Welcome to our presentation! - ASPMN Conference Documents... · Welcome to our presentation! • To participate you must first join our session. ... Utilizing the DMAIC Methodology

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Welcome to our presentation!

• To participate you must first join our session.

• You do this by sending a text to this five digit number 22333.

• In the body of the text message, you’ll type Marylyons445

• You will get a confirmation message that you are now part of

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• Now you’re ready to reply to a polling question with your

response (A,B,C)…”

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Please get your phone out and get ready to respond

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Polling Question Practice

How many new professional contacts have you made since

arriving in Kentucky?

A. None, I’m still recovering from my travels

B. 1-4 Just getting warmed up

C. 5-10 I’m having fun

D. More than 10, I am the life of the party

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APN-Led Initiative Creates MVP (Multiple Visit Patient) Care Plans to Decrease Readmissions and Length of Stay

Presented to: Insert relevant presenter information Calibri 16pt

Presented on: Month day, Year

Presented by: Insert relevant presenter information here

Presented to: ASPMN 26th National Conference

Presented on: September 9, 2016

Presented by: Pam Bolyanatz, MS, FNP-BC, RN-BCMary Lyons, MSN, APN/CNS, RN-BC, ONC

Objectives

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• Describe the process for creating a

multidisciplinary team to reduce acute hospital

utilization for patients with persistent pain or

related conditions.

• Define metrics, care planning process &

implementation of a multi hospital procedure

to provide coordinated care for MVP patients.

• Summarize project outcomes and future

direction of MVP program.

Conflict of Interest Disclosure

Pam Bolyanatz, none

Mary Lyons, Mallinckrodt Pharmaceuticals Speaker’s

Bureau for non-branded presentation

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Polling Question #2

How many of you work at an organization

that is concerned about readmissions?

A. Yes, my organization is very concerned

B. No, my organization is not concerned

C. I don’t work at an inpatient facility

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So what’s the problem??

• Realization that pain patients frequenting the ED were at risk for

misunderstanding & lack of continuity of care

• Interface with Care Coordination who identified increasing readmission rates

• Evaluation of hospital “Top 100” list for hospital ED charges 5/2014-4/2015

− Top 3 Central DuPage Hospital patients incurred between 102K-126K each

− Top 3 Delnor Hospital patients incurred between 103K-210K each

• Benchmarking with local hospitals

− We’re not alone!

− Care plan templates

− Framework for patient and provider communications

− Procedure models

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Self assessment at home and close to home

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Literature Review• Pain and Emergency Medicine Initiative (PEMI) study involving 18 academic centers

across Canada and the United States1

• 20 percent of patient visits had chronic pain as the primary reason for their visit to the emergency department.

• Represents the largest percentage of visits to the emergency department for any one pathology.

Todd, K., Ducharme, J.

etal., 2007

• As substance use issues increase so does the number of patients utilizing the ED for chronic pain management. Given the complex correlation between pain and substance use, attention should be given to standardizing a plan of care and facilitating referrals to appropriate providers for structured treatment with focus on the patient’s physical as well as psychological well-being.

Neighbor,

Dance, Hawk, &

Kohn, 2011

• Substance use disorders (SUD) are a growing health concern, with non-medical usage of opiates at an all-time high. In the United States approximately 22% of all deaths are related in some way to substance use

Chang & Yang, 2013

• Pain management care plans allow ED staff to provide compassionate, comprehensive care while balancing risk.

• Patients will be empowered to become less dependent on the healthcare system with improved self management.

Allen, M, etal,. 2014

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Utilizing the DMAIC Methodology

11

Trying to fix a broken process

Define

Team members

Define key terms/goals

High level process map

1st Charter

Scope

Measure

Analyze

Improve

Control

Project Team

Executive

SponsorSponsors

Improvement

Leader / PM Team Members

• Provides

overall guidance

and

accountability for

the project

• Addresses

project barriers

(organizational)

• Provides

strategic

oversight

• Accountable

for timely and

successful

implementation

of the project

• Addresses

project barriers

(departmental)

• Provides

tactical

oversight

• Accountable for

implementing,

controlling, and

measuring

project outputs

and

improvements

• May also be a

Subject Matter

Expert (SME)

Process

Owner

• DMAIC

methodology expert

•Accountable for

using DMAIC to

manage the project

and complete

deliverables

• As project reaches

control, manages the

process outputs and

transitions to the

Process Owner

• Makes significant and

focused contributions to

the timely and successful

implementation of the

project

• Contributes ideas and

significantly impact the

direction of the project

• May be involved in data

collection & analytics

•Consider “fresh eyes”

Clinical

Sponsor

• Accountable

for reaching

clinical

consensus on

guidelines,

protocols, and

other clinical

decisions

12

5

Project Team

Executive

SponsorSponsors

Improvement


• Provides

overall guidance

and

accountability for

the project

• Addresses

project barriers

(organizational)

• Provides

strategic

oversight

• Accountable

for timely and

successful

implementation

of the project

• Addresses

project barriers

(departmental)

• Provides

tactical

oversight

• Accountable for

implementing,

controlling, and

measuring

project outputs

and

improvements

• May also be a

Subject Matter

Expert (SME)

Process

Owner

• DMAIC

methodology expert

•Accountable for

using DMAIC to

manage the project

and complete

deliverables



process outputs and

transitions to the

Process Owner





project







Clinical

Sponsor

• Accountable

for reaching

clinical

consensus on

guidelines,

protocols, and

other clinical

decisions

13

Project Team

Executive

SponsorSponsors

Improvement


• Provides

overall guidance

and

accountability for

the project

• Addresses

project barriers

(organizational)

• Provides

strategic

oversight

• Accountable

for timely and

successful

implementation

of the project

• Addresses

project barriers

(departmental)

• Provides

tactical

oversight

• Accountable for

implementing,

controlling, and

measuring

project outputs

and

improvements

• May also be a

Subject Matter

Expert (SME)

Process

Owner

• DMAIC

methodology expert

•Accountable for

using DMAIC to

manage the project

and complete

deliverables



process outputs and

transitions to the

Process Owner





project







Clinical

Sponsor

• Accountable

for reaching

clinical

consensus on

guidelines,

protocols, and

other clinical

decisions

14

Project Team

Executive

SponsorSponsors

Improvement


• Provides

overall guidance

and

accountability for

the project

• Addresses

project barriers

(organizational)

• Provides

strategic

oversight

• Accountable

for timely and

successful

implementation

of the project

• Addresses

project barriers

(departmental)

• Provides

tactical

oversight

• Accountable for

implementing,

controlling, and

measuring

project outputs

and

improvements

• May also be a

Subject Matter

Expert (SME)

Process

Owner

• DMAIC

methodology expert

•Accountable for

using DMAIC to

manage the project

and complete

deliverables



process outputs and

transitions to the

Process Owner





project







Clinical

Sponsor

• Accountable

for reaching

clinical

consensus on

guidelines,

protocols, and

other clinical

decisions

15

6

Project Team

Executive

SponsorSponsors

Improvement


• Provides

overall guidance

and

accountability for

the project

• Addresses

project barriers

(organizational)

• Provides

strategic

oversight

• Accountable

for timely and

successful

implementation

of the project

• Addresses

project barriers

(departmental)

• Provides

tactical

oversight

• Accountable for

implementing,

controlling, and

measuring

project outputs

and

improvements

• May also be a

Subject Matter

Expert (SME)

Process

Owner

• DMAIC

methodology expert

•Accountable for

using DMAIC to

manage the project

and complete

deliverables



process outputs and

transitions to the

Process Owner





project







Clinical

Sponsor

• Accountable

for reaching

clinical

consensus on

guidelines,

protocols, and

other clinical

decisions

16


17


Define

Team members



1st Charter

Measure

Defining outcome & process metrics

Operational definitions

Data collection plan

Procedure development

Analyze

Improve

Control


18


Define

Team members



1st Charter

Measure





AnalyzeData analysis

Individual patient review

Process analysis

Ongoing identification of MVPs

Ongoing Charter updates

Improve

Control

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19

Define

Team members



1st Charter

Measure





Analyze

Data analysis

Individual patient weekly & prn review

Process analysis



Improve

Generating solutions/interventions

Engaging executive sponsor support

Developing system & community partners

Applying evidence based guidelines

Control


20

Define

Team members



1st Charter

Measure

Defining outcome &

process metrics




Analyze

Data analysis

Individual patient weekly & prn review

Process analysis



Improve

Generating

solutions/interventions

Enlisting executive sponsors

Developing system & community partners

Applying evidence based practice

Control

Ongoing metrics & monitoring

Developing a sustainable plan

Partnering with Analytics to develop automated reports & data analysis

Dissemination of project plan, progress & possibilities

Charter: Multiple Visit Patient Care Planning

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Exec Sponsors: Cori Zacher VP, Dr. Kevin Most & Dr. Mark Daniels Sponsor(s): Jeannine Harvell, Kim Czaruk

Process Owner(s): Delnor: Sherri Johnson, Kelly Ryan, Pam Bolyanatz CDH: Pam Nass, Mary Lyons, Carol Tulley

Team Members: See attached

Key Metrics

Outcome Metric(s):Reduce ED visits and/or hospitalizations (for the same condition) for patients with MVP

team interventions by 25% annually.

Process Metric(s): Care plan creation, ongoing evaluation and

compliance (patient and caregivers) with plan

Milestones

Description

� Charter completed/revised 06/15

� Multidisciplinary teams at Delnor & CDH 02/15

� Care plan template & communication plan developed

� Implementation of active care plans

� Creation & system approval of patient & provider communication letters &

guidelines 4/16

Date (MM/YY)

Project Overview

Problem Statement: Frequent emergency department & hospital admissions for pain and/or symptom related conditions create financial, throughput & system

resource strains on the healthcare system as evidenced by review of the Crimson Top 100 patient list, admission data & staff referrals for Delnor and CDH.

Goal/Benefit: Ensure patient access to the appropriate level of care through a coordinated care evaluation and creation of an individualized care plan for patients

with persistent pain or other related conditions/symptoms, there by reducing ED visits and/or hospitalizations by 25% annually for patients with MVP care plans.

Scope: Patients who have presented to the West Region EDs or have been hospitalized 3 times per month within the last 6 months for the same or similar pain

diagnosis. Individual exceptions may apply.

Excludes: Patients with terminal conditions such as cancer, ETOH dependency, drug overdose/suicide attempts

System Capabilities / Deliverables: Multidisciplinary assessment, evaluation and creation of an individualized care plan that will be placed in the Media section of the

EMR as communicated in the “FYI” Flag area. Ongoing evaluation & modification of plan based on discussion on a monthly or as needed basis.

Resources Required: Dedicated Care Coordinator, Social Worker, Pain Management APN, ED physician leadership and/or inpatient hospitalist or PCP to

endorse care plans and other specialists as needed. Financial and outcome analysis support.

Last Update: 4/27/2016

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Scope of MVP Team/Project

• Scope includes

− Patients who have presented to the West Region EDs or have

been hospitalized 3 times per month within the last 6 months

for the same or similar pain diagnosis

• Scope excludes

− Patients with terminal conditions such as cancer.

− ETOH dependency

− Drug overdose/suicide attempts

• Individual exceptions may apply at the discretion of the MVP

Team

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D =

Define

How do we know we’re making a difference?

• Outcome Metric(s):

Reduce ED visits and/or hospitalizations (for the same condition)

for patients with MVP team interventions by 25% annually

• Process Metric(s):

Care plan creation, ongoing evaluation and assessment of compliance (patient and caregivers) with plan

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M =

Measure

MVP Individual “Root Cause Analysis”

Who?

• In depth psychosocial evaluation

What?

• The same pain complaint on a frequent basis

• A flare or exacerbation of pain

• A new acute pain complaint

• A patient with substance use disorder

Why?

• Unrelieved symptoms such as nausea

• Co-morbid diagnoses

When?

• Is there a pattern to their visits?

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9

Evolution of a System Procedure for MVP Care Planning

Referrals are made via multiple

methods to the MVP Work Group.

Evaluation by MVP Work Group

Review the patient history

of system encounters

Review patient’s medical, social &

psychological history

Review the IL Prescription Monitoring

Program (ILPMP)

Complete MVP Care Planning Assessment

Contact the patient’s PCP and/or pain specialist.

Medical alert “FYI” flag added to the

EMR for communication to

team

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Care Plan Communication

26

FYI Flag

Evolution of a System Procedure for MVP Care Planning

MVP Team Member meets

with patient Introductory Letter from

hospital administrators

Continued dependence

on system

MVP Care Plan developed

Care Plan disclaimer

Provider Communication

Letter

Ongoing monitoring

Generated by MVP Team

Hand delivery preferred

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This care plan is intended to supplement, rather than substitute

for professional judgement and may be changed based on individual

needs

10

Introductory Patient LetterOur goal at Northwestern Medicine is to provide excellent care to you throughout our

health system. Excellent care means that we evaluate your condition and offer appropriate

treatment in a kind, respectful, efficient and caring manner…..

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The Center for Disease Control (CDC) and many states have

developed guidelines for patients with chronic pain.

The focus is to make sure that patients with chronic pain receive

safe and effective pain care from their Primary Care Provider

or a Pain Specialist. We at Northwestern Medicine support

the CDC recommendations….

We’re concerned that receiving care in these settings may not

be in your best interest. Our goal is to help you receive the

coordinated care that your chronic pain condition requires in the

appropriate setting. Therefore, our clinical team at

Northwestern Medicine has reviewed your records and has

some important recommendations to assist you in managing

your chronic condition….We understand living with and managing a chronic pain

condition can be very challenging. Most patients find that a

combination of different types of treatments are needed to

improve pain relief and increase activity. Our clinical team will

meet with you to discuss your treatment options and if needed

create a care plan to coordinate your care within our health

system and with community providers….

Case Studies

Delnor Care Plan

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11

Go Live!

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52 yo female with chronic HA with psychiatric comorbidities, many years of hospital overuse. MVP Team Intervention: PCP established, scheduled appointments in OPIC for hydration & non opioid HA treatment. Established psychiatric providers, social support & Al-Anon referral

1st meeting Care plan Intensive intervention

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Central DuPage Care Plan

2

3

1

0 0

1 1 1 1

0 0

1

0 0

1 1

3

2

0

1

00

1

2

3

4

Aug Sept Oct Nov Dec Jan Feb March April May June

Vis

its

2015-2016

MW

Inpt ED

33

1st Intervention Care Plan Initiated

12

CDH Individual Patient Outcome Data

34

2.1

1.7

3.8

7

2.3

1.21

6.5

1.7

0.7

-43% -41%

71%

-76% -70%

-2

-1

0

1

2

3

4

5

6

7

8

MW KRS BL TS JC

CDH Average Monthly Visits

Avg visits/mo Pre-Care Plan Avg visits/mo Post Care Plan % Change

Delnor Individual Patient Outcome Data

35

2.32.5

5

4.1

2.3

2

1.5

1.2

1.6

1.2

3.5

2.4

2.7

3

3.5

1.5

4.3

1.5

3.25

3.7

2.9

3.3

1.4

2.7

1.7

5.1

2.83

1.4

0.8 0.80.6

1.3

0.3

0.9

2.1

7.7

1

0.3

2.6

1.31.1

1.4

1.7

1.3

0.7

17%

-32%

2%

-32%

30%

-30%-47%

-33%

-63%

8%

-91%

-63%

-22%

157%

-71% -80%

-40%

-13%

-66% -62%-41%

-61%-50%

-2

-1

0

1

2

3

4

5

6

7

8

9

JA AB AMC TD CF HD DJ JK MK SL TM MMM MK TR MR GS QA RS TS LT RT CW RY

Avg visits/mo Pre-Care Plan Avg visits/mo Post Care Plan % Change

Delnor MVP Process Impact Metric

36

2.29 2.11

-7.55

1.11 1.44

30

-10

-5

0

5

10

15

20

25

30

35

MVP Avg ED Visits/mo 2015 MVP Avg ED Visits/mo 2016 Percent change No Intervention Avg ED

Visits/mo 2015

No Intervention Avg ED

Visits/mo 2016

Percent change

MVP Intervention vs No Intervention

13

Individual Financial Outcome Data 2015-16 (CDH and Delnor)

37

-76%-96%

-48%-100%

-77%-95%

-89%60%

-65%-80%

-29%-21%

-83%-89%

-13%-92%

194%-93%

-72%-71%

-84%-83%

-71%-48%

-25%-100%

79%83%

-150% -100% -50% 0% 50% 100% 150% 200% 250%

% Change Average Monthly Charges per Patient

Summary of Overall Financial Outcome Data 2015-16 (CDH and Delnor)

38

$22,679.79

$11,544.62

$-

$5,000

$10,000

$15,000

$20,000

$25,000

Pre-Intervention Post-Intervention

Overall Average Charges/Month

49% Decrease

39

Ba

rrie

rs

Patient

Lack of insightJudgement by healthcare professionals

Pre-existing maladaptive behaviorsPsychiatric Co-morbid

Caregiver

System

Societal

14

40

Ba

rrie

rs

Patient

Caregiver

Education to ED and PCP providersMisconceptions, previous negative

interactionsLabor/time intensive process to

individualize Care Plans & ongoing (sometimes weekly) follow up with

providers & patients

System

Societal

41

Ba

rrie

rs

Patient

Caregiver

System

Lack of referral sources for mental health providers to address co-morbid psychiatric conditions

Lack of referral sources to addictionologists& treatment for Substance Use Disorder

Limited dedicated resources

Societal

42

Ba

rrie

rs

Patient

Caregiver

System

Societal

Payer sourceOpioidphobia

Lack of family supportJudgement for chronic conditions limiting

15

43

Polling Question

• Which barrier do you feel is the most challenging and

impacts your ability to care for your Multiple Visit

Patients?

• Patient

• Caregiver

• System

• Societal

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In Summary -Progress to date

Delnor begins

Patient Care Plans led by CC & Pain

APN

CDH creates Care

Planning Manage-

ment Team

Refined

process for

patient

identification &

care planning

Collaborate to refine NW

Region process

Implement MVP care plans at CDH

Ongoing care plans at Delnor

Development of MVP Procedure,

patient & provider letters &

care guidelines

Tracking patient and system outcomes

� Feb. 15 � Mar-April. 15 � April. 2015June, 2016

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� Sept. 14 April, 2016

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Next steps for growth & sustainability

1. Celebrate Success

2. Additional FTE for Care Coordination

3. Automated patient identification based on system utilization

4. Financial cost avoidance data

5. Readmission data after MVP team intervention

6. Partner with area hospital “MVP” teams

7. Development of evidence based care plans on common diagnoses

• Migraine Order Set (In Progress)

• Sickle Cell Crisis

• Cyclic Vomiting

• Opioid use disorder and withdrawal protocol

• Back pain

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Thank you to our teams!

Central Dupage Hospital

• Carol Tulley, Co-Chair Professional Development

Specialist

• Pam Nass, Manager Care Coordination

• Dan Doebler, BHS Counselor

• Corinne Grotenhuis, Social Worker

• Katherine Ball, Chaplain, Ethics Committee

• Joe Merryweather, PA Emergency Department

• Dr. Tom Eiseman, Emergency Dept Director

• Dr. Stephen Graham, Emergency Dept Physician

Delnor Hospital

• Sherri Johnson, Co-Chair, Care Coordinator

Jana Hossli, Social Worker

• Kelly Ryan, Manager Care Coordination

• Dr Eric Nolan, Psychiatrist

• Dr Brian Dunleavy, Emergency Dept Physician

• Fran Strong APN, Emergency Dept

• Emily Rowell, RMG Care Coordination

• Richard Watts, Chaplain, Ethics Committee

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System Support• Cori Zacher, VP Outpatient Services/Exec. Sponsor

• Jeannine Harvell, Director of Care Coordination

• Kim Czaruk, Director Patient Care Services

• Michael DeCrescenzo, Senior Analytics Consultant

References/Resources

• Allen, M., etal., (2014). A Framework for the Treatment of Pain and Addiction in the Emergency

Department. Journal of Emergency Nursing, 40(6), 552-559.

• Chang, Y,. & Yang, M. (2013). Nurses’ attitudes toward clients with substance use problems.

Perspectives In Psychiatric Care (49)2, 94-102.

• Gourlay, D., etal., (2005). Universal Precautions in Pain Medicine: A Rational Approach to the Treatment

of Chronic Pain. American Academy of Pain Medicine, 6(2), 107-112

• http://www.samhsa.gov/disorders/substance-use

• http://www.iasp-pain.org/Taxonomy#Pain

• https://intermountainhealthcare.org/ext/Dcmnt?ncid=521023323

• http://updates.pain-topics.org/2012/06/narcotics-vs-opioids-language-matters.html

• Institute for Clinical Systems Improvement

https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_ne

urological_guidelines/pain/

• Kunz, D. (2012)The benefit of a nurse-run pain service to manage frequently admitted persistent pain

patients. Presented at the ASPMN National Meeting, Baltimore, MA.

• Neighbor, M., Dance, T., etal. (2011). Heightened pain perception in illicit substance-using patients in

the ED: Implications for management. American Journal of Emergency Medicine, 29(1), 50-56.

• Todd, K., Ducharme, J. etal., (2007). Pain in the Emergency Department: Results of the Pain and

Emergency Medicine Initiative (PEMI) Multicenter Study. Journal of Pain, 8(6), 460-466

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Thank You!Contact us at:[email protected]@nm.org

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