strategies for reducing avoidable readmissions tn readmissions... · 2019-06-28 · driver #2:...

Strategies for Reducing Avoidable Readmissions

Kim Werkmeister, BA, RN, CPHQ, CPPS

Cynosure Health

What Drives Improvement in Readmissions?

The Readmissions Puzzle

Improvement?

▪ Where did you start?

▪ Where are you now?

▪ What’s working?

▪ What’s not working?

▪ How far to you need to drive?

▪ Which road(s) should you take?

A Few Things We Know

▪ There is no one thing

▪ There is no one person

▪ Interventions are both easy and amazingly difficult at the same time

Many Resources Available to Guide Improvement

Drivers for Improvement in Readmissions

Reduce Readmissions

Use data to inform improvement activities

Improve standard hospital transitions of care

Deliver enhanced services based on need

Collaborate with providers and services across the continuum

Driver #1: Use Data to Inform Improvement Activities

Use data to inform improvement activities

Analyze data to inform your targeting approach

Understand root causes of readmissions; elicit the patient, caregiver and provider perspectives

Periodically update your approach based on findings; articulate your readmission reduction

strategies

Develop a performance measurement dashboard to use data to drive improvement

Big Data, Little Data

Big Data – What Coded Data Tells UsData Drill Down Tool

Readmission by rate

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Understand: Who, What, Where, When, Why

▪Who is being readmitted?

▪What medical conditions are contributing to the most readmissions?

▪Where are the majority of readmissions coming from?

▪How long after discharge are they returning?

▪Why are patients returning? Determine the root cause of the unfulfilled need.

Your Turn

▪Using data provided to you, identify the following:

▪ Top diagnosis codes for your readmission population

▪ Top discharge disposition for your readmission population

▪ Any other important information about your readmission population

What Did You Find Out?

Trends?

Were you able to determine WHY they came back?

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Little Data: Why Did They Return? Really?

Little Data – What Our Patients Tell Us (The REAL Story)

Readmission Discovery Tool

Driver of Utilization Tool

Patient Interviews

Your Turn

▪At your tables, choose two participants to be the “patients” –patients will each receive a brief description about their history to use when being interviewed

▪Choose two participants to be “interviewers” using the ASPIRE interview guide to conduct two mock patient interviews

▪Conduct one interview at a time so the table can listen and take notes

▪As a group, discuss your findings from the mock interviews and identify a few “root causes” for the readmissions

Pulling Big Data and Little Data Together

As a group, based on the sample data and patient interviews, how might this organization prioritize their readmissions reduction efforts?

▪ Is there a population that needs focus?

▪ Is there an underlying root cause that needs to be addressed?

Driver #2: Improve Hospital Care Transitions Processes

Improve hospital care transitions processes

Engage patients and their families to identify the learner, understand care preferences and assess risk for readmission

Facilitate interdisciplinary collaboration on readmission risks and mitigation strategies

Develop a customized care transitions plan that includes patient preferences, risk factors and post discharge contact info

Use teachback and other health literacy tactics to optimize patient/caregiver understanding

Timely post-discharge follow up with patient and/or caregiver

Engage Patients and Families

▪Who is the caregiver?

▪Do we have a standard method for gathering this info?

Assessing Risk for Readmission

Teachback

Stop, Slow Down and Show Me

▪ Ask the patient (or family member) how they learn best.

▪ Provide instruction in plain talk

▪ Assess activation

▪ Ability to manage meds

▪ Understanding red flags

▪ Medical Follow up Plan

▪ Personal Health Record

How Do We Provide Information To Our Patients?

▪ Handing someone a stack of papers and going over a set of instructions won’t guarantee a successful transition from the hospital to home.

▪ People need more.

▪ They need a human touch, emotional recognition, and a sense that they’re not going to be left on their own as they try to recover from the setback that brought them to the hospital.

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We Can Do Better

What was communicated: ▪ Here is a prescription for pain medication. Don’t drive if you take it. Call your surgeon if you

have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to do great!

What wasn’t communicated: ▪ Here’s a number to call if you have any questions. Here’s the medical expert who’s in charge of

your follow-up care and how to reach him or her. Here’s the plan for your care over the next month, and here’s the plan for the next six months.

▪ Or this: You’re going to experience a lot of challenges when you get home. Here are the three or four concerns that should be your priorities. Here’s what your caregiver needs to know to help you most effectively. Here are resources in the community that might be of assistance.

Teach-back Resources

USE TEACH BACK www.teachbacktraining.org

• Training videos

• Conviction & confidence scales

• Tips on making standard work

How Do We Prepare Our Patients For Discharge?

DISCHARGE PAPERWORK/INSTRUCTIONS

DISCHARGE PHONE CALLS MAKE FOLLOW UP APPOINTMENTS

DISEASE SPECIFIC CLINICS

Driver #4: Collaborate with Providers and Agencies Across the Continuum

Collaborate with providers and agencies across the continuum

Identify clinical, behavioral, social and community based support organizations that share the care of your high risk

patients

Convene a cross continuum of providers and agencies that share the care of your high risk patients

Improve referral processes to make linking to social, behavioral and community-based services more effective

and efficient

Finding Agencies for Collaboration

▪Highest utilization for your population

▪Referral sources

▪Community agencies

Working With Partners

Hospitals, Pharmacies

Patients and Caregivers

Skilled Nursing Facilities, Long Term Care

Medical Home

Home Care Agencies, Palliative Care

Board and Care Organizations

Simple But Effective

▪ Get people in the same room

▪ Learn what everyone has to offer

▪ Learn what everyone's frustrations are

▪ Start with one issue and go from there

Hospital and Skilled Nursing 3 C’s Strategy

“3Cs”: COLLABORATION

SNF monthly meetings

SNF administrators and directors of nursing (DONs) invited

Development of mutual goals that are patient-centered

Dialogue opened and issues addressed

Case reviews of all 7-day readmissions - trends & action items identified

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ACH

“3Cs”: COMMUNICATION

Standardized Hospital to SNF Checklist

Standardized SNF to Hospital Checklist

Verbal handoff by nurse practitioner (NP) for high risk patients

Follow-up phone call by NP within 24-48 hours of discharge

Telepresence follow-up on high risk patients

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“3Cs”: COMPETENCY

Provided SNF RNs and LVNs education on specific topics (i.e. COPD, HF, Aspiration Pneumonia)

Needs assessment performed for future topics

Provided education at SNF meeting on special topics (i.e. Palliative Care and Conservatorship Process)

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Your Turn

▪Discuss with your table:

▪Who should we be partnering with in our organization?

▪What kind of collaboration is already occurring in our organization?

▪Where should we be meeting? (Is an opportunity already in existence that we can leverage?)

Driver #3: Deliver Enhanced Services Based on Needs

Deliver enhanced services based on

assessed needs of the patient

Palliative care

Condition specific programs

Pharmacy interventions

Complex care management

Emergency Department pause

Bright Spots in the Room

How are you approaching certain higher need populations in your organization?

How did you find out this population needed assistance/focus?

▪ Which patients will probably do well with “normal discharge”?

▪ Which patients need something more?

▪ Which patients need far more?

▪ How do you know?

▪ What do you do?

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Match needs with resources

Inventory Community Resources

https://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html

www.AuntBertha.com

Palliative Care▪ What are the challenges?

▪ Bright spots?

Emergency Department

Efforts

• Process to inform ED staff that this person had a prior admission

• Pause to interact in-person or on the phone with a care transitions team member

• Decision

• Admit

• Observation

• Home with follow up

What are you doing in your ED?

Highest Utilizer Strategies

▪ Identify highest utilizers▪ How many of your patients are admitted to the hospital 4 or greater

times in any calendar year?

▪ Learn what drives their utilization▪ More than chart audits

▪ Meet the needs of those patients▪ These changes will have far reaching effects for other patients

What are you doing for your highest utilizers?

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Highest Utilizer Strategies: Plan For Their Return

Little Data – What Our Patients Tell Us (The REAL Story)

Readmission Discovery Tool

Driver of Utilization Tool

Many Of These Patients Have, In Combination

• Acute clinical:• Sepsis, UTI

• Chronic clinical:• HF, COPD

• Behavioral health• Mood disorders• Substance use disorder

• Social issues

Methods of Identification

• Goal is real time identification when the patient arrives

• Flags

• Alerts

• Banners

• Lists

• Ideally automated

Some Drivers of Utilization

• Basic needs

• Unstable

• Isolation, anxiety

• Sent by someone else

• End-of-life

Do Something Different

Otherwise it’s groundhog day all over again

What Are The Drivers Of

Utilization?

Match the DOU(s) with the plan

If/Then

If DOU is

•Anxiety

• Isolation

Then

•Reassure

•Build trust

•Frequent contact

•High touch

If/Then

If DOU is

•Lack of advance care planning

•End-of-life

Then

•Determine goals of care

•Palliative care referral

If/Then

If DOU is

•Sent by someone else

Then

•Work with sender

If/Then

If DOU is• Need for food, shelter, etc.

Then• Address basic needs

• Locate community services outreach in ED

• Aunt Bertha

If/Then

If DOU is• Chronic instability

Then• Work to stabilize• Patient goal setting• ED care alert

Plan for Their Return

“If you fail to plan, you are planning to fail!”

Benjamin Franklin

Increase Stability Over Time

What does “Planning for their return” look like?

▪ “When they come back three days later it’s not, ‘Oh it’s you again,’ it’s, ‘How did that work out with that organization I put you in touch with? It didn’t work out? OK, let’s try something else.’”

▪ “You don’t take someone coming to the hospital 27 times in one month and expect them not to come to the hospital at all,” she said. “We take someone coming into the hospital 27 times in one month and try to fix a couple little things so maybe they’re only coming in 17 times next month.”

Expand time between episodes of care

Planning the plan?

What’s in it?

▪ You decide

▪ Balance brevity with depth of information

▪ Key elements to think about:

▪ Demographic information, care plan date or origin and most recent update, reason e.g. >4 hospitalizations in past 12 months, brief hx and DOUs, recent tests/results, clinical and support resources, key contacts, recommendations

Who completes it?

▪ You decide

▪ Establish accountability for creation, review and upkeep

Where is it?

▪ You decide

▪ Best practice alert, Note

What are we trying to

accomplish?

▪ Improve outcomes

▪ Decrease utilization

▪ by

▪ Identifying people with >4 hospitalizations in the past 12 months

▪ Finding out their drivers of utilization (DOU)

▪ Actively work to mitigate these DOU

▪ by

▪ Increasing connectivity between providers

▪ Tailoring clinical and non-clinical interventions

▪ Coordinating care

▪ Integrating disparate systems

▪ And addressing the social determinants of health

What does something different look like?

▪ Extensive outreach and engagement;

▪ Initial whole person assessment;

▪ Goal setting (What matters to you?)

▪ Care plan development;

▪ Health education/coaching;

▪ Frequent care team contact;

▪ Follow-up with patients after discharge;

▪ Direct linkages to housing, substance use disorder services, and other community resources

▪ Encouraging self-advocacy and personal accountability

http://www.chcs.org/media/HNHC_CHCS_LitReview_Final.pdf

What’s can we try?

▪ Patient engagement and activation▪ Are new skills and processes needed?▪ Building trust

▪ Cross continuum team/relationships▪ Who are we working with?▪ How do we link?▪ What do we need that isn’t currently available?

▪ Co-developed cross continuum plan▪ Do we have a template?▪ Who will complete/update it?▪ Where will it reside?

▪ People▪ Do we need non-traditional healthcare workers?

Your Turn

At your tables use the sample patient scenarios and the results of the patient interviews from this morning

Develop a personalized care plan for this patient that “plans for their return” but with a goal to increase the amount of time between visits

Patient engagement and activation

Attributes of Person-Centered Care

▪ Individualized, goal-oriented care plan based on person’s preferences.

▪ Ongoing review of person’s goals and care plan preferences.

▪ Care supported by interprofessional team in which person is integral team member.

▪ One primary or lead point of contact on health care team.

▪ Active coordination among all health care and supportive service providers.

▪ Continual information sharing and integrated communication.

▪ Education and training for providers and, when appropriate, for person receiving services and those important to that person.

▪ Performance measurement and quality improvement using feedback from person receiving services and caregivers.

https://interactives.commonwealthfund.org/2016/modelsgrid/table1.pdf

Motivational Interviewing –OARS

• Ask OPEN ended questions

• Offer AFFIRMING statements

• REFLECT patient’s ideas and feelings

• SUMMARIZE the patient’s perspective

https://motivationalinterviewing.org/

How Activated is Your

Patient?

• What’s the PAM?

• An evidence based tool

• 13 questions

• 4 levels of activation

• Improve activation = better outcomes

Patient Activation Measures

PAM Levels

How to Improve Activation

Patient Activation

Assessment

Maslow’s Hierarchy

Creating trusting relationships

• Engage with the patient in a sensitive, respectful, and strengths-based way

• Sit down

• Make eye contact

• Ask “What matters to you”?

• Ask “How do you think that could be accomplished?

• Request permission to offer suggestions

• Single point of contact

• Be there

• Follow up

It takes a village – Who is on your team?

Integrated Care Team

▪ IT/data

▪ Executive sponsor

▪ Clinical champion

▪ Project manager

▪ Dir. case management/social work

▪ Social worker/care transitions staff

▪ Emergency department champion

▪ Cross-continuum partners

▪Meets frequently to address the DOU

▪Think of them as a DOU pit crew

Informed Improvement Activities - What are you learning?

It takes a plan

Brief Action Planning

▪ The overall goal of BAP is to assist an individual to create an action plan for a self-management behavior that they feel confident that they can achieve.

▪ 3 Questions:▪ Q1:"Is there anything you would like to do for your health in the next

week or two?“

▪ Q2:"How confident or sure do you feel about carrying out your plan (on a scale of 0 to 10)?

▪ Q3: "Would you like to set a specific time to check in about your plan to see how things have been going?"

https://old.centrecmi.ca/wp-content/uploads/2013/08/Gutnick2014BAPevidenceJCOM.pdf

Do you have who you need?

Non-traditional healthcare

workers

▪ Provide cultural mediation;

▪ Deliver appropriate education;

▪ Ensure connections to needed services;

▪ Offering informal counseling and social support;

▪ Advocating;

▪ Providing direct services;

▪ Building capacity

Your Turn

▪Who in your organization should be on your team?

▪ Is there already something like this in place?

▪Discuss at tables

Bringing It Home

Bright Spots

Bright Spots

▪ Use of data to select target populations and priorities

▪ Interdisciplinary collaboration / Improved educational practices

▪ Condition specific programs / Complex care management

▪ Pharmacy involvement in care transitions

▪ Stronger collaborations with SNF & HH

Opportunities

Opportunities

▪ Learning from and engaging with patients

▪ Learning what matters most to patients

▪ Improved health literacy / validating understanding through effective teachback

▪ Use of an ED pause / mechanism to discuss complex patients prior to admit

▪ Discussion about/referrals to Palliative Care

▪ Collaboration with Behavioral Health, Social/Community Resources

What Are YOUR Bright Spots and Opportunities?

Readmissions Prevention Top 10

1. Enhanced patient assessment of discharge needs at time of admission

2. Assess risks for readmission and align interventions to needs

3. Accurate medication rec at admission, transfers, and discharge

4. Customized, literacy & culturally appropriate patient education

5. Identify primary caregiver & include in planning and education

6. Use teach back

7. Send discharge summary to PCP <48h of discharge

8. Build a cross-continuum team to collaborate across providers in region

9. Schedule appointments prior to d/c; work to find unassigned pts a PCP

10. Conduct post discharge phone calls <48h of discharge

Get Started

▪ Identify YOUR Readmission reduction goal

▪ Identify YOUR target population

▪Apply population-specific strategies

▪Choose one new idea to test

Readmissions Resources

▪ Readmissions Change Package

▪ ASPIRE Guide

▪ Trail Guide

▪ Readmissions Top Ten Checklist

▪ Readmissions Whiteboard Video Series

▪ HRET-HIIN Hospital Wide Topics LISTSERV

▪ Huddle for Care Discussion Forum

▪ Discovery Tool, Driver of Utilization Tool, Data Drill Down Tool, ASPIRE Interview Guide

Thank You!

Kim Werkmeister, BA, RN, CPHQ, CPPS

Cynosure Health

kwerkmeister@cynosurehealth.org