shawnee mission medical center kim fuller, msw, mba, cce janet ahlstrom, msn, acns-bc
TRANSCRIPT
TRANSITIONS IN CARE
AKA
REDUCING READMISSIONSShawnee Mission Medical Center
Kim Fuller, MSW, MBA, CCE
Janet Ahlstrom, MSN, ACNS-BC
SHAWNEE MISSION MEDICAL CENTER
PREVENTING RE-HOSPITALIZATION WITHIN 30 DAYS
Selected populations:
Congestive Heart Failure
Pneumonia
Acute Myocardial Infarction (AMI)
OUR JOURNEY IHI Collaborative on Reducing Readmissions in
2009/2010.
Developed multidisciplinary internal team to participate in the Collaborative and to begin designing program.
Did chart reviews of readmissions to assess patterns, failure points, potential interventions and conducted tests of change.
Discovered many readmissions coming back from SNF’s, so invited key partners to join Collaborative.
JOURNEY CONTINUED…. Split internal team and external community
partner group into separate meetings.
Justified initial addition of an FTE by quantifying potential cost to the bottom line following implementation of CMS penalties.
Hired .5 MSW and .5RN and Transition Coach role fully implemented in August, 2011.
SMMC PROGRAM4 MAIN FOCUS AREAS Enhanced Admission Assessment for
Post Hospital Needs
Effective Teaching and Enhanced Learning
Real – time Patient and Family Centered Handoff Communication
Post-Hospital Care Follow Up
INTERNAL TEAM Membership includes:
Nursing representation from cohort areas for CHF, AMI and Pneumonia.
PharmacySocial Work/Utilization ReviewAsk a Nurse Call CenterSMMC Home HealthCardio-Vascular ServicesNursing Education
EXTERNAL TEAM Membership includes
Home healthSkilled nursing facilitiesAssisted Living FacilitiesHospicePrivate DutyLTACEmergency Medical Response
EXTERNAL TEAM FOCUS Case studies of readmissions from various
facilities, identifying breakdowns and creating new processes.
Education re: disease specific protocols provided to SNF’s. i.e. importance of daily weights and use of the zone chart for CHF patients.
Development of common hand off tool that meets needs of hospital and external agencies.
Strategies to increase involvement of palliative care and hospice when appropriate.
EXTERNAL TEAM FOCUS Education about national movement toward
use of Transportable Physician orders for End of Life treatment wishes.
Development of special interest sub-committees to concentrate and problem solve issues that are unique to different settings.
Trend readmission data specific to various agencies/facilities to use in forming stronger community partners with those that have lower readmission rates.
TRANSITIONS IN CARE
Shawnee Mission Medical Center
Melanie Davis-Hale, LMSW
Cathy Lauridsen, RN, BSN
TRANSITION COACH 0.5 Social Worker/ 0.5 RN Identify high risk patients in hospital Initiate individualized program Follow for 30 – 45 days regardless of
setting Facilitate smooth TRANSITIONS Early intervention with any readmissions Meet weekly with physician champions
at SMMC Provide education for patients and
healthcare team partners
IDENTIFYING HIGH RISK PATIENTS Currently utilizing the Better
Outcomes for Older adults through Safe Transitions (BOOST) Tool
Collaborative Care Team (CCT) process at SMMC
Chart review of Electronic Medical Record
BOOST TOOL8P screening tool: Problem Medications –(anticoag, insulin, aspirin, digoxin)
Punk (depression) - screen positive or diagnosis
Principle diagnosis – COPD, cancer, stroke, DM, heart failure
Polypharmacy - >5 or more routine meds
Poor health literacy - inability to do teachback
Patient Support – support for d/c and home care
Prior Hospitalization - non-elective in last 6 months
Palliative Care – pt has an advanced or progressive serious illness
PRE AND POST HOSPITAL CARE AND FOLLOW UP
Initial contact with patients/family during the hospitalization.
Schedule follow-up PCP/Specialist appointment prior to hospital discharge.
Follow patient across all levels of care for up to 45 days post discharge.
Phone/in person home visits.
Continually assess patient needs post discharge.
FOUR PATIENT CENTERED ELEMENTS FOR TEACHBACK Medication management
Follow up with PCP/Specialist
Patient centered record
Knowledge of Red flags and how to respond
STRATEGIES FOR SUCCESS Develop a relationship with patient and/or
family prior to hospital discharge Identifying patients’ healthcare goals Matching patients to Social Worker or RN
based on patient needsSocial Worker
Financial needs Psycho-Social needs Community resources
RN Patient/Family/Caregiver Education Facility/Service Provider Education Symptom management
STRATEGIES FOR SUCCESS Interventions to prevent readmission based
on patients’ discharge planPatient Discharges to SNF/LTAC/Acute
Rehab Visit/phone call to patient, patient’s nurse, social
worker, PT/OT, Medical Director.Ensure patient has seen Medical Director within 72
hours Identify medication issues/concerns/changes and
other areas of symptom management.Awareness of patient discharge plan from facility
Maintain communication with patient’s PCP/specialist Prepare patient for transition to lower level of
care/home
STRATEGIES FOR SUCCESS
Patient Discharges to Home with Home Health Collaborate with Home Health Agency/Case
Manager to develop care plan to prevent readmission
Ensure patient attends follow-up PCP/specialist appointment
Patient Discharged to Home Continue post-discharge education to
patient/family/caregiver Identify medications issues/concerns Identify and referred to needed services Encourage self-management when possible
CHALLENGES Identifying patients that will code out as
CHF, Pneumonia, AMI
Continually educating service providers on role of transition coach
End of life issues
PROGRAM RESULTS
CHF PNA AMI Other DRGs
50
157
60
154
141
42
August 2011 - December 2011
Total # of Patients Followed by Transition Coaches
Total # of Medicare Patients Discharged from SMMC
PROGRAM RESULTS
August September October November December
38% (5/13)
17% (4/23)
35% (8/23)
47% (8/17)
25% (7/28)
31% (4/13)
0% (0/9)
13% (1/8)
0% (0/8)
17% (2/12)
SMMC CHF Readmission RatesAugust 2011-December 2011
Non-Transition Coach Transition Coach
PROGRAM RESULTS
August September October November December
23% (6/26)
23% (3/26) 11% (3/27)
0% (0/17)
10% (3/30)
100% (1/1)
0% (0/2)
33% (1/3)
0% (0/3)
17% (1/6)
SMMC PNA Readmission RatesAugust 2011-December 2011
Non-Transition Coach Transition Coach
PROGRAM RESULTS
October November
23% (3/13)
0% (0/4)0% (0/3) 25% (0/4)
SMMC AMI Readmission RatesOctober 2011-November 2011
Non-Transition Coach Transition Coach
PROGRAM RESULTS
SNF30%
Home30%
Home Health40%
Where Transition Coach Patients Read-mitted From
August 2011-December 2011
PROGRAM RESULTSPt originally admitted to hospital for:
Pt admitted from: Pt discharged to: Readmission reason:
PNA Home SNF Dehydration
CHF Home w/ Home Health SNF CHF
CHF SNF SNF CHF
CHF Home Home w/ Home Health CHF
CHF Home Home w/ Home Health Hemorrhage of Gastrointestinal
CHF Home w/ HH Home w/ Home Health Transient Cerebral Ischemia
CHF Home Home w/ Home Health A-Fib
PNA Home Home Mitral Valve Disorder
CHF Home Home CHF
PNA Home Home Pulmonary Embolism
CONTACT INFORMATION Kim Fuller
913-676-2293 [email protected]
Janet Ahlstrom 913-676-2032 [email protected]
Cathy Lauridsen 913-676-8611 [email protected]
Melanie Davis-Hale 913-676-2168 [email protected]