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AE SAFELY REDUCE HOSPITALIZATIONS
TRACKING TOOL
June 25, 2013
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Poll
Are you registered for the
Advancing Excellence in America’s Advancing Excellence in America’s
Nursing Homes Campaign?
•Yes
•No
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National, Voluntary, Aligned
Registered Participant
� Register/Update Profile
About the Campaign
� Register/Update Profile
� Select Goals
Active Participant
� Submit Data
3www.nhqualitycampaign.org
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Pressure UlcersStaff StabilityHospitalizations
Quality Improvement Resources
for NINE Goals
Mobility
Person-
Centered
Care
Consistent
Assignment
Infections
C. difficile
Medications
Antipsychotics
Pain
Management
4
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Pressure UlcersStaff StabilityHospitalizations
Organizational Goals
Mobility
Person-
Centered
Care
Consistent
Assignment
Infections
C. difficile
Medications
Antipsychotics
Pain
Management
5
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Pressure UlcersStaff StabilityHospitalizations
Today’s Goal
Mobility
Person-
Centered
Care
Consistent
Assignment
Infections
C. difficile
Medications
Antipsychotics
Pain
Management
6
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Poll
Are you using INTERACT Tools?
•Yes
•No
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INTERACT: Overview
8
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Data and the
Quality Improvement Process
How do I know where I am?
Where do I want to be?
What processes are What processes are associated with my outcome?
When I change a process, how do I know it had the effect I wanted?
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QA and PI
Quality Assurance Performance Improvement
Reactive Proactive
Episode or event-based Aggregate data & patterns
Prevent recurrence Optimize process
Sometime anecdotal Always measurable
Retrospective Concurrent
Audit-based monitoring Continuous monitoring
Sometimes punitive Positive change
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• Easy view of individual records allows resident-level RCA of events
• Matrix of individual data allows scanning for patterns
Tracking Tools
Support both QA and PI
patterns
• Summary information helps identify opportunities to improve communication and optimize processes at the system level
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The Tracking Tool
AE_SafelyReduceHospitalizationsTrackingTool.xlsAE_SafelyReduceHospitalizationsTrackingTool.xls
12
www.NHQualityCampaign.org
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3 - For Residents Recently Discharged from Hospital� Resident name
� Date discharged from hospital
� Status on admission to nursing home from hospital (Part A, Other)
4 - For Residents Transferred to Hospital
Required Fields
4 - For Residents Transferred to Hospital� Resident name
� Purpose of nursing home stay
(PAC-type Care/Chronic Long Term Care)
� Date of transfer to hospital
� Outcome of transfer
1- For Your Home (or the group within your home you are tracking)� ADC (or mid-month census) by purpose of stay
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Data Entry & Highlighted
List of Residents in 30-day
window
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Data Entry Step 3
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How do I know where I am?
Identify Baseline
1. 30-Day Readmission
Rate
2. Hospital Admission
RateRate
3. Rate of Transfers to
ED Only
4. Rate of Transfers
Resulting in
Observation Stay
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Optional Fields
Patterns in Admissions from
Hospital
� Day of week
� Hospital
Patterns in Transfers to Hospital
Process when Admitting from Hospital
� Structured communication tool used
� Information adequate to care for resident
Process when Transferring to Hospital
Structured communication tool used when Patterns in Transfers to Hospital
� Payment status at time of
transfer
� Time of day
� Doctor ordering transfer
� Primary clinical reason for
transfer
� Contributing
� Structured communication tool used when
transferring to hospital
� RCA of transfer completed
� Documented ACP discussion in past
quarter
� ACP reviewed at time of transfer
� Structured communication tool used at
nursing home to evaluate acute condition
17
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Optional Fields Help
Identify Next Steps
Patterns in Admissions from Hospital
� Day of week
� Hospital
Process when Admitting from Hospital
� Structured communication tool used
� Information adequate to care for resident� Hospital
Patterns in Transfers to Hospital
� Payment status at time of transfer
� Time of day
� Clinician ordering transfer
� Primary clinical reason for transfer
� Primary contributing reason for
transfer
� Information adequate to care for resident
Process when Transferring to Hospital
� Structured communication tool used when
transferring to hospital
� RCA of transfer completed
� Documented ACP discussion in past quarter
� ACP reviewed at time of transfer
� Structured communication tool used at nursing
home to evaluate acute condition
18
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Use Data to
Track Process Measures
70%
80%
90%
100%
Transfer Related ProcessesPercent of All Transfers for which
Resident had a Documented
Advance Care Planning Discussion in
the Past Quarter
Percent of All Transfers in which
Resident's Advance Care Plan was
0%
10%
20%
30%
40%
50%
60%
Resident's Advance Care Plan was
Reviewed at Time of Transfer
Percent of All Transfers in which a
Structured Communication Tool was
Used at Nursing Home to Evaluate
Acute Condition
Percent of All Transfers for which a
Structured Communication Tool was
Used to Receive Information from
Hospital when Resident was Last
Admitted to Nursing Home
Percent of All Transfers for which a
Root Cause Analysis was Completed
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Use Data to
Explore Patterns
8%
10%
12%
14%
16%
18%
20%
Primary Clinical Reasons for Transfers
20
0%
2%
4%
6%
Tool Tip
INTERACT Change in Condition File Cards
INTERACT Care Paths
AE Goal Packages and Tracking Tools
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15%
20%
25%
30%
35%
Primary Contributing Reasons for Transfers
Use Data to
Explore Processes
0%
5%
10%
21
Tool Tip
AE & INTERACT Advance Care Planning
INTERACT SBAR
INTERACT NH Capabilities Checklist
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Optional Fields Help
Monitor Implementation
Patterns in Admissions from Hospital
� Day of week
� Hospital
Process when Admitting from Hospital
� Structured communication tool used
� Information adequate to care for resident� Hospital
Patterns in Transfers to Hospital
� Payment status at time of transfer
� Time of day
� Clinician ordering transfer
� Primary clinical reason for transfer
� Primary contributing reason for
transfer
� Information adequate to care for resident
Process when Transferring to Hospital
� Structured communication tool used when
transferring to hospital
� RCA of transfer completed
� Documented ACP discussion in past quarter
� ACP reviewed at time of transfer
� Structured communication tool used at nursing
home to evaluate acute condition
22
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Use Data to
Track Process Measures
70%
80%
90%
100%
Transfer Related ProcessesPercent of All Transfers for
which Resident had a
Documented Advance Care
Planning Discussion in the Past
Quarter
Percent of All Transfers in
0%
10%
20%
30%
40%
50%
60%
70%Percent of All Transfers in
which Resident's Advance Care
Plan was Reviewed at Time of
Transfer
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Optional Fields Help
Identify Patterns
Patterns in Admissions from Hospital
� Day of week
� Hospital
Process when Admitting from Hospital
� Structured communication tool used
� Information adequate to care for resident� Hospital
Patterns in Transfers to Hospital
� Payment status at time of transfer
� Time of day
� Clinician ordering transfer
� Primary clinical reason for transfer
� Primary contributing reason for
transfer
� Information adequate to care for resident
Process when Transferring to Hospital
� Structured communication tool used when
transferring to hospital
� RCA of transfer completed
� Documented ACP discussion in past quarter
� ACP reviewed at time of transfer
� Structured communication tool used at nursing
home to evaluate acute condition
24
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Use Data to Explore Patterns
100%
Source of AdmissionsThe 5 places from which our nursing home most frequently admits
residents
with recent hospital stay
0%
20%
40%
60%
80%
Inverness Hospital Blue Sky Never Summer Mountain Top Mount Sanitas Not recorded
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Use Data to Explore Patterns
80%
100%
Transfers by Clinicianfor the 5 clinicians who order the most transfers
0%
20%
40%
60%
80%
Jekyl Strangelove Watson Faustus Frankenstein Not recorded
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Involving Partners
with Data
Share data with staff
Share data with hospitals
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Involving Partners
with Data
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Creating Change
Involving Partners with Data
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How am I doing?
Monitor Progress
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Enter Summary Data on the
AE Website
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Getting Started with the Advancing Excellence Hospitalization Goal
Join us for a series of 3 webinars
June 27 * July 18 * August 1
1:00-2:00pm MT
This FREE series of 3 practicums is hosted by AE and is open for anyone who would like to participate.
Each practicum will include presentation/demonstration, open space for questions and discussion, and
homework
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Thank You For making our nursing homes better
places to live, work, and visit!places to live, work, and visit!
Adrienne [email protected]