1 keith rapp md, cmd [email protected] mary pat rapp phd, rn [email protected] geriatric...
TRANSCRIPT
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Keith Rapp MD, CMD [email protected]
Mary Pat Rapp PhD, [email protected]
Geriatric Associates of America, PA
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Describe Quality Indicators [QI] and Quality Measures [QM]
Describe Medical Director / provider roles in impacting QMs
Discuss avoidability of hospitalizations from nursing facilities
Discuss tools to assist in reducing avoidable hospitalizations
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1990: Development of 24 QIs based on MDS 2.0 by the Center for Health Services Research Association [CHSRA]
2002: Nursing Home Compare www.medicare.gov
Quality Measures 2005: CMS merged QIs & QMs Some risk adjustment Not a static process
◦ Continuing refinement by the National Quality Forum
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Influenza Vaccination During the Flu Season (October 1 thru March 31)
Assessed and Given Pneumococcal Vaccination (Looks back 5 years)
Delirium (Looks back 7 days) Moderate to Severe Pain (Looks back 7 days) Pressure Sores (Looks back 7 days)
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Need for help with daily activities has increased
Moderate to severe pain Pressure Ulcers (high and low risk) Physical restraints Incontinence and Catheters
◦ Low risk residents who lost control of bladder or bowel
◦ Percent with indwelling bladder catheter Residents who spend most of their time in
bed
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Decline in ability to move in and around their room
Urinary tract infection Worsening anxiety or depression Weight loss
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Reporting of Measures Measures with small denominators are not
posted on NH Compare
◦ Post-Acute Measures with less than 20 in denominator
◦ Chronic Measures with less than 30 in the denominator
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Physician/Nurse Practitioner Collaboration on Medical Direction
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NP in facility 5 days per week◦25% NP time is contracted to facility
◦75% of NP time spent seeing GAA pts
Physician weekly or more visits Physician is Medical Director of facility
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Daily stand up rounds with NF team Quality Assurance committee participation Mentoring and education for staff Available for assessment of all residents Available for “special projects”
◦ Use of resident level summaries to improve QM / QIs
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Masters trained nurse in the facility 5 days/week Increased level of communication Increased facility census More resources at the facility level Increased ability to care for higher acuity patients =
discharging hospital physicians with a higher comfort level
Lower hospitalization rates ◦ (keep the backdoor closed)
Improved and increase in relationships with discharging Physicians and facilities
Enhanced tracking of referral resources
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2 units with BID dosing
Over 1,500 less pills/day dispensed
Improvement of other associated QA/QMs
Per
cent
on
9 or
mor
e m
edic
atio
ns
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$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
2001 2002 2003 2004 2005
Other GAA
2002 9 requests 0 requests
2004 13 requests 4 requests
2005 3 requests 0 requests
Totals: 25 4
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GAA Quality Model Outcomes at 14 Facilities
Benchmarking Provider Care
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Privileged and Confidential - Proprietary Information
ALL GAA Quality ModelsHOUSTON/CENTRAL TEXAS9 + MEDS
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXASCOGNITIVE IMPAIRMENT
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXASNO TOILET PLAN
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS
CATHETERS
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Privileged and Confidential - Proprietary Information
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Privileged and Confidential - Proprietary Information
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Privileged and Confidential - Proprietary Information
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Privileged and Confidential - Proprietary Information
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS
Pressure Ulcer High Risk
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Privileged and Confidential - Proprietary Information
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS ANTIPSYCHOTICS Low Risk
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS
ANTIANXIETY
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Privileged and Confidential - Proprietary Information
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Privileged and Confidential - Proprietary Information
ALL GAA Quality Models HOUSTON/CENTRAL TEXAS
RESTRAINTS
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Management Pearls Include MDS Coordinator in QA Committee Focus on residents that have upcoming MDSs
◦ Use resident level summary◦ Provider documentation
Root Cause analysis of QM issues◦ Understand MDS questions for indicators◦ Obtain user manual for QMs◦ Understand exclusions
Prioritize focus◦ One to Three action areas per month is reasonable
Responsibility needs to be assigned Follow up on action items in QA meeting
◦ Sentinel events (dehydration, impaction, low risk PU)◦ Indicators in 90 + percentile
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http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf
http://www.cms.hhs.gov/NursingHomeQualityInits/10_NHQIQualityMeasures.asp
Google “Quality Measures Nursing Homes”
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Used with permission
Joseph G. Ouslander, M.D.
Director, Boca Institute for Quality AgingBoca Raton Community Hospital
Mary Perloe, MS,GNP-BCProject Coordinator
Georgia Medical Care Foundation
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Background
40% of 100 admissions to 8 LA nursing homes rated as inappropriate1
68% of 200 admissions to 20 Georgia nursing homes rated as potentially avoidable2
1Saliba et al, J Amer Geriatr Soc, 20002CMS Special Study, 2008
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Common Disruptive for the resident and
family Fraught with many complications
◦ deconditioning, delirium, incontinence/catheter use, pressure ulcers, polypharmacy
Costly Sometimes an inappropriate and
avoidable use of the emergency room and acute hospital
Hospitalization of Nursing Home Residents
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Reducing avoidable hospitalizations represents an opportunity to improve care and reduce costs
Some of the costs avoided can be reinvested in the infrastructure for nursing homes to provide high quality care
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Georgia Medical FoundationN = 105
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The same benefits can often be achieved at a lower level of care
One physician visit may avoid the transfer
Better quality of care may prevent or decrease the severity of acute change
Better advance care planning is necessary
The resident’s overall condition may limit the ability to benefit from the transfer
Provider Resources Physician or NP/PA present in
facility at least 3 days per week
Exam by physician or NP/PA within 24 hours
Availability of lab tests within 3 hours
Intravenous therapy
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Appropriate reporting mechanisms to ensure that changes of condition are reported appropriately to the right person
Ability to start treatment, e.g., antibiotics, pain medication in a few hours
Ability to start intravenous or clysis therapy for hydration within 2 hours of the order
Sufficient nursing staff coverage to oversee appropriate monitoring over 24 hours
Sufficient nursing staffing to ensure daily assessment until the acute behavioral change has resolved or stabilized
Sufficient nursing staffing to recognize and report possible complications of treatment within 24 hours of their identification
AMDA CPG Recognition of Change in Condition40
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A Tool Kit to Improve Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations
Developed based on the data collected, and Expert Panel ratings of importance and feasibility
Care Paths
Communication Tools
Advance Care Planning Tools
http://www.qualitynet.org/dcs/ContentServer?cid=1181668673046&pagename=Medqic%2FContent%2FParentShellTemplate&parentName=Topic&c=MQParents
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Keeping it Simple
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Target Audience Tools
Certified Nursing Assistants Early Warning Assessment (“STOP AND WATCH”)
All nursing home licensed nursing staff SBAR* Communication (general) SBAR Communication Templates related to specific conditions
o Acute mental status changeo Fevero Pneumonia/Lower Respiratory Illnesso Dehydrationo UTIo CHF
Communicating acute changes in status – file cards by the telephone
Primary care physicians, nurse practitioners, physician assistants
SBAR Communication Templates related to specific conditions Communicating acute changes in status – file cards by the telephone
Emergency room and acute care hospital staff Transfer checklist
Administrative nurses, medical director Unplanned acute care transfer review
*Situation, Background, Assessment, Recommendation43
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Seemed like himself/herselfTalked the sameOverall function the sameParticipated in usual activities
Ate the same amountNDrank the same amount
WeakAgitated or nervousTired or drowsyConfusedHelp with dressing, toileting, transfers
No?
Yes?
Adapted from Boockvar, Kenneth et all, JAGS 48: 1086-1091,2000.
TELL A NURSE
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Boockvar KS, Lachs, MS [2003] JAGS, 51:1111- 1115.•Symptoms predict illness about 50% of the time. •Likelihood ratios show there is a moderate increase in the likelihood of disease.•However, if the signs are absent, you can be 90% positive the person is not ill.
0
10
20
30
40
50
60
Symptom
Lethargy
Weakness
DecreasedAppetiteAgitation
Falls
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Immediate Notification
Any symptom, sign or apparent discomfort that is:
1.Sudden in onset2.A marked change (i.e. more severe) in relation to usual symptoms and signs3.Unrelieved by measures already prescribed
Sources:AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003.Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996
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Conditions that usually warrant transfer to the hospital:
Acute abdominal pain with vomiting Chest pain not due to stomach pain,
musculoskeletal pain, and not relieved with antacids or nitroglycerin
Fall with pain and signs of fracture Hypertension with systolic BP over 230 mmHg
and chest pain or signs of stroke Vomiting blood and low blood pressure and
tachycardia Respiratory distress with rate over 28 and not
relieved with oxygen, nebulizers, or suctioning
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Labored breathing / shortness of breath New or worsened cough New or increased sputum production New or increased findings on lung exam
◦ Rhonchi: sputum◦ Wheezes: restricted airway◦ Crackles: fluid
Chest pain with inspiration or coughing
http://www.qualitynet.org/dcs/ContentServer?cid=1211554364427&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools48
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Lungs◦ Asthma◦ Chronic obstructive
pulmonary disease◦ Infection
Viral [influenza] Bacterial
Pulmonary embolism
Heart◦ Congestive heart
failure Atrial fibrillation Myocardial infarction
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Physician/NP/PA Notification Resident unable to eat and
drink Temp over 102ºF (38.9ºC)
or less than 96.8ºF (36ºC) Apical heart rate more than
100 Respiratory rate > 30/min BP less than 90 systolic Oxygen saturation less than
90% Call urgently Diabetes mellitus
◦ Finger stick glucose◦ Less than 70 or more than
400
Consider hospital transfer
Results of chest radiograph show an infiltrate or pneumonia
Critical values in blood count or metabolic panel◦ WBC over 12, 000 or
less than 4000
*Suspect sepsis if there are two or more signs from red bolded parameters 50
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Before Calling Physician/NP/PA Assess the resident Check vital signs Check pulse oximetry and/or
finger stick blood glucose if indicated
Read recent progress notes and nurses notes
Be Ready to Report Advanced directives, code status,
do not hospitalize, do not use IVs or subcutaneous fluids, do not use artificial nutrition
Allergies Medications, especially warfarin
[Coumadin]
S Situation I am calling about __________ He/she has signs/symptoms of pneumonia: Shortness
of breath, new/worse cough, new/increased sputum, fever, change in lung sounds, chest pain with breathing or with cough, other
B Background Diagnoses New medications, started oxygen, gave nebulizer Able to eat/drink [yes or no] Vital signs, pulse oximetry
A Assessment I think he/she has pneumonia Vital signs are stable, unstable
R Recommendation Chest radiograph Maybe a CBC or BMP Possibly start antibiotic now, IM and/or PO Monitor every _____ hrs Transfer to the hospital [yes/no]
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Quality Improvement Measures
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IF Temperature is more than102º F
Respiratory rate more than 25/minute
ORIF Temperature is more than
100º F or less than102º F Cough AND
◦ Pulse greater than 100/minute◦ Delirium◦ Chills◦ Respiratory rate more than
25/minute
IF temperature is normal AND resident has COPD
Increased cough or increased sputum
IF afebrile [no COPD] New cough Purulent sputum AND Respiratory rate more than
25/minute or deliriumIF infiltrate on chest radiograph AND Respiratory rate over 25 Productive cough Temperature over 100º F
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The LVN/LPN/RN assesses the resident each shift for 3 days or until the symptom resolves
At a minimum, the LVN/LPN/RN assesses:- How the resident feels- Vital signs and pulse oximetry- Level of alertness, aggressive, combative behaviors- Appetite and fluid intake
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Resident-Family-Facility-Provider Partnership
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CureRestoration/RehabilitationMaintenanceComfort
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Demographics Staff on duty Urgency of the transfer Resources not available Pretransfer treatment Factors associated with transfer decision
◦ Physician orders◦ Medical Instability◦ Directives
Authorizing person for transfer Diagnoses at time of transfer
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CNA says resident “different”, more confused, tired, back pain, slept in chair last night. Resident says she feels okay. “Something is wrong, she is sharp as a tack.”
History: No past history of dyspnea or chest pain, no cardiac history, no diabetes, usually capable of making her own decisions. No cardiopulmonary resuscitation, wants hospitalization.
Did not sleep well last night, acetaminophen [Tylenol] did not relieve pain, slept in her chair because of coughing, non-productive, no fever reported. She has not fallen.
Normally she eats well, today says stomach is upset, she’s nauseated, and did not eat breakfast or lunch. No change in bowel or bladder pattern, confirmed by nurse aide.
Two days ago had one urinary incontinent episode which is unusual for her. She says she knew she had to go but was just too weak and out of breath. No burning, or frequency. In talking with her today she loses track of the conversation, “I’m not eating, but I don’t like waffles anyway. Didn’t we have waffles yesterday?”
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Should the nurse contact the physician/NP? What do you expect the nurse to report?
What is the urgency of her condition? orders do you anticipate? nursing interventions do you expect? is your rationale?
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A 76 year old with a history of COPD complains of weakness. He is not on oxygen at the nursing home. He is more short of breath than usual, and has a cough. He tells you he always has a cough. He denies fevers, chills, rigors, or chest pain. His wife and the nurses aide tell you he is weaker, more short of breath and seems confused. He has not been eating or drinking as much for several days. Advanced Directives: Code status undetermined, does want hospitalization.
Past medical history: COPD, osteoarthritis mostly in the knees
Medications: Albuterol and ipatropium via metered dose inhalers, both 2 puffs 4 times a day. Acetaminophen for knee pain twice a day.
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Vital signs: BP lying 132/72, pulse 80 and regular, sitting BP 110/60, pulse 90, standing unable to obtain due to unsteadiness, sensation of falling. Respirations 24, temperature 99.9 orally, weight 140 [3 pounds less than last week].
HEENT: Mouth and throat dry Skin: Axilla dry Lungs: Decreased breath sounds over usual exam, course rhonchi in right base Heart: Regular rhythm, no cyanosis Neurological: Weak, but equal strength bilaterally in arms and legs Mental Status: Alert, rambling speech, easily distracted Gait and Balance: Cannot stand as he was too unsteady
The white blood cell count is normal, with a left shift The chest radiograph shows a small infiltrate on the right base.
The nursing staff and his wife would like him transferred to the hospital. The facility has RNs on the skilled unit 24 hours/day and they do start and maintain IVs. The NP is in the building daily Monday – Friday and the resident can be seen by the NP daily for 3 days before the weekend.
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