2016 ihi webinar series - tennessee center for …...2016 ihi webinar series rhonda dickman, rn,...

Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar

3/20/2014

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2016 IHI Webinar Series

Rhonda Dickman, RN, MSN, CPHQ

Rhonda Dickman is a Quality Improvement Specialist with

the Tennessee Hospital Association’s Tennessee Center

for Patient Safety, supporting hospitals in their quality

improvement work, particularly in the area of

readmissions. She is also the clinical manager of the

Tennessee Center for Patient Safety’s PSO (patient

safety organization).

Rhonda has worked in the field of hospital quality

management since 2006 and has a clinical background in

trauma, critical care, oncology, and organ donation.

[email protected]

615-401-7404

mailto:[email protected]


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Introduction to Webinar Series

Exclusive program for clinical leaders in hospitals that are part of the Tennessee Hospital Association Hospital Engagement Network (HEN)

Focused on supporting clinical leaders who supervise front-line staff

18 webinars in total

1.5 contact hours for each webinar

Transitioning to new webinar platform

How to chat


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How to chat

How to chat


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How to chat

How to chat

Roll Call

Please chat your

name, organization,

and number of

people listening with

you today


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How to communicate with presenters

How to make your mark


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How to point to a spot


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How to answer a poll

How to find materials


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Kathy Duncan, RN Kathy D. Duncan, RN, Director, Institute for Healthcare Improvement (IHI), oversees multiple areas of content, directs multiple virtual multiple learning webinar series. Currently she serves as Faculty for the AHA/HRET Hospital Engagement Network (HEN) 2.0 Improvement Leadership Fellowship Ms. Duncan also directed content development and spread expertise for IHI’s Project JOINTS, an initiative funded by the Federal Government to study adoption of evidenced-based practices. In 10 US States, Project JOINTS spread three evidence-based pre-and perioperative practices to reduce the risk of surgical site infections in patients undergoing total hip or knee replacement. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She has also served as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care, Orthopedics and Neuro for a large community hospital.

Peg Bradke, RN, MA

Peg M. Bradke, RN, MA, has held various administrative positions in her 25-year career in heart care services. Currently she is Vice President of Post-Acute Care at St. Luke's Hospital in Cedar Rapids, Iowa, where she oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also serves as faculty for the Institute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (STate Action on Avoidable Rehospitalizations) initiative.


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Gail A. Nielson, BSHCA, RT(R), FAHRA Fellow and Faculty of the Institute for Healthcare Improvement (IHI). Nielsen is the former system-wide Director of Learning and Innovation for UnityPoint Health (formerly Iowa Health System). Her current work as faculty for IHI includes reducing avoidable readmissions and improving transitions in care, leading 2-day Reducing Readmissions seminars, improving the quality of care in nursing facilities, and other assignments. Nielsen’s ten years of experience in improving care transitions and reducing avoidable readmissions began during her 1-year IHI Fellowship. Her most recent experience includes system-wide work in Iowa; four years in the STAAR initiative across three states: Massachusetts, Michigan, and Washington; and support to Hospital Engagement Networks in multiple states. Additional past areas of expertise and work with IHI includes six years on the Patient Safety faculty; four years on the faculty for Transforming Care at the Bedside; engagement and patient-centered care; reducing falls and related injuries; spread and scale-up of innovations; and ACOs-Post Acute Care.

Objectives:

Assess their current challenges in reducing avoidable readmissions and identify opportunities for improvement.

Use proven communication methods to better understand a patient’s post-acute care needs and capabilities

Make their care more person-and family-centered to improve coordination and transitions across the continuum of care

Describe methodologies for clarifying opportunities for improvement from the diagnostic review

Assess current challenges in reducing avoidable rehospitalizations and identify opportunities for improvement

Build an effective improvement team including patients and families as well as acute, post-acute and community care partners


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Action Period Assignment:

Go Observe: “Be a patient”

The Always Use Teach-back! Toolkit

www.Teachbacktraining.org (view at least one

training module and review the site).

Teach Back Observation tool with one patient

being taught by a nurse. (this is also in the

online toolkit)

Teachback: How did it go?

http://www.teachbacktraining.org/


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Developing Post-Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke

These presenters have

nothing to disclose

March 2016 : THA

Assume one of the following roles :

Patient Caregiver

Sending Hospital dept. Receiving SNF

Hospitalist Medical Director SNF

Home Care Clinic Physician

Outpatient Social Worker Community Serv. Agency

Chat in your ideal transition into the

that setting……….(what would you need or

want in that transition)


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“….effectively communicate the

plan of care (based on the

assessed needs and capabilities)

to the patient/caregiver and

community-based providers of

care?”

How Might We….

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.

Simply

What do we know about the

patient/caregiver that will help

the next level provide the needed

care in the transitions?

How will we communicate that?

Sender Role vs Receiver Role


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Identifying Opportunities

• Visually display the patterns of

return to hospital within 30 days;

what questions arise?

29

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

# o

f patie

nts

readm

itte

d

# of days between discharge and readmission

Frequency of Readmissions by Number of Days Between Discharge and Readmission


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Opportunities: Observe Current

Discharge Processes


Identifying Opportunities (cont.)

Follow a patient as they transition to a SNF

facility, or home care visit.

– Was the information the receiver need there?

– Did the patient see/feel that information important

to them had been communicated?

– Where were opportunities for improvement?

Interview a Primary Care Office to determine if

they are receiving the appropriate information to

receive the patient back in the clinic


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Recommendations

Risk Level: Review daily the patient’s medical and social risk and/or barriers that would contribute to a readmission.

Customized plan of care: with real-time critical information to the patient and next clinical care provider(s).

Timely follow-up care: initiate clinical and social services as indicated from identified post-hospital needs

Determine capabilities of the patient/caregiver and the post acute services to meet the identified needs


High Risk

Risk


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Assess Risk of the Transition

Build risk-assessment into clinicians workflow in order to identify patients/caregivers at risk

Number of risk-assessment tools are reported in the literature (BOOST, LACE, IHI, Transitional Care Model (TCM), etc.)

Inconsistencies regarding which characteristics and/or variables are most predictive of patients who are at risk for readmissions

Equip clinicians with the training and tools to match patients to the most appropriate level of care.

Eric Coleman, MD: Identification of Patients at

Risk for Admission

Ideally a risk tool would not only identify those at high-risk for readmission but more precisely those who have modifiable risk.

– In other words, risk tools should be aligned with what we understand about how our interventions work and for which patients our interventions work best

In the case of heart failure, we should be careful to not assume that the primary readmission for heart failure is after all…the heart

– Low health literacy, cognitive impairment, change in health status for a family caregiver, and more may be greater contributors than left ventricular ejection fraction


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Eric Coleman, MD: Identification of Patients at

Risk for Admission (cont.)

Asking the patient to describe, in her or his own words,

the factors that led to the hospitalization and where they

need our support may provide greater insight into risk

for return-

Non-patient factors may have a larger role in

readmission rates, such as the health care system and

access

Include the Patient’s Perspective

Ask patient/caregiver:

• What matters most to you during this transition?

• What are your concerns or worries about going home or to the next care setting?”

• Who do you want involved in your transition (your Support person)



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Proposed Agenda for

Patient Care Rounds

Reasons for this admission? Are health care teams’ and patient’s/caregiver’s goals in sync?

What needs to happen during this hospitalization?

What post-acute plan of care will meet the patients’/ caregivers’ level of activation and comprehension of the plans? (using teach-back)

Routinely ask: “what is the likelihood that this patient will be readmitted in the next 30 days?”

– If the likelihood is high, why?

– What services can be put in place to mitigate potential problems?

IHI’s Approach: Assess the Patients Medical

and Social Risk for Readmission

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the

Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for

Healthcare Improvement; June 2013. Available at www.IHI.org.

High-Risk Moderate-Risk Low-Risk

Admitted two or

more times in the

past year

Patient or family

caregiver is unable

to Teach Back, or

has a low confidence

to carry out self-care

at home

Admitted once in the

past year

Patient or family

caregiver is able to

Teach Back most of

discharge information

and has moderate

confidence to carry

out self-care at home

No other hospital

stays in the past

year

Patient or family

caregiver has high

confidence and can

Teach Back how to

carry out self-care

at home


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Customized Plan of Care Develop one comprehensive assessment and plan for patients post-acute care needs that integrates input from all members of the care team

– Make sure each member of the care team is clear about what information they must bring to the assessment and plan

• Consider: Patients Preferences,

Patient Capabilities

Activation Level.

Change the focus on daily patient care rounds to include a discussion on current site but anticipating needs for next site

Develop Bidirectional dialogue and collaboration between sender and receivers

Key Elements in Transitions of Care

• Ensure that the patient and caregivers are present for

discharge instructions

• Provide both the patient and caregiver a copy of the written

discharge instructions

• Use Teach Back in your discharge instructions

• Highlight important points in the patient’s d/c instructions

• Provide instructions that give them actions of what to do

• follow-up care, list of reasons to call for help and phone numbers for emergent and non-emergent questions.

• what to expect when they return home and medication instructions



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If the patient is transitioning home and will be receiving care in primary care office or specialty practice:

• Ensure timely and action oriented discharge summary that arrives prior to the patient’s visit

• Final reason for Hospitalization

• Recommendation for f/u

• Pending studies needing attention

• Arrange for access to patient discharge instructions in the office practice

• Determine how you can add value to the TCM in the Patient Centered Medical Home

Timely Follow Up Care

Our Most Formidable Challenge

Year after year we try to improve med rec

However gains have been modest

Not due to lack of trying

Why do you think medications represent

our most formidable challenge?


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Reconcile Medications

Review the patient’s pre-hospital and hospital medication

regimens:

– Name each medication clearly and reason for taking

– “Red stop sign” for discontinued medications

– Highlight changes compared to pre-hospital medications

– Clear instructions for medications that should NOT be

taken

– Reconcile medications with formulary of skilled nursing

facility

– Have both Generic and Brand names

Look for ways to simplify the medication regime.

Identify medication schedules that are unrealistic in a

home setting and propose a more realistic schedule.

Use Teach Back to reinforce what the patient should take.

Help the patient and family caregivers understand the

importance of taking their list to all appointments and

ensuring it is updated in real time.

Emphasize the advantage of building a relationship with

one retail pharmacy.

Helpful Tips for Patients & Families


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Resources for Creating User-friendly

Medication Lists

How to Create a Pill Card

For more information, please visit the patient

safety and errors section at:

http://www.ahrq.gov/

Iowa Healthcare Collaborative (IHC)

Med Card

For more information, please visit:

http://www.ihconline.org/aspx/consumerresources.aspx#MedCard_Anchor

Warm Handover to Community Partners

Written handover communication for the patient

at risk is insufficient : direct verbal communication

allows for inquiry and clarification

http://www.ahrq.gov/

http://www.ihconline.org/aspx/consumerresources.aspx


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Transition to Home Health Care, Long-term Care,

Skilled Nursing or Other Community Settings

• Consider establishing HHC, SNF or LTC

liaisons that are based in the hospital (ex.

HHC liaison helps MDs determine

qualifications for HHC)

• Work with Liaisons and community partners

to standardize critical information to be

included


Skilled Nursing Facility or Other Community Settings


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Skilled Nursing Facility or Other Community Settings

Co-design handover communication

processes (i.e. preferred formats for

information)

Create processes for bidirectional

communication for care coordination,

continual learning and ongoing

improvement efforts

Handovers to Home Health Care, Skilled

Nursing Facilities or Community Services

• Share patient education materials and

educational processes across care settings

• Offer education for the staff in HHC, SNF,

LTC and community services


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Post-hospital Follow-Up Phone Calls

Have been frequently cited as a cost-effective

method to enhance communication with

patient/caregiver in the critical period following

discharge

Give patient/caregiver the opportunity to reinforce

education and assess self-care knowledge through

the use of Teach Back

There is little standardization or consensus on the

timing and frequency of post-discharge follow-up

calls

Johnson M, Laderman M, Coleman E. STAAR Issue Brief: Enhancing the Effectiveness of Follow-up Phone Calls to Improve Transitions in Care. Cambridge, MA: Institute for Healthcare Improvement; 2012.

How much coordination do you have?

• How many services are wrapped around the

patient/ caregiver? • Are all the services communicating? Do they all understand the

Plan of Care?

• If there are multiple services involved is a “lead person” identified

and communicated to the patient/caregiver and the care team?


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How much coordination do you have?

• How many phone calls is that patient/caregiver

receiving after they get home? • What are each of the calls purposes?

What Are We Learning About Providing

Handover Communications?

• There are a “vital few” critical elements of patient information that should be available at the time of transitions for the community providers

– “Senders” and “receivers” agree upon the information and design reliable processes to transfer information effectively

• Written handover communication for an at risk patient is insufficient; direct verbal communication allows for inquiry and clarification

• Written plan of care for patients and caregivers should use clear, user-friendly formats for describing care at home


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Assignment for next session

Follow a patient as they transition to a SNF facility, or go with Home Care on a home care visit.

– Was the information the receiver needed there?

– Did the patient see/feel that information important to them had been communicated?

– Where were opportunities

for improvement?

OR

Do an observation of a

discharge process?

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Observe Current Discharge Processes



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Assignment Options for next session

Interview a Primary Care Office to determine if

we they are receiving the appropriate information

to receive the patient back in the clinic

OR

Do a random chart review and determine

percentage of time post hospital

appointments are made for the patient

prior discharge.

Call Number 5

Developing Post Hospital Follow up care plans and real

time handover communication

March 16 – 1-2:30 EST

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2016 ihi webinar series - tennessee center for …...2016 ihi webinar series rhonda dickman, rn,...

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