samir k. sinha md, dphil, frcpc director of geriatrics mount sinai and the university health network...
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Samir K. Sinha MD, DPhil, FRCPCSamir K. Sinha MD, DPhil, FRCPCDirector of Geriatrics Director of Geriatrics Mount Sinai and the University Health Network HospitalsMount Sinai and the University Health Network Hospitals
Virtual Ward Rounds15 February 2011
A Practical and Evidence-A Practical and Evidence-Based Approach to Reduce Based Approach to Reduce Potentially Avoidable Potentially Avoidable Hospitalizations of Nursing Hospitalizations of Nursing Home ResidentsHome Residents
None related to the contents of this presentation.
DisclosuresDisclosures
Presentation ObjectivesPresentation Objectives
Demonstrate how current paradigms for providing acute care for nursing home residents are problematic.
Introduce three evidence-based care models that deliver better patient and system outcomes.
Identify some practical tools that can help you transform the care you deliver.
Does this sound familiar?
Margaret is 86F NH resident. She has a host of chronic medical problems and a moderate degree of dementia.
Her nurse becomes concerned one afternoon that she is more confused, and is not eating or drinking as usual. She is found to have a spreading erythematous area on her right foot.
The nurse consults with the off-site doctor over the phone on how best to proceed and…
Why Our Current System fails ResidentsWhy Our Current System fails Residents
Our Current System
1. Limited LTC options & resources push ‘911’ calls for transfer to ED
Our Current System
2. Travel to hospital causes Resident Anxiety and can be an Inefficient use of EMS resources.
Our Current System
3. Long ED Waits create added health risks and increase a resident’s chance of admission.
Our Current System
4. The potential risks of Hospital Stays should not be underestimated.
Our Current System
5. Discharge Planning can be particularly Complex.
Our Current System
6. The return home requires Resources and can again produce added Anxiety.
Our Current System
7. Potential Gaps in Communication around care needs can complicate transitions and thus…
Our Current Reality Hospitalization of nursing home residents can
cause discomfort for residents, morbidity due to iatrogenic events, and excess healthcare costs.
At least 25% of hospital visits/admissions are for ambulatory-care sensitive diagnoses. (Grabowski et al, 2007; Walker et al, 2009; Gruneir, In Press)
Reducing potentially avoidable hospitalizations presents a significant opportunity to improve care and reduce healthcare costs.
Finding better ApproachesFinding better Approaches
What Defines Better Care?
1. On-Site or Phone Assessments and Care provided within Nursing Homes.
What Defines Better Care?
2. ED Transfers averted or facilitated when required
What Defines Better Care?
3. Enhanced Caregiver Capacity, Knowledge and Interprofessional Communication
The Mobile Long-Term CareThe Mobile Long-Term CareEmergency Nursing ProgramEmergency Nursing ProgramTorontoToronto
Investigators:
Annabelle Bandurchin, MHSc, Project ManagerMary Jane McNally, RN, MN, Director of Nursing, TWH Mary Ferguson-Paré, RN, PhD, Chief Nursing Executive, UHNSamir K. Sinha, MD, DPhil, FRCPC, Director of Geriatrics MSH/UHN
Program Objective
To determine whether a Mobile Emergency Nursing Program in Toronto, Canada could reduce avoidable transfers of NH residents to Acute Care Hospitals.
Program Structure 3 RNs (2.5 FTE) and 1 NP (1.0 FTE), based
out of the ED of an urban teaching hospital.
Available for consultation 09:00 – 21:00 Daily.
Medical Supervision provided by NH Physicians.
17 Partnering NHs (3313 Residents) joined pilot between October 1, 2008 to October 1, 2009.
500K Pilot Grant - Nursing Secretariat, Ontario.
Program Structure
PREVENTION
Proactive Rounds to build NH Staff Capacity
AVOIDANCE
NH Staff contact Mobile RNs for telephone mediated assessment and coaching and/or on-site visit to help manage acute conditions.
RAPID ED ENGAGEMENT
Enables rapid transfer, intervention and discharge.
FOLLOW-UP
Active Consults and Discharges within 48Hrs.
Program Structure
PREVENTION
Proactive Rounds to build NH Staff Capacity
AVOIDANCE
NH Staff contact Mobile RNs for telephone mediated assessment and coaching and/or on-site visit to help manage acute conditions.
RAPID ED ENGAGEMENT
Enables rapid transfer, intervention and discharge.
FOLLOW-UP
Active Consults and Discharges within 48Hrs.
Pilot Program Outcomes
497 required acute care (or 911)
388 averted ED & received acute
care at NH109 sent to the ED
78% success
rate
October 1, 2008 to October 1, 2009
35% decrease in ‘Non-Urgent’, ‘Less Urgent’, and ‘Urgent’ unscheduled Ambulance Transfers.
617Consultations
120 did not require acute care
5 Most Common Consultation Requests*
HYDRATION CONCERNS
PAIN MANAGEMENT
DYSPNEA
INFECTION
ENTERAL FEEDING TUBE PROBLEMS
* 70% of total requests
Conclusions/Implications This is a cost-effective model that delivers
acute care in NHs and prevents ED visits.
It is unique in its focus on peer-to-peer consultation and cross-sector partnerships.
It has been effective at building the capacity and morale of Nursing Home RNs.
This model has now been expanded to cover all NHs in Central Toronto and funded by the Toronto Central LHIN.
Lessons Lessons LearnedLearned
Lessons Learned Much of what has been proven to work really
comes down to applied common sense.
The Mobile LTC Emergency Nursing Model demonstrates how a needs-based resourcing service delivery model can still deliver significant benefits.
The success of each of this model requires individuals to champion implementations and sustain momentum.
Questions?
Samir K. Sinha MD, DPhil, FRCPCSamir K. Sinha MD, DPhil, FRCPCDirector of Geriatrics Director of Geriatrics Mount Sinai and the University Health Network HospitalsMount Sinai and the University Health Network Hospitals
416-586-4800 x7859416-586-4800 [email protected]@mtsinai.on.ca