S .T. A . R .T. W I T H T H E PAT I E N T:

A S A F E T R A N S I T I O N A S S E S S M E N T A N D R I S K T O O L

M A R Y L A N D P A T I E N T S A F E T Y C E N T E R

A P R I L 2 0 1 8

S T A R T B Y D O I N G W H A T ' S N E C E S S A R Y,

T H E N D O W H A T ' S P O S S I B L E ;A N D S U D D E N L Y Y O U A R E D O I N G T H E I M P O S S I B L E .

- S T . F R A N C I S O F A S S I S IRE

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LEARNING OBJECTIVES

1. Describe the process of development and implementation of the START Status Board in the context of a collaborative interdisciplinary workgroup.

2. Identify risk stratification methods, interventions that mitigate readmission risk factors, and appropriate resources for patient transitions.

3. Discuss sustainability strategies for the START tool to improve the quality and experience of care transitions for patients.

US HEALTHCARE SPENDING BY POPULATION PROPORTION

1%

5%

20%

50%

51-100%

22%

49%

80%

97%

Source: AHRQ

98-100%

Percent of Population

Percent of Health Expenditure

HCAHPSDischarge

Coordination

TM

Engagement

NTMO

HAI

Rounding

CDU

CCTA

Just Culture

Empathy

Experience

Efficiency Quality Safety

FY17 ImprovementProjects

FY18 Strategic Initiatives

Measurement

Reporting/Analytics

Advisory

FY19 Integration

ED Throughput

PPCCentralized

Transport

Physician

Engagement

Care

Transitions

Sepsis

MHAC

Workgroups

Reporting/Analytics

PFCC Advisory

Do No Harm (HRO)

Transformational Leadership

Patient Family-Centered Care

Pat

ient

Safe

ty (

Just

Culture

)

Contin

uous Im

pro

vem

ent C

ultu

re

ORGANIZING FOR HIGH RELIABILITY

TRANSFORMATIONAL LEADERSHIP

Transitions of Care

Patient Model of Care Steering

Committee

Patient and Family

Centered Care Oversight Council

• For both Fiscal Year 2017 and Fiscal Year 2018, the TOC work was highlighted as a primary Operating Plan objective, which is reported up through our Chief Executive Officer.

• Our leadership believes this work is critical to the achievement of our organizational objectives for safe, quality, empathetic and efficient care for all our patients.

• The work also aligns with our strategic goals of innovation, better patient outcomes, and integrated health care delivery.

CULTURE OF SAFETY

• The goals of Transitions of Care were to

enhance our culture of safety by:

- Providing Structured Communication

- Mitigating Risks Proactively

- Decreasing Errors Due to Safer Transitions

The Patient Safety Program serves to promote compassionate and high quality, clinically effective care to patients across the care continuum.

CONTINUOUS IMPROVEMENT IMPRVis a continuous improvement

framework and business engagement strategy designed

to improve the patient experience, reduce operational

waste, and transform the culture of our organization.

IMPRVwas founded upon UM UCH’s

Culture of Excellence and leverages industry-leading

techniques and tools from Lean, Six Sigma, Business Process

Reengineering, and Project and Change Management

disciplines.

PROJECT CHARTER & GOALS

Effectively managing patients under the new Global Budget model requires excellent communication, education and collaboration across the entire continuum of care for patients in our community. Utilizing the START tool in Meditech to identify appropriate interventions to optimize safe discharge. We need to coordinate and operationalize the selected interventions to mitigate identified risks.

• In: IT platform for communication across continuum, patient stratification data, E-Discharge, Patient Education, Teach Back, Meditech Patient Portal, TNN/CM delegation protocols, Care Center referral process, call backs for high risk patients, PCP communication, patient appointments, Discharge Care Plan, coordination with Behavioral Health, coordination with Palliative Care.

• Out: Coordinated Inpatient Model of Care (do not duplicate efforts); Med Rec. Dr. First.

• Decreased 30 day readmission rates• Patient Experience metric improvement for transition of care and

discharge• Explore the opportunity to effectively stratify patients to focus resources• Increase number of appropriate referrals to Comprehensive Care Center • Streamline processes for referrals to Community Resources• Standardize Patient Educational Information (Health Literacy)• Develop Teach Back Education & Competencies (Observation)• Achieve 90% utilization of E-Discharge for inpatient providers• Percentage completed nursing callbacks for identified patients (80%)• Define delegation of patients to either TNN or CM and appropriate

resources. (protocols)• Develop consistent protocols for chronic disease management with

community partners.

• Human Behavior (resistance to change current processes)• Human Resources (FTE’s)• Financial/ Capital Resources• IT Infrastructure/ Resources• Staff Education • Effective Measurement of Success/ Data Extrapolation• Team Member/ Unit/ Provider ownership of changes• Patient Engagement• Infrastructure in Place to Coordinate Care Post Discharge

Process Opportunity Scope Definition

Objectives & Benefits Constraints & Dependencies

IDEN

TIFY

BASELINE DATA

Rate = [Observed RA/Expected RA * CY Statewide RA Rate]

Data is for full 12 months in each Calendar Year

11.1311

13.86

12.93

0

2

4

6

8

10

12

14

16

2015 2016

Per

cen

t R

ead

mis

sio

n

Calendar Year

UCMC vs State RRIP Readmission Data

UCMC MD

MEA

SUR

E

BASELINE DATAM

EASU

RE

FY16 HCAHPS Data by Quarter

BACKGROUND LITERATURE REVIEW

• Research literature and evidence

• Agency for Healthcare Research and Quality

• Assess if established programs will meet our needs

• Leverage technology to meet objectives

PR

OC

ESS

READMISSION RISK FACTORS• Diagnosis:

- Cancer, stroke, diabetes, COPD or heart failure

• 180 days:

- Non-elective admission in the past 6 months

• Polypharmacy:

- Equal to or greater than 10 routine medications

• High Risk Medications:

- Insulin, anticoagulants, oral hypoglycemic agents, dual antiplatelet therapy,

digoxin or narcotics

• BRIEF:

- Assesses health literacy, inability to do teach back

PR

OC

ESS

• Activity:

– Physical assistance needed for patient mobility

• Support:

– Current level of assist available in home setting

• Palliative:

– If patient has a progressive illness that requires management by

palliative care team

• Depression:

– Using the PHQ-9 assessing the patient’s risk for depression

READMISSION RISK FACTORSP

RO

CES

S

CURRENT STATE EVALUATIONCategories Currently

Documented?

Who/Where? If No, Who

Should/Where?

Comments

Polypharmacy > 10

Routine Medications

Yes Physician Orders,

Medication

Reconciliation,

Home Medication

List

Pharmacy, Case

Management address

at admission, 2 hours

after admission,

throughout stay,

formulary issues, drug

classes, possible

query for hospitalists

Depression Screening Screening- No; H/O

Depression- Physician

H&P Depression Screening-

Suggest Nurse Responsible

PHQ-9

High Risk Diagnosis- CHF,

COPD, Diabetes, Stroke,

Cancer

Yes Physician H&P,

Problem List,

Progress Notes,

Nursing

Assessment

Can this be pulled?

PR

OC

ESS

CREATION OF THE S.T.A.R.T. STATUS BOARDR

ETH

INK

Step 1:• Understand current queries and information in the EMR

Step 2:• Create new queries/assessments to populate a “Yes”

Step 3:• Build in TEST

Step 4:• Build in LIVE

Step 5:• Validate the START Board and pilot on one unit

S.T.A.R.T. STATUS BOARDR

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INK

INTERVENTIONS

INTERVENTIONS TO MITIGATE RISKSIN

TER

VEN

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RISK/INTERVENTION MATRIXFollow-Up

Phone CallsPatient

Appointments

Patient/Caregiver Education

PCP Engagement

Post DischargeCare Plan

Transition Coach (TNN)

MedicationCommunity Resources

High Risk Meds/Polypharmacy

x XElimination of

unnecessary meds

x x

Depression Risk x x

High Risk Diagnosis

x

Mobility Limitations

x x

BRIEF x x x x x x

Support Network

x x x XCare Plan

x x

180 Days x x x

Palliative Care

INTE

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ON

S

IMPACT/EFFORT MATRIX• Utilized an Impact/Effort

Matrix to rank priority

of interventions based

on impact the

intervention would have

to the readmission risk,

and the effort it would

take to implement.

• Matrix was then used to

develop project plan

and begin work on

interventions.

AUTO GENERATE CONSULTS• Palliative Consults

– A palliative care screening question was designed

– “Does this patient have a condition likely to be progressive, debilitating and/or life limiting?”

– If answer is “Yes“, an automation consult is ordered for the patient to be screened by the palliative team

– PC Team determines appropriateness for interventions, i.e. advance directives, goals of care, etc.

• Behavioral Health Consults

– The Patient Health Questionnaire (PHQ-9), a depression-scoring tool is documented during all inpatient

admissions within the EMR

– Score auto populates to the START Status board

– Nursing protocol developed to automate a Behavior Health consult for all patients whose scores were in the

moderate to severe depression range

• Comprehensive CARE Center

– If a patient has four or more “Yes” on the START Board, a consult is automatically generated for our high-risk

Transitional Nurse Navigators

INTE

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CARE ALERT & S.T.A.R.T. TOOL REPORT: TNN AND CASE MANAGER

Room Name Age 1st InsArrival Date

Readmit Status LOSLACE Score

Care Alert

Dx 180 Poly Med BRIEF Actv Support Palltv DepressionCare

Manager

U100-1 Mouse,Mickey

77 MCC 2/20/18 ! IN 6* 15 Y Y Y Y Y NONE SUE X1166

U101-1 Hill, Snow

88 UNITDHMO

2/22/18 IN 4* 11 Y Y Y Min Risk SUE X1166

U102-1 Duck,Daisy

65 MCC 2/21/18 INO 5 Y Y $ Y SevereRisk

LIZ X3928

U103-1 Bees,Burt

34 AMERIGRP

2/25/18 ! INO 1 Y NONE SUE X1166

INTE

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PATIENT CALLBACK PROGRAM• Stratification of Callbacks into 4 categories:

1. Comprehensive Care Center

2. High Risk

• Focus on:

– Medications- Understanding of purpose and side effects of new medications and

whether patient could get prescriptions filled

– Follow up appointments

– Referrals to Case Management

3. Patient Experience

4. Provider

• Development of report to eliminate duplication of calls

• Utilization of report to assess readmissions

INTE

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PATIENT CALLBACK SCRIPTIN

TER

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HIGH COST MEDICATIONS Identified high-risk medications

with high out-of-pocket costs

Added a “$” to the selected

medications

The $ displays on the:

EMR ordering screen

Medication Administration

Record

Prescriptions

Discharge Instructions

START Status Board

Each $ sign represents $100 in

out-of-pocket costs (i.e.

$$=$200,$$$, $$$$ >$400)Goal to Improve Compliance of our Patients Filling Their Medications

M E A S U R A B L E O U TC O M E S

Rate = [Observed RA/Expected RA * CY Statewide RA Rate]Data is for full 12 months in each Calendar Year

Implementation of Start Tool

READMISSION OUTCOMESV

ALI

DA

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AUTO GENERATE CONSULTSV

ALI

DA

TE

2016 2017

Admit to Consult

86 hours 47 hours

Length of Stay

8.54 days 7.5 days

Palliative Care Outcomes

COMPREHENSIVE CARE CENTER OUTCOMES

Patients

Pre 90 Day Post 90 Day Visits Saved Total Saved

Inp/Obs Visits 3,536 267 2,000 $3,000,000

ED Visits 743 689 175 $21,000

TOTAL 4,279 957 2,175 $3,021,000

2,800 patients were seen in the Comprehensive Care Center; the data is available for FY17 (this is all payer)

VA

LID

ATE

HCAHPS OUTCOMESV

ALI

DA

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FY16 & FY17 HCAHPS Data by Quarter

FY18 Q2 CALLBACK OUTCOMES

32VA

LID

ATE

FINAL THOUGHTS

KEYS TO SUCCESS

Investment of time and resources

The team truly believed that this was the right thing to do

Personal experiences

Having the right mix of people at the table from the start

People that can make decisions and people that actually do the

work

Ongoing auditing and validation to promote sustainability

Periodic review of project charter

ONGOING GOALS

• Expansion of interventions

• Always think: “Are we asking the right questions?”

• Always prioritize the interventions: “What is next?”

• Deeper analysis of the data to understand impact

& prioritize interventions

THANK YOU TO OUR TEAM

• Christina Pedini- Rehab

• Rebecca Adelman- PI

• Dr. Jokhadar- Hospitalist

• Alexis Rivers- Utilization

• Gary Hicks- Education

• Tina Hornung- QHIM

• Steve Prouse- IT

• Niki Seling- RN/IT

• Vicki Bands- Community Health

• Allen Siegel- Spiritual Support

• Karen Rapposelli- Business Intelligence

• Val Leatherman- RN/PI

• Jean Almacy- RN

• Karen Goodison- Director Respiratory

• Angela Kaitis- Pharmacy

• Angela Wrzosek- Physician Documentation/ PI

• Diana North- Physician Documentation/PI

• Dr. Sharma- Hospitalist

• Heather Beauchamp- Medical Staff Strategic Support

• Marnille Coppola- Nurse Manager

• Mary Edmonson- RN

• Andrea Countryman-Patient/Family Advisor

• John Trotsky-Patient/Family Advisor

• Evelyn Yawn- Patient/Family Advisor

• Joyce Fox- VP, Nursing

• Michelle Townsley- RN/IT

• Hollie Eid- Case Management

• Dr. Barrueto- VP/Chief Medical Officer

• Nate Albright- AVP/Clinical Service Lines/Palliative Care

• Pat Thompson- RN/Director Behavioral Health

• Dr. Lewis-Medical Director Behavioral Health

QUESTIONS & THANK YOU!