Emergency Department/Hospital Inpatient Initiative

1 | Group Health Solutions for Transforming Care

Kate Brostoff, MD, medical director, APPLE (Acute, Post-acute, Pharmacy, Laboratory, Emergency) Patient Resources & Options, Group Health Physicians

Brenda Bruns, MD, executive medical director, Health Plan Services, Group Health Physicians

Barbara Trehearne, PhD, RN, vice president of Clinical Excellence, Quality, and Nursing Practice, Group Health

Barbie Wood, RN, MBA, director, Care Management Services, Group Health

Emergency Department and Hospital Inpatient Initiative


OBJECTIVES

• Improve health care quality for our patients by streamlining care transitions

• Reduce avoidable costs during care transitions

• Reduce preventable hospital admissions, readmissions, and ER visits


GOALS

• Improve the patient experience

• Ensure the best possible outcomes


PATIENT EXPERIENCEPATIENT EXPERIENCE


STRATEGIES

• Pre-admission assessment for alternative placement/services

• Personalized transition management for admitted patients

• Coordinated transitions with skilled nursing facilities and home health agencies

• Engaging patients with their end-of-life choices

EPRO

Transition Mgmt

SNF Discharge

Palliative Care


PATIENT EXPERIENCEPRE-ADMISSION ASSESSMENT | Emergency Patient Resources and Options (EPRO)


PROVIDING ALTERNATIVES TO ED AND HOSPITAL ADMISSION | 24/7 Telephonic Physician + Care Mgt RN Team

• Urgent Care access expanded

• Same day or urgent primary care and specialty appointing

• Next morning guaranteed home health RN visit

• Direct Skilled Nursing Facility placement

• Options to avoid “social admits”

• Telemetry Observation in UC or Extended Observation Service care

• 24/7 Benefit assessment and explanation

EPRO: 2011 Expansion

1/1/2011: Primary Care Pilot using EPRO for all hospitalizations

EPRO


PATIENT EXPERIENCEPLACEMENT


PATIENT EXPERIENCEADMISSION


PATIENT EXPERIENCETHE METHOD | The Four Pillars

Teach

Medication

Self-

management

Teach a

patient about

their condition

and use of

a personal

health record

Provide

knowledge

of warning

symptoms

and how to

respond

Have a

patient set

up follow-up

care with

their doctor


Patient Sorting Criteria Red Pathway – Needs Palliative Care CMLN/MSW • Would benefit from a Palliative Care Plan • Score 4 or more on Palliative Care Screening tool • “Would you be surprised if this person died in the next

year – Answer, “no” • Patient/Family expressing openness to talk abo ut

palliative care/end of life issues. Yellow Pathway – Discharged Home CMLN unplanned admissions, CMLN/DCP planned admissions if needed for leveling. • Is a Readmit • Plans are complex or have a need for continuity of care • Has a primary diagnosis of a Chr onic Disease • Significant medications changes made during LOS • Significant concerns with self -medication management Green Pathway – Transferring to another facility DCP/CMLN Discharge Planning Meets SNF/Rehab criteria Transfer to LTAC for continued weaning , wound care, etc. Blue Pathway – Meet & Greet Care Partner No significant discharge needs Discharge planning prior to hospitalization Less than or equal to 2 day LOS Not in isolation Not short stay/ambulatory surgeries

DAILY HUDDLE AND PATIENT IDENTIFICATION

Using new standard scripting and processes, staff manage patient care tightly and collaboratively via a daily huddle:

• UPON ADMISSION, sort patients into 4 pathways

• EACH SUBSEQUENT DAY, review patient progress and daily plan, discharge planning, and expected next steps.

• FOCUS ON AVOIDABLE DAYS, review whether admission / day was avoidable, LOS against expected target, and if a re-admit, what they could have improved to avoid the re-admit.


TRANSITION MANAGEMENT | How do we do it?

WITHIN THE HOSPITAL• Huddle

• Transition Coaching (4 pillars)

• 48-Hour Post-Discharge Phone Call

• Readmit and Long Length of Stay Reviews

• Avoidable Days / Admissions Capture

Transition Mgmt

SNF Discharge

WITHIN THE SNF• Timely SNF Placement

• SNF MD Rounding within 48 Hours

• ARNP Rounding within 72 Hours

• POLST / DPOA Confirmation or Completion


HOSPITALIST / CARE MANAGEMENT PARTNERSHIP | Collaborative Standard Work

• Participate in daily huddle

• Transition management dictation

• Palliative care review, discussion, and dictation

Upon patient admission• Participate in daily huddle

• Transition coaching using 4 pillars

• Schedule 7-day and 14-day follow-up visits with primary provider

• Readmit and long length of stay reviews

• Avoidable days/admissions capture

Upon patient discharge• 48-hour post-discharge phone

call

HOSPITALISTS CARE MANAGERS


HOSPITAL BASED MD TRAINING

•Communication skills focused on setting Goals for Care, End of Life planning

•Decision support tools for identifying patients in need of those conversations

•Lean principles including Standard Work

•Daily Management system


Would you be surprised if this patient died within the next 2 years?

PALLIATIVE CARE SUPPORT

PPS = 10% = 3 pts Totally bed bound ; no activity, total care ;

no oral intake; drowsy/ coma

PPS = 20% = 3 pts Totally bed bound; no activity, total care,

minimal oral intake; drowsy/confused

PPS = 30% = 3 pts Totally bed bound; no activity, total care,

reduced oral intake; drowsy/confused

PPS = 40% = 2 pts Mainly in bed; limited activity, assistance required; normal/reduced oral intake; full

consciousness to confused

PPS = 50% = 2 pts Mainly sit/lie; una ble to work; considerable

assistance; normal/reduced oral intake/ full consciousness to confused

PPS = 60% = 1 pt

Reduced activity; unable housework; occasional assistance; normal intake; full

consciousness to confused

Disease ProcessFunctional Status Level of Intervention+ =

Source: Pyramid tool adapted from Victoria Hospice Palliative Performance Scale; Disease Process Assessment adapted from a variety of hospital-based palliative care service tools.

Basic Disease Process (2 pts each) Cancer (metastic/recurrent), ad vanced COPD, stroke w/ decreased Function by at least 50%, end stage renal disease, adv. cardiac disease (CHF, severe CA D, etc), other life -limiting illness

Concomitant Disease Process (1 pt each) Cancer (metastic/recurrent), ad vanced COPD, stroke w/ decreased Function by at least 50%, end stage renal disease, adv. cardiac disease (CHF, severe CAD, etc), other life -limi ting illness

Other Criteria (1 pt each) Not a candidate for curative therapy Has life -limiting illness & declined life prolonging therapy Unacceptable pain or symptoms > 24 hours Has inadequate care system Readmit < or = 7 days Readmit < or = 30 days Frequent visits to ED Prolonged LOS w/o evidence of progress Prolonged stay in ICU w/o evidence of progress Is in an ICU setting with poor/futile prognosis Score = 2:No intervention/Score = 3: Observation Score = 4 or more:Palliative Care discussion

Score = 2 ptsNo intervention

Score = 3 ptsObservation

Score = 4+ ptsPalliative Care Discussion

Palliative Care


PATIENT EXPERIENCEPOST-DISCHARGE


CONNECTING BACK WITH OUR MEDICAL HOME

Key leadership within our Medical Home and Specialty divisions helped guide how patients would be reconnected back to their primary provider.

Key Points include:

• All patients called within 7 days following discharge from the hospital by a clinical pharmacist to reconcile medication

• All patients receive 14-day face to face visit with Physician post-discharge

• Initiate palliative care conversations as appropriate/when needed

• Specialists integrate transition management into hospital care of patients (in progress to be completed by end 2009), and incorporate palliative care planning into regular workload (expected 2010)


Patient

Satisfaction:

SEPT 2010

DEC 2009

91st percentile

74th percentile


OBJECTIVES• Reduce inpatient costs and readmit rates by providing consistent and reliable post-acute care transitions

• Optimize post-acute care processes

• Reduce unnecessary Emergency Department (ED) utilization and costs

$51 million total savings for 2010

METRICS• Readmit rate

• IP admit rates

• Hospital length of stay (LOS)

• SNF admits/1,000

• SNF LOS

• ED visits/1,000

GOALS AND MEASUREMENT


$51mHOSPITAL

COST SAVINGS


RESULTS


Medicare patient readmission:

NATIONALLY:

19.6%

WASHINGTON:

16.4%

GROUP HEALTH:

15%


OVERALL IMPROVEMENT

Medicare inpatient admits by 6.3%

Medicare inpatient days by 3.3%

Non-Medicare inpatient admits by 7%

Non-Medicare inpatient days by 10%

SNF Medicare admits

SNF Medicare inpatient days by 5%

ER visits by 5%

Health & Medicine

Emergency Department/Hospital Inpatient Initiative