Maximizing HHQI Resources to Reduce Readmissions: Part 1

Presented by:E. Eve Esslinger, Lead HHQI Project Coordinator

Cindy Sun, HHQI RN Project Coordinator

Home Health Quality ImprovementGoal: Improve the

quality of care home health patients receive

Special Project funded by Centers for Medicare

& Medicaid Services

Evidence-based practice

Free tools, resources, & networking

History 101Phase 1: 2007-2008

Focused on reducing ACH

Home health setting

Focus on agency leadership

More than 5,500 home health agencies enrolled to participate

Phase 2: 2010-2011

Focus on reducing ACH & Improving Oral Medication Rates

Home health focus but shifting towards cross-setting care

Patient-Centered, Interdisciplinary

More than 8,000 participant representing 4,000+ home health agencies

Phase 3: Sept. 2012 – July 2014

Focusing on quality of home health care measured by :

• ACH reduction• Improvement in oral medication management

• Improvement of immunization rates

Continuing HH focus, but all care settings and patients encouraged to participate

Introducing Special Population Assistance Network (SPAN)

More than 8,600 participants

www.homehealthquality.org

www.homehealthquality.org

Best Practice Intervention Packages (BPIPs)

• Phase 1 BPIPs (12)– Monthly

• Phase 2 BPIPs (6) – Quarterly

• Phase 3 BPIPs (8)– 6 Focused– 2 Primary

Focused BPIPsBPIP Release Date

Patient Self-Management November 1, 2012

Medication Management April 2, 2013

Disease Management--Part 1 August 1, 2013

Disease Management—Part 2 November 1, 2013

Fall Prevention February 3, 2014

Cross Setting Care April 1, 2014

Primary BPIPs

BPIP Release Date

Dual-Eligible Providers (SPAN) February 1, 2013

Immunization June 3, 2013

Fundamentals of Improving ACH

• Introduction BPIP• January 2010

BPIP Contents

• Introduction• Leadership– Tools– Checklists– Organizational Culture– Ideas for working with other providers– Timeline

• Discipline Checklists

Timeline and Checklist

• Page 14 (Timeline)• Pages 20-23

Home Health Compare

• How often patients had to be admitted to the hospital (End Result Outcome Measure) – Tennessee: 29% National 27%

Absolutes

• Hospitalization Risk Assessment• Emergency Care Planning• Front loading based on risk assessment• Easy access to a nurse (24/7 call, office

nurse)• Phone monitoring and/or telehealth• Patient education centers on patient

participation

Hospital Risk Assessment

• What it isn’t—– M1032– A stand-alone document

• What it is—– Individualized– Helps guide care plan

Discipline Tracks

To Do List

• To do by week 1:– Download the BPIP– Break it apart (e.g., circulate discipline tracks)– Check compliance with ACH risk assessment,

emergency care plan (or initiate implementation ASAP)

Continue…

• To do by week 2:– Ask staff to tell you what they think about

reducing ACH • RULES: No whining; No throwing up hands like it is a

lost cause• Use staff meetings, post-it boards, etc

– Adopt a turn-key tool and circulate it– Start concurrent evaluation on every single

hospitalization

Call First

Improving Management of Oral Medication

April 2010• Medication adherence can

often be a problem among older adults and requires additional resources and strategies on the part of health care providers (MacLaughlin et al., 2005).

• Multiple factors impact adherence.

OASIS-C• A complete drug regimen review for any potential

clinically significant medication issues (M2000)• Documentation of follow-up with the physician regarding

clinically significant medication issues, including medication reconciliation (M2002 and M2004)

• High-risk drug education to the patient/caregiver (M2010)• Drug Education to the patient/caregiver (M2015)• Assessment of management of oral medications (M2020)• Assessment of management of injectable medications

(M2030)• Prior medication management (M2040)

Home Health Compare

• How often patients got better at taking their drugs correctly by mouth (End Result Outcome Measure) – Tennessee: 49% National 48%

• How often the home health team taught patients (or their family caregivers) about their drugs (Process Measure)– Tennessee: 89% and National 90%

Potentially Avoidable Events

• Emergent care for improper medication administration, medication side-effects

• Emergent care for hypo/hyperglycemia• Substantial decline in management of oral

medications

Medications and Hospitalizations

• Adverse drug events cause over 700,000 emergency department visits each year. Nearly 120,000 patients each year need to be hospitalized for further treatment after emergency visits for adverse drug events. (CDC)

• Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for ADEs in older adults (Budnitz et al., 2011)

Medications Causing Hospitalizations

Drug Annual # of Hospitalizations

Proportion of ED visits resulting in Hospitalization

Warfarin 33.3% 46.2%

Insulins 13.9% 40.6%

Oral antiplatelet agents 13.3% 41.5%

Oral hypoglycemic agents 10.7% 51.8%

Budnitz et al., 2011.

Discipline Tracks

Oral Medications: The Essentials

Using the Evidence

• Reminders, feedback, and decision-support systems lead to quality care by alerting clinicians to problems

• Fewer medications reduce the likelihood of medication problems

• Packaging, memory and organizing aids such as pillboxes or blister packs help adherence

http://champ-program.org/page/68/evidence-briefs

Using the Evidence, cont.

• Medication “reconciliation” and reviews conducted by doctors, nurses or pharmacists reduce discrepancies and errors and help find potential drug related problems

• Multifaceted programs that include ways to simplify medications, increase convenience, and provide counseling help with medication adherence

CHAMP Evidence Briefs: http://champ-program.org/page/68/evidence-briefs

Implications for Home Care

• Compile and communicate accurate, complete, and current medication information.

• Assure that older people and everyone involved in their care understand the purpose of their medications and signs of potential problems.

• Simplify medications whenever possible given medical needs.

• Identify and address barriers to medication adherence.http://champ-program.org/page/68/evidence-briefs

Medication Management Tools

To Do List

• To do by week 1:– Download the BPIP– Break it apart (e.g., circulate discipline tracks)– Check compliance through record reviews and

staff discussion with:• Medication Reconciliation• Medication Adherence• Medication Management • Medication Simplification

Continue…

• To do by week 2:– Ask staff to tell you what they think about

improving management of oral medications• RULES: No whining; No throwing up hands like it is a

lost cause• Use staff meetings, post-it boards, etc

– Adopt a turn-key tool and implement with small group of nurses

• Appoint medication nurse leaders• Staff need to understand which meds

cause more ADEs and Show –don’t tell: Tell me how you take your medicines How do you schedule your meal and medication times? Do you use a pill box or organizer to help you take your medicines? How do you manage to pay for your medicines? If possible, would you like me to simplify your medication regimen? If possible, would you like to explore some options for reducing your out-

of-pocket medication expenses? Show me how you use your inhaler.

(MacLaughlin et al., 2005)

Continue…

Medication Management: A Community Project

• Who is on the ‘team’?– Nurse?– Physician?– Therapist?– Pharmacist?– Patient?– Caregiver/family?– Social worker?

• Show Me and Teach Back

Patient Medication Management

Resource links

• Speak up:– http://www.jointcommission.org/speakup.aspx

• AHRQ guides:– http://www.effectivehealthcare.ahrq.gov/

index.cfm/research-summaries-for-consumers-clinicians-and-policymakers/

Fall Prevention• July 2010• Falling is NOT an inevitable result

of aging. Through evidence-based interventions, practical lifestyle adjustments, and community partnerships we can substantially reduce the number of falls

(Bonita) Lynn Beattie, PT, MPT, MHAVice President, Injury Prevention Falls FreeTM Initiative Center for Healthy Aging National Council on Aging

OASIS-C• M1910: Has this patient had a multi-factor Fall Risk Assessment

(such as falls history, use of multiple medications, mental impairment, toileting frequency, generally mobility/transferring impairment, and environmental hazards)?

• M2250 Plan of Care Synopsis: Does the physician-ordered plan of care include fall prevention interventions? (Note: Fall prevention interventions is only 1 of 7 selected interventions for this measure.)

• M2400 Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Note: Fall Prevention interventions is only 1 of 6 selected interventions.)

Home Health Compare• How often the home health team checked

patients’ risk of falling. (Process Measure)– Tennessee 93% and National 95%

• How often patients got better at walking or moving around. (Outcome Measure)– Tennessee 58% and National 57%

• How often patients got better at getting in and out of bed. (Outcome Measure)– Tennessee 54% and National 54%

Potentially Avoidable Events

• Emergent Care for Injury Caused by a Fall

Falls and Hospitalizations

• In 2009, 2.2 million nonfatal fall injuries among older adults were treated in emergency departments and more than 581,000 of these patients were hospitalized.

• In 2008, over 19,700 older adults died from unintentional fall injuries.

―CDC

Discipline Tracks

Falls Prevention: Insights

Our intake department and liaisons in the hospitals and skilled nursing facilities identify patients at high-risk for falls, before we admit them (recent fall, fall precipitating hospital admission, specific diagnoses/injury due to fall, etc.) and these become High Priority Patients. Though nursing may be admitting, PT also goes in on that first day after the admission. If the admission is occurring on a weekend, PT is scheduled to assess on the first day also.  Patients at high risk for a fall are priority patients for PT on the weekend, just like those with acute orthopedic and neurological diagnoses.

Jean E. Zaleski, PT, DPT, MEd, Director of Community Resource Development

Holyoke Visiting Nurses Association and Hospice Life Care Holyoke, MA

Falls Prevention: Insights•Each person has their own story of why they fall - so the fall risk assessment must be multifaceted•Intervene early and up front by recognizing risk factors and before the patient falls. How do you do that?o Teach clinicians to be as educated about falls as you—the ‘fall

coordinator’ are. Be passionate about falls!o Collect data to see the trends .

Share trends with staff Make the trends meaningful (e.g., How many with/without an

assistive device?)o Review the patient record when a fall occurs and use this as a teaching

tool for the staff. (e.g., Are you checking her BP each time? Is the doctor aware that her BP is falling like this?)

o Don’t let staff overlook fall risk with any patient. Gail Mello, PT, Rehabilitation DirectorBrockton Visiting Nurses Association, Brockton, MA

Evidence-based practice

• Evidence-based clinical decision making– External evidence from research, theories, opinion

leaders, expert panels– Clinical expertise– Patient preferences and values

Melnyk and Fineout-Overholt, 2011, p. 4

Using the Evidence

• Many people who fall, even if they are not injured, develop a fear of falling. This fear may cause them to limit their activities leading to reduced mobility and loss of physical fitness, which in turn increases their actual risk of falling. (CDC)

• Risk for falls should not be identified by an individual tool. The most consistently successful approach to prevention of falls has been multifactorial assessment, followed by interventions targeting the identified risk factors. Such targeted assessment and management strategies have been shown to reduce the occurrence of falling by 25 to 39 percent. (Tinetti, 2003)

Using the Evidence: Medications and Falls

• Medication review is appropriate for fall risk if patient is taking 4 or more medications OR a high-risk medication.

• Medications and falls can be a problem, because the patient may need the medication even though the medication can attribute to fall risk.

• All types of psychoactive medications increase fall risk:

– Sedatives– Antidepressants– Anxiolytics (antianxiety drugs)– Antipsychotics

(Tinetti, 2010)

Using the Evidence, cont.• AGS/BGS Clinical Practice Guideline:

Prevention of Falls in Older Persons (2010)

AGS/BGS Clinical Practice Guideline

Fall Prevention Tools

Focus Section

• Pages 13-20

To-Do List – Week 1

• To do by week 1:– Download the BPIP– Break it apart (e.g., circulate discipline tracks)– Know your fall trends (all falls)– Check compliance through record reviews and

staff discussion with:• Multifactorial and Validated Fall Assessment• Fall prevention interventions

To-Do List - Wk. 2

• To do by week 2:– Ask staff for input on fall prevention• Use staff meetings, post-it boards, etc

– Share and discuss the AGS/BGS guidelines with your staff

– Appoint a Fall Coordinator– Adopt a turn-key tool and implement

with a small group of staff

To-Do List – Wk. 2 continued• Spread implementation

of successful tools• Analyze every fall

– Was assessment completed?

– Were specific interventions implemented based on the assessment?

– What was the outcome?

Patient Education

Resource Links• Speak up: http://www.jointcommission.org/speakup.aspx• AHRQ guides:

http://www.effectivehealthcare.ahrq.gov/index.cfm/research-summaries-for-consumers-clinicians-and-policymakers/

• Stop Falls http://www.stopfalls.org/resources/downloadables/Falls_Pets.pdf

• CDC http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallsmaterial.html

References• Budnitz, D.S., Lovegrove, M.C., Shehab, N., & Richards, C.L. (2011). Emergency

hospitalizations for adverse drug events in older Americans. The New England Journal of Medicine 365 (21), 2002-2012.

• CHAMP. Evidence Briefs. http://champ-program.org/page/68/evidence-briefs• Centers for Disease Control and Prevention (CDC).

http://www.cdc.gov/MedicationSafety/Adult_AdverseDrugEvents.html• Centers for Disease Control and Prevention (CDC).

http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html• MacLaughlin, E. J., Raehl, C.L.,Treadway, A.K., Sterling, T.L., Zoller, D.P., & Bond, C.A.

(2005) Assessing medication adherence in the elderly: Which tools to use in clinical practice? Drugs & Aging 23 (3), 231-255.

• Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins

• Tinetti, M., (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348 (1), 42-49.

• Tinetti, M., & Kumar, C. (2010). The patient who falls: it’s always a trade-off. Journal of the American Medical Association, 303 (3), 258-266.

HHQI Data Reports

www.homehealthquality.org

hhqi@wvmi.org

This material was prepared by the West Virginia Medical Institute, the Quality Improvement Organization supporting the Home Health Quality

Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

Services. The views presented do not necessarily reflect CMS policy. Publication Number: 10SOW-WV-HH-BK-92412. App. 9/2012.