ave

rage

Dai

ly C

ensu

s

Avg Daily Census UCL +2 Sigma +1 SigmaAverage -1 Sigma -2 Sigma LCLMean Avg Daily Census Age 19-64 (Excluding Maternal/Child)

Adult Average Daily CensusAdult Average Daily Census

Length of StaySeniors 65+

5.51

4.404.21

3.50

4.00

4.50

5.00

5.50

6.00

6.50

Jan-

06Fe

b-06

Mar

-06

Apr

-06

May

-06

Jun-

06Ju

l-06

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07Fe

b-07

Mar

-07

Apr

-07

May

-07

Jun-

07Ju

l-07

Aug

-07

Sep

-07

Oct

-07

Nov

-07

Dec

-07

Jan-

08Fe

b-08

Mar

-08

Apr

-08

May

-08

Jun-

08Ju

l-08

Aug

-08

Sep

-08

Oct

-08

Nov

-08

Dec

-08

Jan-

09Fe

b-09

Mar

-09

Apr

-09

May

-09

Jun-

09

Leng

th o

f Sta

y D

ays

LOS Age 65+ UCL +2 Sigma +1 SigmaAverage -1 Sigma -2 Sigma LCLMean LOS Age 19-64 (Excluding Maternal/Child)

Senior Services Senior Services Programming and IntegrationProgramming and Integration

Complication PreventionMaintaining Function Care Transitions

To assess and improve the interdisciplinary, comprehensive processes of care for seniors

using the Crouse Hospital care network, paying particular attention to geriatric syndromes and other

issues unique to seniors accessing healthcare.

Care TransitionsCare Transitions Goal – Improve the patient’s ability to

self manage chronic conditions Global Outcomes

Reduce readmissions Enhance patient satisfaction/loyalty Ready Crouse for healthcare reform

Eric Coleman, MD University of Colorado

Why do patients return to the hospital?Why do patients return to the hospital?Medication issues Medication record &

discrepancy analysis

Lack of timely follow up with MD/NP

Follow up appointment

Lack of knowledge/mgt of chronic conditions

Red flags & personal health record

Care Transitions ProcessCare Transitions Process Community-dwelling patients with

congestive heart failure / atrial fibrillation

Patient visited early in hospital admission

Home visit within 72 hours Phone calls on days 2, 7, 14, and 30

Reduce the 30 day readmission rate of CHF Reduce the 30 day readmission rate of CHF patients in the program to below 9.71% patients in the program to below 9.71%

(the hospital mean)(the hospital mean)Percentage of CHF Patients in Program Readmitted within 30 Days

1.79%2.62% 1.93%

9.71%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

10/1

5/20

07 (

n=0/

8)

10/3

1/20

07 (

n=1/

10)

11/1

5/20

07 (

n=1/

3)

11/3

0/20

07 (

n=0/

10)

12/1

5/20

07 (

n=0/

3)

12/3

1/20

07 (

n=0/

1)

1/15

/200

8 (n

=0/1

)

1/31

/200

8 (n

=0/6

)

2/15

/200

8 (n

=0/2

)

2/29

/200

8 (n

=0/6

)

3/15

/200

8 (n

=1/9

)

3/31

/200

8 (n

=0/6

)

4/15

/200

8 (n

=0/4

)

4/30

/200

8 (n

=0/5

)

5/15

/200

8 (n

=0/6

)

5/31

/200

8 (n

=0/7

)

6/15

/200

8 (n

=0/2

)

6/30

/200

8 (n

=0/5

)

7/15

/200

8 (n

=1/1

2)

7/31

/200

8 (n

=0/5

)

8/15

/200

8 (n

=0/3

)

8/31

/200

8 (n

=0/3

)

9/15

/200

8 (n

=0/3

)

9/30

/200

8 (n

=0/3

)

10/1

5/20

09 (

n=0/

7)

10/3

1/20

09 (

n=1/

8)

11/1

5/20

09 (

n=0/

6)

11/3

0/20

09 (

n=0/

6)

12/1

5/20

09 (

n=0/

3)

12/3

1/20

09 (

n=0/

3)

1/15

/200

9 (n

=1/7

)

1/31

/200

9 (n

=0/7

)

2/15

/200

9 (n

=0/4

)

2/28

/200

9 (n

=0/3

)

% o

f Rea

dmis

sion

s

Percent UCL +2 Sigma +1 Sigma Average -1 Sigma -2 Sigma LCL Goal

Care Transitions - Medication Discrepancies

3.73

5.17

0

2

4

6

8

10

12

14

16

10/1

5/20

0710

/31/

2007

11/1

5/20

0711

/30/

2007

12/1

5/20

0712

/31/

2007

1/15

/200

81/

31/2

008

2/15

/200

82/

29/2

008

3/15

/200

83/

31/2

008

4/15

/200

84/

30/2

008

5/15

/200

85/

31/2

008

6/15

/200

86/

30/2

008

7/15

/200

87/

31/2

008

8/15

/200

88/

31/2

008

9/15

/200

89/

30/2

008

10/1

5/20

0910

/31/

2009

11/1

5/20

0911

/30/

2009

12/1

5/20

0912

/31/

2009

1/15

/200

91/

31/2

009

2/15

/200

92/

28/2

009

3/15

/200

93/

30/2

009

4/15

/200

94/

30/2

009

5/15

/200

95/

31/2

009

# of

Med

Dis

crep

anci

es

Med Discrepancies UCL +2 Sigma +1 Sigma Average -1 Sigma -2 Sigma LCL

Patient Satisfaction with the Care Transitions ProgramQuestion: "I was very satisfied with the Care Transitions Program"

3.63

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

10/1

5/20

07

10/3

1/20

07

11/1

5/20

07

11/3

0/20

07

12/3

1/20

07

1/15

/200

8

1/31

/200

8

2/15

/200

8

2/29

/200

8

3/15

/200

8

3/31

/200

8

4/15

/200

8

4/30

/200

8

5/15

/200

8

5/31

/200

8

6/15

/200

8

6/30

/200

8

7/15

/200

8

7/31

/200

8

8/15

/200

8

8/31

/200

8

9/15

/200

8

9/30

/200

8

10/3

1/20

09

11/3

0/20

09

12/3

1/20

09

1/31

/200

9

2/28

/200

9

3/30

/200

9

4/30

/200

9

5/31

/200

9

Patie

nt S

atis

fact

ion

Scor

e

Patient Satisfaction UCL +2 Sigma +1 Sigma Average -1 Sigma -2 Sigma LCL

Resource UtilizationResource Utilization

285 encounters Average # admits = 2.85 Total cost = $1,958,197

100 CHF/Afib patients examined 1/2007 – 9/2008

All inpatient and outpatient visits related to CHF or Afib

Financial ImpactFinancial Impact(1/2007 – 9/2008)(1/2007 – 9/2008)

100 patients studiedPatients stayed out of hospital

70

Patients with subsequent admissions

30

*Admissions any time in study periodED & inpatient visits

Patients with Multiple Visits Patients with Multiple Visits Before InterventionBefore Intervention

45 patientsPatients stayed out of hospital

26

Patients having subsequent admissions

19

*Admissions any time 1/2007 – 9/2008ED & inpatient visits

Patients with Multiple Visits Patients with Multiple Visits Before InterventionBefore Intervention

19 Patients w Subsequent Admissions

Before AfterAvg # visits = 3.4 Avg # visits = 1.7

ALOS = 4.8 ALOS = 3.9

*Admissions any time 1/2007 – 9/2008ED & inpatient visits

Days to ReadmissionDays to Readmission26 Patients with Multiple Admissions

before CT Intervention & no readmits after intervention

Avg. days to rehospitalization before intervention = 86

Avg. days out of hospital after intervention = 175

Patients Enrolled Patients Enrolled During First CHF AdmissionDuring First CHF Admission

55 PatientsPatients stayed out of hospital

44

Subsequent admissions

11

*Admissions any time 1/2007 – 9/2008ED & inpatient visits

Patients Enrolled Patients Enrolled During First CHF AdmissionDuring First CHF AdmissionN= 55 / 11 with Subsequent Admissions*

Before AfterAvg # visits = 1.0

Avg # visits = 1.5

ALOS = 6.0 ALOS = 4.2

*Admissions any time 1/2007 – 9/2008ED & inpatient visits

Sharing Our SuccessSharing Our SuccessUniversity of Rochester

BassettThompson Health

Healthcare Advisory Board Cardiovascular RoundtableHealth Quest, Poughkeepsie, NY

Glens Falls HospitalBronson Hospital, Kalamazoo, MI

Christiana CareOcean Medical Center, NJ

Wheaton Franciscan HealthcareAlegent Health/Immanuel Health Systems

OSF FranciscanMorton Plant Mease Health CareSt. Francis Hospital, Tulsa, OK

Sharing Our SuccessSharing Our SuccessAmerican Hospital Association

Wall Street JournalHANYS Annual meeting

Dept of Health -- Patient Centered Care Northeast Home Care Nurses Association

American Heart Association Regional meetingIPRO Teleconference

HC Pro Teleconference

What’s Next?What’s Next? Complex elders with multiple

comorbidities Transitional Care – Mary Naylor, PhD,

RN University of Pennsylvania COPD, frequent ED visitors, diabetes

– good possible populations