reducing hospital readmissions: home care as the solution · 2014-06-13 · integrated care...

© 2014 Sutter Health

Reducing Hospital Readmissions: Home Care as the Solution

Kathy Duckett RN, BSN Sutter Center for Integrated Care [email protected] www.suttercenterforintegratedcare.org

mailto:[email protected]


Review the 3 principles of Integrated Care Management (ICM)

Define key ICM Transitions of Care practices in the hospital and home

Discuss home care’s unique value as a transitions of care partner

Learning Objectives

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Facts About Who We Serve

Sutter Care at Home

28 Locations • 11 Home Health • 7 Hospices • 2 Infusion • 2 HME • 1 Private Duty &

Geriatric Care Management

1,800 Employees 770 Volunteers 18,000 Average Daily Census

Sutter Health: Transitions of Care, PCMH, Case Management 5900 Providers outside of SCAH/SH 48 States 3 Countries: US, Canada & Singapore

Sutter Center for Integrated Care


Integrated Care Management (ICM): Where it Started

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Journey Towards Excellence In Homecare:

Improving Outcomes

of Care


The Right Thing to Do: IOM Quality Chasm Report

• Current healthcare systems cannot do the job

• Trying harder will not work

• Changing care systems will work

• Make the right thing to do the easy thing to do

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The Right Thing to Do: IOM Quality Chasm Report

ALL health care providers should pursue six major aims: 1) Safe 2) Effective 3) Patient Centered 4) Timely 5) Efficient 6) Equitable

“ A New Health System for the 21st Century” (IOM, 2001)

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“Providing care that is respectful of and responsive to individual patient preferences, needs, & values & ensuring patient values guide all clinical decisions.”


Integrated Care Management (ICM) Model What is It?

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• A care delivery model • Based on Wagner’s Care

Model (aka Chronic Care Model)

• Integrated Health Literate Care

• All patients across continuum • Defines key best practices

& competencies for all providers across settings


Integrated Care Management (ICM): A Care Delivery Model for Improved Outcomes

Person Centered - Care with dignity and respect

- Goals drive care - Patient as partner

Evidence-Based - Clinical best practices - Patient Engagement: Self-management

support Health literate care

Coordinated Care - Seamless transitions across providers, settings, and time

- Meaningful and timely information exchange

Improved outcomes leading to better health, better care and lower cost


Patient Goals BEFORE: Patient will…

Wellness At Risk Chronic Conditions

Complex Conditions

Advanced Illness

• Receive flu and pneumonia vaccine according to guideline level care.

• Remain free of signs and symptoms of infection at surgical site.

• Reach control of diabetes with BS levels of 100 – 130 and daily control of diabetes as evidenced by HgA1C of less than 7.

• Be able to walk 100 feet unassisted. • Be at acceptable pain level while remaining as alert as

possible.

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ICM Person-Centered: Patients Goals Drive Care

Wellness At Risk Chronic Conditions

Complex Conditions

Advanced Illness

• Return to weekly bridge game without undo fatigue. • Remain in home without going to ER or Hospital in order

to participate in all of grandchildren’s school and ballet activities.

• Be able to safely drive again. • Walk on my own to the activity center without assistance. • Able to join ROMEO (Retired Old Men Eating Out) group

for lunch once a week.

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Stoplight: Supports Patient & Family Engagement • First person

• Patient daily assessment drives navigation

• Font, layout, graphics consistent with health literacy and plain language principles

• Supports patient and caregiver engagement

• Supports teach back with content ready for “chunk and check”


ICM Evidence-Based: Patient Engagement

Where we tend to focus: • Adherence to

clinical guidelines • Patient education • Directing

Where new focus is needed: • Clear communication • Comfortable with

questions • Choices provided, not

just advice • Confidence building

focus


Health Literate Stoplight Tools In Action

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http://bcove.me/ckmub1o1

One Patient’s view on the Stoplight tool

http://bcove.me/ckmub1o1


Care Transitions Definition

“Care transitions refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.”

Eric A. Coleman, MD, MPH

Care Transitions ProgramSM

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ICM: Coordinated Across Providers, Settings, & Time

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Hospital Home

Transitions Can Be Tricky

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Stats and Facts – Medicare pts

• 1 in 5 patients discharged from hospital readmitted within 30 days

• Readmissions often a sign of inadequate discharge planning, poor care coordination between hospital and community clinicians, and the lack of effective longitudinal community-based care.

• The additional hospital stays imply that many patients are getting sicker, not better, after their initial discharge.

• Other patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care.

• These readmissions lead to more tests and treatments, more time away from home and family, and higher health care costs. After Hospitalization:

A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries September 28, 2011


WHAT

Literature Review of Care Transitions Best Practices Across Providers & Settings

Hospital Programs Ambulatory Care Programs

Home/Community Programs Accrediting Organization Programs


1. Patient/family action/ engagement

2. Early identification for “at risk” patients

3. Transitions planning 4. Medication management 5. Multidisciplinary

collaboration 6. Transfer of information 7. Leadership support

Source: Hot Topics in Healthcare, Issue # 2, Transitions of Care: The need for

collaboration across the healthcare continuum. The Joint Commission, February, 2013

ICM TOC Aligns with The Joint Commission 7 Foundations For Safe Transitions

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• Comprehensive assessments including risk assessments

• Focus on medication reconciliation, signs & symptoms, MD Follow - up appointments

• Case management & care coordination • ICM Training: Skills for effective health coaching in

self management support & evidence-based guideline care

Home Care's Unique Role in Transitions


• Expand the role of home health professionals • Provide transition of care services in the hospital

and home settings • Restructure in-home care processes to optimally

support transitioning patients • Provide systematic approach for care of home

health high-risk patients discharged from the hospital

ICM Transition of Care Objectives


ICM Transitions of Care (TOC) Compared to Other TOC Models

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INTERVENTION

Coleman CTI

Naylor TCM

Project BOOST

Re-engineered Dis-Charge RED

ICM

Risk Assessment √ √ √ √ √ Medication Reconciliation √ √ √ √ “Red Flags” & Follow-up √ √ √ √ √ 24/7 on call response √ √ Hospital Visit √ √ √ √ √ Physician F/U √ √ √ √ Home Visit post discharge √ √ √ √ Remote Monitoring √ √ √ Active engagement of pts √ √ √ √ √ PHR (Patient Health Record)

√ √ √ √


ICM Unique TOC Interventions

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INTERVENTION Coleman CTI

Naylor TCM

Project BOOST

Re-engineered Dis- charge RED

ICM

Health Literacy Screen √ √ Depression Screen √ √ Personal concerns/goals √ √ Med Management √ √ Pt friendly med list √ √ √ √ Health Literate stoplights √ Case conf High Risk pts √ Family Caregiver Assessment

√ √


• Care transition support begins in the hospital and continues in the home by same healthcare sector – home health

The fewer the transitions the less the risk • No – one size fits all • Patients have fewer layers of care providers • Clinicians are trained to identify patients’ common

barriers for self-care • Clinicians provide care based on patient goals and

aspirations

How Is This Model Different?


ICM Transitions of Care: Hospital & HH Partnership In Hospital Process

Multidisciplinary Rounds

•Attendees: MDs, Case Management, Nursing, Social Work, Pharmacists

• Risk Assessment

Transitions Care Planned by Team

•Appropriate for Homecare

•MD writes order

Hospital Secures Pt Choice

•Hospital Case Manager meets with patient and secures Pt Choice

•Notify SCAH if selected to provide Home Care services

HCC Accesses Patient Data

• Chart Review • Reviews with RN

Case Manager • Initiates Referral

Intake (RI)Note

HCC Initial Bedside Visit

• Explains program and inquires about patient’s concerns

HCC Second Bedside Visit

•Continues assessment and stoplight teaching

•Builds rapport •Updates RI note

Admission

HCC notifies branch of discharge

Discharge • Pt Assessments: Risk for readmission

• Begins Stoplight teaching

Family/caregiver conference may be held to determine appropriate level of care: HH, AIM, Hospice

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Risk Stratification: Institute for Health Improvement

High-Risk Pts Moderate Risk Pts

a. Patient has been admitted two or more times in the past year

b. Patient failed teach back, or the patient or family caregiver has a low degree of confidence to carry out self-care at home

a. Patient has been admitted once in the past year b. Patient or family caregiver has moderate degree of confidence to carry out self-care at home

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Person-Centered Starting in Hospital

“I have four areas we need to focus on to help prepare you and your family for discharge, but before we start on my list can you tell me what you are the most concerned about when you leave here and go home?”

Then transitions of care focus areas ….

1. Medication Management Post-Discharge 2. Early Follow-up 3. Symptom Management 4. Personal Health record

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Provider specific instruction determined here: • Call your nurse • Call your doctor • Call HH/hospice • Call Case Manager

Patient Facing Tools: Consistency Across Providers & Settings

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14 Topics available: 1. Heart failure 2. COPD 3. Diabetes 4. Depression 5. Pneumonia 6. Falls 7. Wounds 8. Pain 9. Constipation 10. Nausea 11. Anxiety 12. Stroke 13. Shortness of breath 14.High risk medication stoplights

(Coumadin, Lovenox & anticoagulants, Plavix & antiplatelets, Tamoxifen, Methotrexate)

Coming soon: • Skin care • Aspiration • Insulin/oral hypoglycemics • Weight gain/edema


ICM Transitions of Care: Home Health “Touch-Points”

Pre-discharge

•Home Care Coordinator in-hospital pt visit

•Pt Assessments: Risk for readmission

•Pt Concerns & Stoplight teaching

Home visits

•1st visit w/in 24 hrs of dc

•2nd visit w/in 72hrs by same clinician

•3rd visit same week •Focus on med rec, signs & symptoms, MD f/u, personal health record

Remote monitoring

• Remote monitoring to detect signs of exacerbation

3 home visits

• Focus on patient engagement, med management , barriers and confidence-building

Remote monitoring

• Remote monitoring with focus on health coaching

Additional interventions

•Case conference •Pt –friendly med list •Medication Management •SBAR communication

Week 1

Week 2

Home visits continue based on need

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Health Coach in the Home: Medication Management

• Emphasis on med reconciliation and adherence • Med – “brown bag” – bring all meds out • Include all meds taken before hospitalization • Ask: - What concerns do you have about your medications? - Do you take any herbs and over the counter meds? - Teach back: Show me which meds you take when… • NOTE: Ongoing Reconciliation: Any new or changed meds

since my last visit?

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Medication and Route Dose Frequency Reason Instructions

Client Friendly Medicine List

Font size increased

to 14 pt


SBAR Application

• Transitions of Care Notes

• EMR Documentation

• New or change order requests of MD

• Personal Health Record

• Case Conferences/ Huddles

• Eliciting information from

patients/families/caregivers

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MY Personal Health Record (PHR)

• Record belongs to patient and they are asked to be responsible for maintaining it

• Helps them take a more

active role in care and empowers them

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SBAR for Patients in PHR

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Technology in Transitions Theory-Based Telehealth

• Utilized for early identification of exacerbation

• Demonstrate cause and

effect relationships • Coaching for symptom

reporting • Postive reinforcement/

confidence building


ICM Transitions Of Care: Provider, Payor, Healthcare System

-40% -47% -38%

-100%

-80%

-60%

-40%

-20%

0%

20%

40%

Decrease in 30-Day Readmission Rates After Implementing ICM Transitions Of Care

Sutter-SantaRosa

White CountyMed Ctr (AR)

First Health(NC)

Our care transitions partnership with Sutter Santa Rosa resulted in a 40% decrease in 30-day rehospitalization rates from Q2-2012 to Q3-2013.

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ICM Transitions Of Care: Outcome Measure from Patients’ Perspective

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Mar2012

Apr2012

May2012

Jun2012

Jul2012

Aug2012

Sep2012

Oct2012

Nov2012

Dec2012

Jan2013

Feb2013

Mar2013

Apr2013

May2013

Jun2013

Jul2013

Aug2013

Santa Rosa HH 89.5% 75.0% 87.5% 84.6% 89.3% 94.4% 88.5% 68.4% 85.0% 81.0% 89.5% 76.9% 78.9% 95.2% 84.6% 91.7% 88.9% 100.0%All SCAH HH 81.7% 86.5% 81.3% 82.8% 85.6% 82.1% 84.7% 83.0% 86.8% 83.2% 83.2% 80.3% 85.0% 84.8% 78.9% 83.5% 87.7% 84.9%

n=19

n=200 n=24

n=13

n=28

n=18

n=26

n=188

n=20

n=21

n=19

n=200

n = 21

n=13

n = 12

n = 9

n = 11

n=229

n=20

n=252 n=157

n=188 n=184

n=196

n=19

n=212 n=226

n=179 n=188

n=19

n=211

n=204

n = 154 n = 126

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Perc

enta

ge o

f "al

way

s" re

spon

ses

Did your clinician listen carefully to you?

n=182

n=26


ICM: Tools, Practices, and Competencies Across the Health Care System

Disease/ Population

Management Case

Managers

Patient-Centered Medical Home

Practices

Hospital Staff: Coordinators Transitions

Coach

Home & Community

Services Providers

• Person-Centered – Patient as partner – Dignity and respect – Goals drive care

• Evidence-Based – Patient engagement – Clinical best practices – Self-management

support – Behavior change

• Coordinated Care – Meaningful and timely

information exchange – Across settings,

providers and time

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ICM Transitions of Care: Hospital staff perspective

I just wanted to take the opportunity to let you know how much we appreciate the Sutter Home Health hospital liaisons. We have had several cases lately that required an enormous amount of post discharge follow up and their follow through has been amazing. Just wanted you to know! Thank you!

Susan Case Management Sutter Medical Center, Santa Rosa

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What patients should expect from their health care team:

Cooperation: “Those who provide care will

cooperate and coordinate their work fully with

each other and with you. The walls between

professionals and institutions will crumble, so

that what you experience becomes seamless.

You will never feel lost.”

Crossing the Quality Chasm: A new Health System for the 2st Century, (IOM, 2001)

10 rules to redesign and improve care

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Thank You

What questions do you have?

Kathy Duckett RN, BSN Director of Training and Development [email protected] www.suttercenterforintegratedcare.org

mailto:[email protected]

reducing hospital readmissions: home care as the solution · 2014-06-13 · integrated care...

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