hhar-leadingage ny-final.ppt [read-only]
TRANSCRIPT
5/6/2013
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David Weinstein, Executive VP and COOMary Frances Thaler, Vice President of
AdministrationDr. Zachary J. Palace, Medical Director
May 22, 2013
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Presentation ObjectivesReview :
Best practices The role of clinical interventions and technologyThe importance of collaborations
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Hebrew Home at Riverdale: Advancing the Delivery of Care
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Summary of Hospitalizations by Cause
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Reason for D/C 7/1/09 ‐ 6/30/10 7/1/10 ‐ 6/30/11 7/1/11 ‐ 6/30/12Percentage
Year 1 to Year 3
Anemia 36 23 20 44%
CHF 10 9 4 60%
Elec. Imbalance 6 2 1 83%
Resp. Infection 112 70 62 45%
Sepsis 40 32 49 23%
UTI 13 1 3 77%
Overall Hospitalization totals for tracked
categories 217 137 139 36%
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Presentation Outline
I. Description of the CMS Nursing Home Value Based Purchasing Demonstration Project (NHVBP)II. Review of communication tools and clinical assessment utilized to reduce avoidable hospitalizationsIII. Review of technological interventions used to promptly identify changes in resident conditionsIV. Description of an Institutional Special Needs ProgramV. Description of Care Transition Efforts
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Nursing Home Value Based Purchasing Demonstration Project (NHVBP)
Background:NHVBP is a Centers for Medicare and Medicaid Services (CMS) Pay for Performance Initiative Goal: to improve the quality of care furnished to all Medicare beneficiaries in nursing homes
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Nursing Home Value Based Purchasing Demonstration Project (NHVBP)
CMS selected three states to host the demonstration: Arizona, New York, WisconsinAs of June 30, 2010 there were 78 participating nursing homes in New York, 61 in Wisconsin and 38 in ArizonaComparison group nursing homes were selected either through random assignment or matchingThe Hebrew Home at Riverdale was selected as a participating nursing home for the duration of the demonstration project – July 1, 2009 to June 30, 2012
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Overview of NHVBP DesignObjective: To improve the quality of care furnished to all Medicare beneficiaries residing in nursing homes
Approach:Assess nursing home performance based on selected measures of qualityMake annual payment awards (if savings are achieved) to those nursing homes that achieve the best performance or the most improvement based on the performance measures
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NHVBP Performance Payments
In each State, a payment pool will be determined each yearThe payment pool will be based on the estimated Medicare savings achieved by the participantsHigher quality of care is expected to result in fewer avoidable hospitalizationsIf no savings are achieved, then no payment pool
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NHVBP Performance MeasuresEach year of the demonstration, CMS will calculate an overall quality score by summing the scores in four domainsNHVBP Demonstration Project included four domains/performance measures:
Nurse staffingOutcomes from State survey inspections Outcomes on selected MDS‐based quality measuresRates of potentially avoidable hospitalizations
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Four NHVBP Performance Measure Categories
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Nurse Staffing 30 pts.
Outcomes from State Survey Inspections
20 pts.
Quality Measures (from MDS) 20 pts.
Potentially avoidable hospitalizations
30 pts.
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NHVBP Performance MeasureStaffing (30 Pts.)
RN/DNS hours per resident dayTotal licensed nursing hours (RN/DNS/LPN) per resident dayCertified Nurse Aide (CNA) hours per resident dayNursing staff (RN, LPN, CNA) turnover rateAgency staff count 80% of staff level measureCase Mix adjustedQuarterly Payroll data will be source for staffing levels and turnover measures
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NHVBP Performance MeasureState Survey Inspections
(20 pts.)Deficiencies are assigned values based on scope and severityReturn visit to correct deficiencies will be consideredFacilities cited for sub‐standard care will be ineligible for an incentive paymentF‐Tags only, no life safety
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NHVBP Performance MeasureQuality Measures
(from MDS) (20 Pts.)
Chronic Care (LT Stay)Points reduced for percentage of residents:
whose need for help with ADL has increasedwhose ability to move in & around their room became worsewho are considered high risk residents with pressure ulcerswho have had a catheter left in their bladderwho were physically restrained
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NHVBP Performance MeasureQuality Measures (from MDS) (20 Pts.)
Post‐Acute Care (short‐term)Points gained for percentage of residents:
with improving ADL’s.who improve status on mid‐loss ADL functioning.with failure to improve bladder incontinence.
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NHVBP Performance MeasurePotentially Avoidable Hospitalizations
(30 Pts.)“Avoidable” is defined as hospitalizations with any of these diagnoses:
• Heart Failure• Respiratory Infection• Electrolyte Imbalance• Sepsis• Urinary Tract Infection• Anemia (Long Term Residents Only)
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NHVBP Implementation StrategiesProtocols Developed for Reducing Unnecessary Hospitalizations:
All RN’s IV certifiedIncreased in‐house Lab hours to 6 days per week and on‐call for 7th dayEstablished out‐patient transfusion capabilities without hospitalizationPurchased EKG machine for stat EKGs on‐siteImplemented Care Paths for the identified diagnoses
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Concurrent Evaluation Strategies
Creation of NHVBP Committee comprised of:Executive Vice‐President / Chief Operating OfficerAssociate AdministratorMedical DirectorDirector of Nursing ServicesDirector of Clinical Documentation and ReimbursementInfection Control Nurse
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Concurrent Evaluation Strategies
NHVBP Committee objectives:To track all hospitalizations for all diagnostic categories To review bi‐weekly data to identify patterns of incidence of hospitalizations by diagnostic categoriesTo complete in‐depth medical and nursing audit for a sample of all residents hospitalizedTo review audit results for identification of patterns/trends
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Concurrent Evaluation StrategiesNHVBP Committee objectives continued:
To complete an in‐depth audit of a selected sample for comparison to the defined clinical care pathTo review audit findings discussed at bi‐weekly committee meetings with the clinical teamTo revise clinical pathways based on audit resultsTo further develop strategies to reduce hospitalizations
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Communication Tools and Clinical Assessment
• The Hebrew Home is committed to treating patients in place
• The Hebrew Home chose to participate with the Continuing Care Leadership Coalition (CCLC), an affiliate of the Greater New York Hospital Association (GNYHA), in implementation of the INTERACT II program
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The INTERACT II ProgramINTERACT: “Interventions to Reduce Acute Care Transfers”
Is a quality improvement program designed to improve the care of nursing home residents with acute changes in conditionIncludes evidence and expert‐recommended clinical practice tools, strategies to implement them, and related educational resources
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The INTERACT II Program GoalTo improve care, not to prevent all hospital transfersCan help with more rapid transfer of residents who need hospital careCan help your facility safely reduce hospital transfers
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INTERACT II Communication Tools
Early Warning Tool – Stop and WatchSBARQuality Improvement Tool
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INTERACT II Communication ToolsObjectives of the Tools:
Improve management of acute changes in clinical status:IdentificationAssessmentTreatment in the facilityDocumentationCommunication
InternalWith hospitals
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Early Warning Tool ‐ Stop and Watch
Utilized by clinical and non‐clinical staff who have direct resident contactUtilized when an important change in condition is noted when caring or interacting with the residentPresented to the charge nurse before the end of the shiftUtilized by charge nurse in evaluation and treatment of the residentResults in earlier identification of subtle changes in resident condition
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EARLY WARNING TOOL “Stop and Watch”If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift.Name of resident: __________________________________________� Seems different than usual� Talks or communicates less than usual� Overall needs more help than usual� Participated in activities less than usual
� Ate less than usual (not because of dislike of food)� No bowel movement in the last 48 hours� Drank less than usual
� Weight change� Agitated or nervous more than usual� Tired, weak, confused, or drowsy� Change in skin color or condition� Help with walking, transferring, toileting more than usualStaff: ____________________________ Reported to: _______________________________Date: _____ / _____ / ________ Time: ____________________ 29
SBAR: Physician/NP/PA Communication
and Progress Note
S = SituationB = BackgroundA = AssessmentR = Request
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SBAR: Physician/NP/PA Communication
and Progress NoteBefore calling the MD/NP/PA the Nurse should:
Evaluate the resident – complete the SBAR formCheck vital signsReview the medical chart – including recent labsReview an associated clinical care path if applicableHave relevant information available when reporting –including advanced directives, allergies, medication list, and the medical record
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SBAR
SBAR provides clear guidelines for communication around a resident’s change in conditionSBAR utilization results in more efficient and effective transmission of important informationSBAR form can also be used in place of a nursing progress note
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Purpose of this tool is to retrospectively review acute care (non‐elective) transfers to an emergency department or for direct admission to the hospitalTool should be completed within 24 to 48 hours after a resident is transferredUtilization of this tool helps facility staff:
Understand the reasons for acute care transfersIdentify possible opportunities to prevent avoidable transfersIdentify common patterns among the acute care transfers
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Quality Improvement Tool
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The QI Review Tool1. Background Information2. Change in Condition3. Evaluation and Management4. Transfer Information5. Opportunities for Improvement
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Quality Improvement Tool
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Quality Improvement ToolRetrospective review of quality improvement tool information is used to determine if the patient transfer might have been preventedOpportunities for improvement are discussed to determine if the team thinks the transfer might have been prevented:
The new sign, symptom or other change might have been detected earlierThe condition might have been managed safely in the facility without transferAdvance directives and/or palliative or hospice care could have been discussedOther
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Summary of Interventions Utilized to Reduce Unnecessary Hospitalization
Stop and watch early warning tool utilized by care team members SBAR tool utilized by nursing staff in communicating with MD/NP/PAQuality improvement tool utilized for retrospective audit of staff performance, clinical team education, and identification of opportunities to prevent avoidable transfers
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Clinical Assessment and Interventions
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Problem Intervention
Problem InterventionRecognition Assessment
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AssessmentClinical assessment is about asking the right questionsIt is a data‐driven processImproving the process will improve the outcomes
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CHF InterventionsOngoing continuing medical and nursing staff education utilizing evidence‐based medicine guidelines as well as clinical care paths, including INTERACT, for each diagnostic category
Raised level of awareness of physicians to manage the patients in‐house
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CHF InterventionsBaseline numbers low to start as medical staff vigilance was focused
INTERACT NY quality improvement review tool is used for the retrospective chart review comparing the care path with actual practice – Medical Director provides feedback to the Attending Physician regarding their decision to transfer
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CHF Discharges
49• 60% Decrease in CHF Discharges
Electrolyte Imbalance InterventionsImproved monitoring via increased availability of labs on‐site and over the weekendAvailability of STAT labs with results available within 30 to 45 minute timeframeIncreased utilization of IV fluidsIncreased nursing vigilance for symptom managementUtilization of care paths for medical and nursing staff education
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Electrolyte Imbalance Discharges
52•83% Decrease in Electrolyte Imbalance Discharges
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Anemia ChallengesMost patients with chronic anemia and a low hemoglobin do not need to be admitted to hospitalMany can be managed on site (eg. iron, erythropoetin)Some do need a blood transfusionPatients presenting to the emergency room for a blood transfusion are ADMITTED
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Consequences of the Elderly Being Admitted to the Hospital
Loss of physical function due to prolonged immobilityDevelopment of new decubitiiNosocomial infections (MRSA, VRE)Acute adjustment reaction
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Asking the Question…How can our facility send patients for a blood transfusion without them getting admitted?
Hematologists send their patients living in the community to the blood bank for transfusions.
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Anemia Interventions• Developed anemia care path for education and audit purposes
• Created outpatient transfusion protocol• Developed anemia / transfusion transfer tool which is completed by MD.
• Scheduled transfer to blood center the following day• Same day return to nursing facility
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Anemia Interventions
Objective: To develop a favorable alternative to the unnecessary hospitalization of nursing home residents requiring blood transfusionThrough clinical collaboration with a geriatrician liaison at a local hospital, the transfusion protocol transfer form was developed.
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Anemia InterventionsThe protocol was developed for the nursing home resident who is evaluated for anemia and a clinical decision is made for a blood transfusion without pursuing an extensive diagnostic workup and an inpatient admission.
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Anemia Interventions:Clinical Collaboration
Developed transfusion transfer formTransfusion transfer form is faxed to the hospital geriatricianHospital geriatrician coordinates with the hospital blood center for an out‐patient transfusion the following dayResident is transported to the hospital blood center for transfusion and returned to the nursing home later that same day, avoiding an in‐patient hospital stay
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Anemia InterventionsOutpatient Transfusion Protocol
Exclusion CriteriaActive bleedingHemodynamic instabilityFamily request for admission
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Anemia Discharges
62•44% Decrease in anemia discharges
Transfusion Protocol
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Anemia InterventionsFrom 7/1/09 through 7/31/11 there were 78 residents with hemoglobin values less than 8 mg/dl on evaluation31 of these residents (40%) were successfully transfused through use of the out‐patient transfusion protocol
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Reducing Hospitalizations: Technological Interventions
Nearly 20% of Medicare hospitalizations are followed by readmission within 30 daysEarly detection and timely intervention is a key element in preventing adverse eventsProvision of real‐time alerts transmitted to the nurse control station and directly to caregivers using handheld devices enables timely intervention by the medical staff
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Technological Intervention: EarlySense
The system is a patient status monitoring solution for currently unmonitored unitsEarlySense measures changes in patients’ respiration rate, heart rate, patient movement and turn statusEarlySense provides continuous, contact‐free bedside monitoring with real‐time alertsBuilt‐in management tools include a wide range of patient status and alert reports
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Proactively Reduce Adverse Events
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EarlySense –Optimized monitoring for unmonitored patients
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• Under-the-mattress contact-
free sensor
• Wall-mountedbedside Monitor
• Patient management center
• Vital signs trends, alerts &
documentation
• Daily reports:patient status & alerts
• Immediate, real-time alerts on
mobile devices
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Falls Prevention
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6 levels of bed exit sensitivity
Delayed activation feature
Wandering patients feature
Personalized Sensitivity level
Response time
Daily unit reports
Individual & team response times
Enabling improvement goals
# of alerts per patient
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Patient Falls
Pressure Ulcer
Code Blue
Interim clinical results achieved by first sites
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Prior 12 months
Monthly # of events
Actual data – CHW site #1 2010/’11
5 months with EarlySense
Same level of patient acuity
Sustained, more predictable results
Reduction in hospital acquired
pressure ulcer cases
Actual clinical data of 6 months: CHW site #2 2010
# of pressure ulcer events ‐75%
# of patient falls ‐62%
# of Code Blue events ‐50%
# of ICU transfers ‐63%
Overall Length of Stay ‐14%
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Results from Hebrew Home
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Results from Hebrew Home
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Clinical Assessment is a data‐driven process.Direct staff observation/recognizing a change
(Stop and Watch/SBAR)Technological solutions (EarlySense)Timely interventions that are appropriate.Practicing Evidence‐Based MedicineUtilizing Clinical Care Pathways
Problem Assessment InterventionRecognition
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Reducing Hospitalizations: Impact of an Institutional Special Needs Program
A Medicare Advantage health plan available to nursing home residents who meet certain eligibility requirementsResidents receive an extra layer of care through the personal support of a Nurse Practitioner (NP)NP helps anticipate and identify health concerns early, before they become more serious
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Institutional Special Needs ProgramThe Nurse Practitioner:
builds one‐on‐one relationships with the resident and their familyprovides hands‐on care and monitoringacts as a communication link to the doctor, nursing facility staff and familycoordinates and integrates the different aspects of the resident’s care
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Institutional Special Needs ProgramNP provides the following services, under a physician’s direction:
Conducts physical examinationsManages chronic conditionsOrders lab testsWrites prescriptions (in most states)Quickly determines need for preventive or diagnostic servicesCommunicates with all parties to coordinate services Ensures that treatments are working well together
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Institutional Special Needs ProgramNP assists with analysis of resident transfers to hospitalTransfers are investigated to determine:
Who transferred the residentWhat day/time the transfer occurred
Transfers are categorized as:AvoidableUnavoidable but potentially preventable transferAppropriate hospital admission
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Institutional Special Needs ProgramResults of Analysis of Transfers from August 2011 to July 2012:
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Avoidable transfer 18%
Unavoidable but potentially preventable transfer
13%
Appropriate hospital admission 68%
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Care Transition EffortsIn 2010, The Hebrew Home worked with one of our hospital partners in the “Hand Off Communication Project”This project was a quality and patient safety collaborative with the Joint Commission and peer‐collaborators across the countryThe goal of the project was to improve care transitions by providing all critical information needed for medical management and discharge planning
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“Hand Off Communication Project”Project involved the use of a revised resident transfer formTransfer form was paper basedProject initially focused on hospital and nursing facility staff completion of a survey at the time of specific patient transferProvider input was utilized in identifying required transfer documents for both hospital and nursing facilityDevelopment of transfer documents for both hospital and nursing facility utilization was achieved
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“Hand Off Communication Project”Hospital and nursing facility providers were surveyed to determine if they:
Received the hand‐off communication in a timely mannerReceived all of the relevant medical and social information to provide safe/quality care for the patientProvided sufficient time for the hand‐offExperienced limited interruptions during the hand‐offCommunicated directly with the sender regarding any questions and concerns for safe care of the patient
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ACUTE CARE TRANSFER DOCUMENT CHECKLISTThese documents should ALWAYS accompany patient:• Resident Transfer Form• Face Sheet• Current Medication List or Current MAR• Advance Directives• Care limiting Orders• Out of hospital DNR• Bed hold policySend these documents IF INDICATED:• SBAR/Nurse’s Progress Note• Most Recent History & Physical and any recent hospital discharge• summary• Recent MD/NP/PA Orders related to Acute Condition• Relevant Lab Results• Relevant X‐Rays
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Care Transition EffortsCurrently working with Continuum of Care Improvement Through Information New York, Inc. (CCITI NY) – a not‐for‐profit corporation engaged in health information exchangeCCITI NY:
received health information technology grants from NY State related to improving care transitionsdetermined transfer form data elements by working with a team of clinicians from numerous institutions around the country
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Care Transition EffortsCCITI NY received additional NYSDOH grant funding to conduct a project to improve care transitions between acute and post‐acute settingsThe project is piloting the use of an interoperable electronic transfer form with Hebrew Home, New York Presbyterian Hospital and several other facilitiesUtilization of Regional Health Information Organizations (RHIO) facilitates information exchange between sitesThe system allows for clinical data from an EMR to be leveraged in the sending of the transfer form
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Care Transition Efforts
Currently, CCITI NY is modifying the transfer form to more closely resemble the INTERACT transfer formCCITI NY plans to offer a less complex web based version of the transfer form for organizations who are not part of a RHIOBeta testing of the electronic transfer form is in progress
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Care Transition EffortsThe Hebrew Home at Riverdale utilizes an EMRClinical providers initiate transfer of patient demographic information and clinical data from our EMR to the Healthix RHIO CCITI System transfers patient and clinical data from RHIO into the transfer formDemographic information and clinical data is prepopulated onto the CCITI NY transfer form from the RHIO
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Care Transition EffortsProvider logs into transfer form and completes additional information
Reason for transferUpdated problems, medications, allergies Most recent vital signs, painImmunizationsFunctional status including advance directivesFollow up interventionsAdditional comments
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Care Transition EffortsClinical decision support is integrated into the computerized transfer form
Drug – drug interactionsDrug – allergy interactions
Nursing facility provider selects the receiving hospitalHospital ED registration of SNF patient triggers alert within the ED EMRAlert directs hospital staff to log into the RHIO to access patient transfer formPatient specific information is available prior to patient arrival at ED
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Care Transition EffortsUse of the electronic transfer form is intended to:
Improve staff efficiency in completing transfer formProvide automated clinical decision support to clinicians managing medically complex patientsFacilitate efficient and timely exchange of accurate information between care providers in advance of patient arrivalReduce the incidence and cost of avoidable readmissions to acute care facilitiesImprove quality of care
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Long Term Care Facilitysends ADT and Clinical Data
Patient readyfor discharge
Provider logs into EMR, reviews documentation and launches CC Transfer form
CCITI System transfers patient and clinical data from RHIO into the CC Transfer form
Hebrew Home to HospitalRHIO
Internet
Provider logs into CC Transfer form and completes information.
Hospital Admits Patient and Receives Transfer Form
Provider logs into system and accesses transfer form
Patient arrives at Hospital
Care Transition: Resident Transfer Form
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Care Transition: Resident Transfer Form
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Conclusion• Clinical staff communication tool utilization contributed to achieving a decrease in hospitalization rates
• Diagnostic care paths continue to be utilized and refined as needed
• The quality improvement tool provides timely and specific feedback to clinicians responsible for resident transfer
• An electronic transfer form is being developed to improve care transitions between providers
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Conclusion
Collaboration with regional health care organizations facilitates
Effective care transitionsEnhanced care across settingsImproved quality of care during transitions
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Conclusion
The Hebrew Home was recently selected to participate with the Greater New York Hospital Association/Continuing Care Leadership Coalition in the CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
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ConclusionParticipation in this CMS initiative will
Strengthen nursing home‐hospital partnershipsProvide for engagement of registered nurse care coordinators to implement INTERACT and other evidence‐ based practicesProvide the support of an electronic information and exchange systemAssist with monitoring care coordination and the transfer process
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Referenceshttp://interact2.net
http://www.earlysense.com
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The INTERACT II ProgramAcknowledgement
The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Center for Medicare and Medicaid ServicesThe current version of the INTERACT Program was designed by the INTERACT team, with input from many direct care providers and national experts in projects based at Florida Atlantic University and supported by the Commonwealth Fund. The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.
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Speaker Contact InformationDavid Weinstein, EVP, COOExecutive Vice Present, Chief Operating [email protected]
Mary Frances Thaler, P.T., M.H.A.Vice President of [email protected]
Zachary Palace, M.D., C.M.D.Medical [email protected]
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