Building the Cross

Continuum Collaborative

Baystate Medical Center

Stephanie Calcasola, RN, MSN, RN-BCSusana Hall, RN, BSN, MBA

Ruth Odgren, RN, MS

• 680 bed tertiary care referral center ( ~1M)• Flagship of Baystate Health • 42 k admissions/year • Annual surgical volume: 29,043 • Western Campus of TUFTS• Member CoTH, 9 residency programs/244 PGs• 1200 member medical staff, 206 faculty MDs• Level 1 Trauma Center • IHI Mentor Hospital (SCIP/AMI/HF/HAPU/VTE) • Magnet facility –re designated 2010

Quality Accomplishments

STAAR Collaborative AimsReducing re-hospitalizations goal for 2010, 2011

• Threshold: Implement a standardized discharge process for heart failure patients

• Target: Decrease heart failure re-hospitalizations by 15%• Maximum: reduce heart failure re-hospitalizations by

30%Makes business sense to be proactive in light of:

• Upcoming changes regarding healthcare • Throughput and capacity issues • Right thing to do for patients & families

Study Says US Hospitals Fail To Reduce Avoidable Readmissions.• Bloomberg News (9/28, Wechsler) reports, "US hospitals risk cuts in

Medicare payments next year after failing to reduce avoidable readmissions, a Dartmouth Atlas Project study showed." The study, by tracking "10.7 million discharges at 1,925 hospitals from 2004 to 2009,...found that readmissions of elderly patients within 30 days of a hospital stay have remained the same or increased." And "the Centers for Medicare and Medicaid Services in Baltimore plans to cut payments by 1 percent to hospitals with excessive rates starting in fiscal 2013."

•         The Pittsburgh Tribune-Review (9/28) reports, "Readmission rates for Medicare patients ages 65 and older within 30 days barely changed from 2004 to 2009." Study author Dr. David C. Goodman commented, "For a long-standing problem, not much progress has been made." National Journal (9/27, Fox) also covers the report.

• Deb Hawkes RN -Unit Manager Springfield 3 Oncology• Laurie Kaeppel RN / Deb Hawkes RN – Springfield 3 Medicine• Carol Morrison RN – S4 Case Manager • Brenda Krumpholz RN – S3 M Case Manager • Bonnie Geld MSW - Director Care Management • Maria Giordano, RN – Assistant Nurse Manager, Daly 5A • Carlo Real RN /Jodi Kashouh RN - Splfd 4 Short Stay Cardiology • Gini Staubach RN -Assistant Director Critical Care & Cardiology PCS • Ann Maynard RN -Director ED • John Santoro MD -Vice Chair, Chief Emerg Svcs • Surinder Yadav MD - DHQ /Attending Hospitalist • Carol Richardson MD - Associate Med Director Hospital Medicine • Donna Borah RN Director Hospital Medicine Program • Ruth Odgren RN President BVNA&H • Aaron Michelucci PharmD, Assistant Director, Clin Pharm • Regional Western Mass Cross Continuum Partners • Stephanie Calcasola, RN Director of Quality• Win Whitcomb,MD, Medical Director of Healthcare Quality• Susana Hall, RN Director of Post Acute Care Services• Cara Kenny, RN, S1 Clinical Educator

Cross Continuum Regional Meetings

Cross Continuum Invite

Planning for Cross Continuum Meetings

• Regularly scheduled, advance notice • Geographically neutral meeting location• Continental breakfast• Timely agenda/attachments• Ongoing and frequent communication• Topics of varied and cross sectional interest

9

Objectives

• Education dissemination

• Networking

• Shared Stories/shared commitment

• Relationship/partnership building

• Readmission prevention collaboration

Keys to SuccessPersistence and reinforcement/high visibility Senior leader supportMultidisciplinary cooperation & collaboration

• Accurate, timely and relevant data • Communicate – flexibility • Right people

Willing to try changes and take a risk Develop reliable systems Incorporate into workflow

• Make changes easy => transparent => meaningful

Make The Right Thing The Easy Thing

Baystate All-Cause 30-Day Readmissions

Next Steps/Priority Focus

Standardization of patient education tools (HF, AMI, PN, Stroke, COPD zones) among cross continuum regional partners

Increase frequency of meetings with cross continuum regional partners. Shift from primary knowledge sharing to work groups and integrated projects. • 3026 grant partner• Interact survey (post acute facility survey on readmisson

patterns) Pilot med rec/teaching/on original pilot unit with

pharmacists (August, 2011) Submitted letter of intent for Partnership for Patients Spreading the methods of Ask me 3/teach back

throughout organization. Web based training for all nurses fy 2012

MHA - STAAR Fall Learning MHA - STAAR Fall Learning SessionSession

Ruth Odgren, RN, MSPresident Baystate VNA & HospiceSenior Executive for PAC Relationships, Baystate HealthRuth.Odgren@baystatehealth.org

October 11 & 12, 2011October 11 & 12, 2011

Baystate VNA & Hospice (BVNAH)Baystate VNA & Hospice (BVNAH)STAAR INVOLVEMENTSTAAR INVOLVEMENT

• 2008─Focus – Patient Centered Care of those with

Heart Failure (HF) as 1o or 2o diagnosis

• 2009─Hired part time Heart failure Clinical Nurse

Specialist─Developed protocols─ Incorporated use of telemonitoring

BVNAH STAAR INVOLVEMENT (Cont.)BVNAH STAAR INVOLVEMENT (Cont.)

• 2010─Implemented use of HF Zones, ASKME3 and

Teach Back─Coordinated patient care with BMC HF Unit

Staff─Began subsidy program for uninsured and

underinsured HF patients

BVNAH STAAR INVOLVEMENT (Cont.)BVNAH STAAR INVOLVEMENT (Cont.)

• 2011─Began journey to educate and certify all home

care clinicians in Integrated Chronic Care Management (ICCM)

─By end of year, 90% of staff to complete the ICCM Program (currently at 60%)

BVNAH STAAR INVOLVEMENT (Cont.)BVNAH STAAR INVOLVEMENT (Cont.)

• Results – All cause HF readmissions

• CMS Home Care Compare Data – All cause readmissions rate for all diagnoses is 23%─ This is lower than regional, state & national results

2008 41% (OCS data)

2011 21% (internal STAAR Data)

Interact Survey ResultsTransfers back to Acute Hospital

0

2

4

6

8

10

12

14

16

18

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

%

Authorization for Transfer

Q16. Who authorized the transfer?

23.80%

16.90%

24.90% 25.40%

1.10%

7.90%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

AttendingPhysician

On-call Physician NP/PA On-call NP/PA Medical Director Other

Pre-Transfer Management

Q14. Pre-Transfer Management (check all that apply)

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

MD on-site NP/PA on-site MD/NP/PA

Telephonic

"Telemedicine" IV or SQ fluids Labs Drawn X-ray Med

changes/starts

Family/HCP Advance Care

Planning

Other

Day of Week

Q10. Day of WeekSun

13.3%

Mon17.6%

Tues12.2%Thurs

18.1%

Fri18.6%

Sat11.7%

Wed8.5%

Questions

Thank you