TACKLING AVOIDABLE READMISSION THROUGH CARE …...Days at SNF % Discharged to Hospital Most Frequent Diagnosis 1 day 4.7% CHF 2-3 days 11.5% Pneumonia 4-7 days 17.10% Pneumonia 8-14

Harmony Healthcare International, Inc.

Copyright © 2012 All Rights Reserved 1

Tackling Avoidable Readmissions through Care Transition: Part II

“The SNF Playbook”

HARMONY UNIVERSITY The Provider Unit of

Harmony Healthcare International, Inc. (HHI) Presented by:

Diane Buckley, BSN, RN, RAC-CT Director of Quality & Performance Improvement

Joyce Sadewicz, PT Director of Corporate Consultants

Housekeeping

Sign In

Contact Hours Certificate

A Little About Me

Handouts

Contact Information for Questions

Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 2

The SNF Playbook Tackling Avoidable Readmissions through Care Transitions

Course Objectives Learner will be able to summarize the CMS quality initiative for Healthcare Reform related to hospital readmissions

Identify underlying causes and barriers related to readmission

The learner will be able to identify hospital and SNF strategies for collaboration

Discuss Interact Tool and other Initiatives to Reduce readmissions

Identify Care Paths and Implementation strategies




The SNF Playbook Tackling Readmissions



Hospital

Readmissions

The SNF Playbook Tackling Readmissions

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The SNF Playbook Tackling Readmission

June 2007 & 2008 Medicare Payment Advisory Commission (MedPAC) Report to Congress highlighted avoidable Rehospitalizations as an area of high cost and low quality

Prompted leaders of healthcare systems across the country to focus on avoidable Rehospitalizations in anticipations of potential changes in the market




.


2009 Re-Admissions emerged as a Major Quality Initiative of Healthcare Reform

Reducing Re-hospitalization is an important element of President Obama’s February 2009 proposal for financing Health Care Reform



The Affordable Care Act

From a Policy perspective performance variation indicated lack of reliable attention to executing successful transition out of the hospital and into the next care setting

Several provisions regarding improving Care Transition, Care Coordination and Reducing readmissions



IHI (Institute for Healthcare Improvement) on May 1, 2009 launch the State Action on Avoidable Rehospitalizations (STAAR) Initiative

Grant support from the Commonwealth Fund.

Initial phase, Two year Multi state project to reduce avoidable Rehospitalizations focusing on two components





Hospitalizations and Rehospitalizations are symptomatic of multi process defect in the health care system due to lack of:

Timely or equitable access to care

Effective handoffs and coordination of care

Safe care

Patient centered and appropriate end of life care


High rates of readmissions have gained attention due to cost and quality concerns

1 in 5 Medicare patients discharged from the hospital is readmitted within 30 days

A cost of over $17 billion each year




Resources consumed by Rehospitalizations

5 million Rehospitalizations per year

14% to 19% Rehospitalization rate

25% of Medicare hospital costs

12% rate of Rehospitalization of post-acute or nursing home patients occur even before the actual transfer process out of the hospital can be completed





Five most common Medical condition for Readmission:

Heart Failure

Pneumonia

COPD

Psychoses

GI problems


The SNF Playbook Tackling Readmission: Skilled Nursing Facilities

The Frequent Causes identified:

Pneumonia

Urinary Tract Infections

Heart Failure

Dehydration

Pressure Ulcers

Injuries due to falls

The SNF Playbook Healthcare Policy Priority

The Affordable Care Act established the Hospital Readmission Reduction Program (HRRP) which ties payment to Performance on Measures

HRRP begins October 1, 2012

Lowers Medicare payment rate for hospitals with greater than expected readmission rates for specific conditions




Conditions beginning FY 2013

Heart Failure

Acute Myocardial Infarction

Pneumonia

These three conditions made up approximately 10% of hospital discharges in 2009

(Avalere analysis of 2009 Medicare 100 Percent Standard Analytic files claims data from CMS.)



Conditions Beginning FY 2015

Chronic Obstructive Pulmonary Disease

Coronary Bypass Graft

Percutaneous Transluminal Coronary Angioplasty

Other Vascular Conditions



Hospitals with excessive readmission rates will have their Medicare payments reduced by up to

1% in fiscal year 2013

2% in 2014

3% by fiscal year 2015 and beyond






The SNF Playbook Tackling Readmissions: Financial Implications

Hospitals with risk adjusted 30 day readmission performance in the lowest quartile will incur penalties against their total Medicare Payment beginning in fiscal year 2013 (starting October 1, 2012)

CMS will evaluate prior year’s readmission data starting October 1, 2011

Harmony Healthcare International, Inc. 20

The SNF Playbook Tackling Readmission: Skilled Nursing Facility

Medicare readmission rates for Skilled Nursing Facilities to hospitals increased 30% from 2000 to 2006

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The SNF Playbook Why do Readmissions happen?

Discharge from Hospital is critical and requires adequate planning and preparations to avoid

Medication errors

Poor discharge planning

Inadequate arrangements

Poor communication

Adverse events





Evidence suggest several specific interventions reduce the rate of avoidable Rehospitalizations:

Improving core discharge planning and transition processes out of the hospital

Improving transition and care coordination at the interface between care settings

Enhance coaching, education, and support for self management

Focus on both the senders and receivers of patients transitioning from the acute care setting

Harmony Healthcare International, Inc. 23


Four stages of care that allow effective interventions

Preparation for discharge, a process starting on admission making staff aware of home environment

Hand-off to the out patient physician

Medication reconciliation to make sure new prescriptions are filled and that patients are not falling back on their old medication routines

Home visits and/or phone call, daily or weekly for first 30 days

Copyright © 2012 All Rights Reserved

SNF Playbook

Know Your Data

Know Your Team

Know Your Opponent

Know and Implement Interventions that are Evidenced based and are Effective

Know Your Offense & Defense

Have A Diverse Playbook

Make Adjustments




SNF Playbook - Data

DATA


Readmission Rates (Hospital)

Readmission Rate (SNF)

CHF Rate Pneumonia

Rate

Acute Myocardial

Infarction Rate

SNF Playbook - Data Medicare for LOS for Re-Hospitalization 2011

Destination 2011

Home 55.6%

Hospital 20.2%

Death 4.7%

Other SNF 2.3%

In-House 16.9%




55.6%

20.2%

4.7%

2.3%

16.9%

Discharge Destination Percentages by Patient 2011

Home Hospital Death Other SNF In-house




Days at SNF % Discharged to Hospital Most Frequent Diagnosis

1 day 4.7% CHF

2-3 days 11.5% Pneumonia



15-21 days 14.70% CHF

22-30 days 11% UTI



Greater than 90 days .80% CVA


SNF Playbook - Data

American Healthcare Association Goal:

Reduce Hospital Re-admissions within 30 days during a SNF stay by 15% by March 2015


SNF Playbook Know your Team

Formulate Your Team

Owners/CEO/CFO

Administrator

DON

MDS/PPS Coordinator

Nursing

Therapy

Social worker

Case Managers




Know Your Players:

Players Positions: Their roles and responsibilities

Team Players: Work as a Team


SNF Playbook Know your Team

SNF Playbook Know your Opponent

KNOW YOUR OPPONENT:

Readmissions

Hospitals

Physicians

Home Care

Families

Community Resources

Financial


SNF Playbook Offensive Team

Implement Interventions that are Evidenced based and are Effective:

INTERACT (3 specific areas):

Communication

Care Paths

Advance Care Planning

Core Discharge Planning & Transition

Transition Coach/Nurse Care Coordinators

Care Transition Bundle





SNF Playbook: Offensive Team INTERACT(Interventions to Reduce Acute Care Transfers

Communication: SBAR communication tool disease specific and corresponds with a Care Path

CNA Early Warning tool was printed on 3x5 cards and laminated for all CNA staff

Acute Change in Condition Tool was printed on 3x5 cards and laminated and placed in file box. (Instructions of when to report changes)

Acute Care Transfer Checklist

Case Examples for staff awareness

Unplanned Acute Care Transfer Review used as a QI tool. (Evaluation of strategies and results)


“Handoff Communication”

SBAR


SNF Playbook Offensive Team: SBAR Communication

A Communication Strategy Designed to Enhance Patient Safety By Standardizing the way Caregivers Talk to Each Other




SNF Playbook: Offensive Team What is Meant by “Handoff Communication”?

The process of providing patient specific information from one caregiver to another, or from one team of caregivers to another

Patient’s current condition

Ongoing treatment

Recent and possible changes in condition

Complications to watch out for

A system to enhance the continuity and safety of patient care


SNF Playbook: Offensive Team SBAR Communication

S: Situation Why are you Placing the call?

B: Background

What happened leading up to the situation?

A: Assessment

What did your assessment reveal?

R: Recommendation What are you asking the physician to do?


SNF Playbook: Offensive Team INTERACT Focus Areas: Disease Specific Care Paths Tools

Disease Specific Care Paths: Printed on bright paper and placed in sheet protectors and mounted on clipboards. ( Care Paths: Include a pathway of clinical assessment, observations and interventions)

All licensed staff were trained in the use of Care Paths. Acute Mental Status change

Fever

Lower Respiratory Infection

Hydration

UTI

CHF




SNF Playbook: Offensive Team INTERACT Focus Areas: Disease Specific Care Paths Tools

Disease Specific Care Paths: Printed on bright paper and placed in sheet protectors and mounted on clipboards. ( Care Paths: Include a pathway of clinical assessment, observations and interventions)

All licensed staff were trained in the use of Care Paths. Acute Mental Status change

Fever

Lower Respiratory Infection

Hydration

UTI

CHF


SNF Playbook Offensive Team: INTERACT Focus Areas

Advanced Care Planning Communication Guide:

Notebook with materials for Social Workers and DON’s with materials for use when talking with residents

Tips for starting conversations.

Helpful Language for discussing End of Life Care.

Identifying Residents at high risk for Entering the Actively Dying Process.

Comfort Care Order Set.

Display rack in Social Workers office with materials for families


SNF Playbook: Offensive Team Care Transitions Coach

A Transition Coach Implement Transition Coaches

Follow up visit in home

Phone calls designed to provide continuity across the transition

Medication self-management

Use of patient-centered record

Primary care and specialist follow up

Knowledge of red flags – signs that the patient’s condition is getting worse and how to respond



SNF Playbook: Offensive Team Nurse Care Coordinators

Pre and Post discharge coordination

Assessment of Care Needs

Hand off

Medication

Education



SNF Playbook: Offensive Team Nurse Care Coordinators

Nurse Care Coordinators:

Teach patients to assess their own symptoms using a traffic light model

Green: feeling fine

Yellow: small weight increase or mild swelling that means call nurse practitioner

Red: shortness of breath or other severe symptoms that indicate 911 or go to ED

SNF Playbook: Offensive Team National Transitions of Care Coalition

The Medicare Transitional Care Act puts in place an infrastructure to promote care transition interventions that have been proven successful

Seven key elements found in evidence-based care interventions




SNF Playbook: Offensive Team Care Transition Bundle

Seven Essential Intervention Categories

Medication Management

Transition Planning

Patient and Family Engagement/Education

Information Transfer

Follow-Up Care

Healthcare provider Engagement

Shared Accountability across Providers and Organizations


SNF Playbook: Defensive Team

Partnership/Relationships Structure

Care Delivery Model

Care Pathways

Care Coordination

Quality Rehabilitation

Alignment Strategy

Handoff/Communication

Information Technology

Transfer/Access



Care Pathways: Ensure that hospitals and SNFs work together to develop evidence-based protocols that standardized and optimize care across acute and Post Acute Care settings





Care Coordination: Form cross-continuum teams that cover both PAC and the acute care sites to identify and address problems in care transitions, using coordinators to bridge both settings



Quality Rehabilitation: Ensure that inpatient discharge planners are familiar with the therapy staff and technology available at area SNFs to select destinations that best meet patients' rehabilitation needs



Alignment strategy:

Inventory area PAC facilities to determine SNF supply and alternate PAC options.

Identify top performers in quality metrics to help patients make educated SNF choices.

This may include the decision to create a formal SNF network.





Handoffs/communication:

Engage hospital physicians to increase their accountability for handoffs and any subsequent readmissions

Better link patients' primary care physicians with emergency department physicians to avert avoidable admissions

Create comprehensive medication and personalized care records for all patients



Information Technology:

Explore software applications that enable discharge planners to search electronically for area SNFs that best match patients' care needs

Automate data sharing with SNF medical directors on key quality metrics



Transfers/Access:

Utilize a standardized transfer form

Formalize a referral system with area SNFs and facilitate real-time information on bed availability





Hold Forums for collaboration between SNFs and hospitals

Medical Directors

Chief Nursing Officer

Post Acute Care Nursing Staff

Forums include DATA sharing of potential avoidable readmissions and readmissions and Root Cause Analyses for trends


SNF Playbook: Special Teams

Care Path

CHF

Pneumonia

COPD

Medication Management

Falls



CHF Care Path

Implement Care Path

Daily CHF rounds

Monitoring weights

Vitals signs

Respiratory Assessment

Diet

Education

Labs

Medication changes





Pneumonia Care Path:

Implement Care Path

Early identification and notification

Nurse notes respiratory symptoms and contacts MD within 1 hour

MD/NP/PA responds within 1 hour, elicits nurse assessment of signs and symptoms, decides whether patient probably has pneumonia, and assesses patient’s desire for hospitalization, resuscitation and parenteral antibiotics and fluids if indicated




MD/NP/PA decides to evaluate and treat in nursing home if patient prefers, nursing home is capable of acute care, and/or vital signs stable




MD/NP/PA orders antibiotics prior to any further evaluation, if there are any unstable vitals signs. Chest x-ray is ordered. Patient is seen by MD/NP/PA within 24 to 72 hours. If there is no evidence of pneumonia, antibiotics may be stopped.

OR






Patient is evaluated prior to further treatment in nursing home by chest x-ray within 24 hours and in person MD/NP/PA assessment within 24 to 72 hours




Antibiotic, if indicated, is chosen according to guidelines and delivered to patient within 4 hours of MD/NP/PA order. Blood culture is done if it will not delay treatment > 1 hour. Oral route is preferable if possible

Chest x-ray and in person evaluation should determine need for complete course of treatment, 10 to 14 days




MD/NP/PA orders immediate hospitalization if 2 or more unstable vitals, or if 1 unstable vital and nursing home lacks capacity for acute care. One dose of a parenteral antibiotic is given prior to transfer unless that would delay transport > 1 hour





Prevention

Vaccination: Pneumonia & Influenza

Nursing Facility strongly recommend staff immunization against Influenza for all employees



SNF Playbook – Special Teams Pneumonia Care Path:

Physician notification of serious Respiratory Symptoms

New or worsening cough

Increased or newly purulent sputum

Decline in cognitive, physical, or functional status

Fever

Hypothermia

Dyspnea

Tachypnea

Chest pain

New or worsening hypoxia


SNF Playbook - Special Teams Pneumonia Care Path:

Nurse evaluation at symptom onset should include:

Vital Signs ( Temperature, pulse rate, respiratory rate, and blood pressure)

Oxygen saturation

Physician is notified and should call back within 1 hour




If Nurse does not hear back within 1 hour, he or she should notify the director of nurses or designee

The nurse and director of nurses should agree on a plan to notify the medical director or designee and ask him or her to assume care of the episode until the medical director can contact the attending physician



Once physician is notified, he or she must decide whether pneumonia is a leading consideration in the diagnosis of the reported change



The Physician and nursing home staff should concur that Pneumonia is a leading consideration in the diagnosis

Decision to treat in SNF versus hospitalize





2 or more of the following symptoms suggest hospitalization:

Oxygen Saturation <90% on room air

Systolic BP <90 mm Hg or 20 mm Hg less than baseline

Respiratory rate >30 breaths per minute more than baseline

Requiring 3 liters per minute of O2 more than baseline

Uncontrolled COPD,CHF, DM

Un-arousable if previously conscious

New or increased agitation



If SNF cannot provide:

Vital sign every 4 hours

Laboratory access

Parenteral hydration

2 Licensed nurses per shift in the facility

Consider Hospitalization



Patients with none of the symptoms or care able to be provided in the SNF setting should continue to be treated in the SNF





Monitoring Patients in the SNF

Nurse evaluation each shift should include:

Vitals signs with measured Respiratory Rate and Oxygen saturation until symptoms resolve



Patient with Probable Pneumonia should have a CXR, however nursing home acquired Pneumonia are likely to have infiltrate on CXR and is acceptable to treat without first obtaining CXR



Patients with Probable Pneumonia should be:

Evaluated in person by Physician with 24 hrs

Blood culture drawn without delaying treatment





Antibiotic Use:

Patient going to hospital should receive one parenteral dose prior to transporting unless it would delay treatment

A single dose Antibiotic ordered simultaneously with CXR if the following:

BP <90 mm Hg or 20 mm Hg less than baseline

Oxygen Sat <90% on room air

Pulse >130 beats per minute

Respiratory rate > 30 breaths per minute



Antibiotic Use with Probable Pneumonia and are stable:

Oxygen Sat >90%

Pulse , 120 beats per minute

Respiratory rate < 30 breaths per minute

Decision to use antibiotic may wait result of CXR if available within 24hrs.

If CXR does not confirm Pneumonia consider stopping antibiotic treatment



Antibiotic

If ordered should be delivered with 4 hours to patient of orders being given by physician

Oral route is preferred except for patient transferring to hospital

Broad-spectrum antibiotic covering

S pneumoniae

Haemophilus influenzae

Gram negative rods

Staphylococcus aureus

Treat 10 to 14 days





Kick Off Team


SNF Playbook: Kick Off Team

Form Readmission Reduction Team: RRT

Internal

External

Engage Senior Leadership/Board

QAPI

Culture Change


Questions/Answers

Harmony Healthcare International

1 (800) 530 – 4413

[email protected]

[email protected]





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Documents

TACKLING AVOIDABLE READMISSION THROUGH CARE …...Days at SNF % Discharged to Hospital Most Frequent Diagnosis 1 day 4.7% CHF 2-3 days 11.5% Pneumonia 4-7 days 17.10% Pneumonia 8-14