REDUCING READMISSIONS St. Luke’s Hospital Case StudyCedar Rapids, IA

IHI National ForumOrlando Florida December 9, 2013

ST. LUKE’S HOSPITALMEMBER, UNITYPOINT HEALTH

Private hospital – Cedar Rapids, Iowa

Affiliate in the UnityPoint Health system

Licensed for 500 Beds with more than 17,000 admissions

Truven Top 100 Hospital – 5 years (2013); Heart Hospital 3 years (2012)

Iowa Recognition for Performance Excellence Gold Award - 2010

Magnet Designation – 2009 The Joint Commission Disease-

Specific Certification in Advanced Heart Failure, Stroke, Palliative Care and Total Joint. Society of Chest Pain Center – Chest Pain Certification

Gold Award from Get with Guidelines for Heart Failure 2010-2013

WHY IS REDUCING AVOIDABLE REHOSPITALIZATIONS STRATEGIC FORST. LUKE’S HOSPITAL?

It is part of our mission: “To give the healthcare we’d like our loved ones to receive”

It represents goals that are aligned with healthcare reform: providing better value for decreased costs. Learning has been incorporated into our present work with development of population management and ACO work

TRANSITION TO HOME TEAM MEMBERS CHAIR: Peg Bradke, VP-Post-Acute Care Robinn Bardell, Mgr-Case Mgmt Sarah Baumert, Mgr-5E Diane Pfeiler, PCC-3C Alexis Benion, Living Center West Dean Bleadorn, Mgr-RT Myrt Bowers, Assoc Exec Dir-Witwer

Center Shelley Cahalan, Gen Mgr-VNA Christy Charkowski, STL Hospitalists Sara Claeys, Dietary Svcs Christina Djerf, Prog Coord-Lifeline Elizabeth Eichhorn, ARNP-Living Center

West Krissy Elder, PCC-5C Karen Forster, Pharm Terri Grantham, APN-Card Outcomes Renee Grummer-Miller, OP Pall. Care Barb Haeder, APN-Card Outcomes Sue Halter, ARNP-STL HF Clinic Signe Henderson, Coord-Home Care Amrita Samra, MD, CRMEF

Sherrie Justice, Dir-PI Carmen Kinrade, VP-Nursing Excellence Patty Koelker, PCC-5E Jennifer Mahoney, UPH Clinic - Northridge Shirley McCloy, Resp Ther Sandi McIntosh, Dir-ED Jennifer Owens, Med Soc Svcs Julie Peterson, Mgr-Card Rehab Karen Pierce, Data Analyst, PI Amrita Samra, MD - CRMEF Brandi Simmons, Living Center West Amy Schweer, STL HF Clinic Marilinne Staub, UM Spec. Aimee Traugh, Mgr-3C Sheila Tumility, Reg PI Proj Mgr Brook Van Dee, ARNP-OP Pall. Care Jean Westerbeck, Living Center West Pam Williams, JRMC Resp Care Sharon Zimmerman, Resp Care Dr. Todd Langager, Cardiology Medical

Director

VOICE OF THE CUSTOMER

Feedback from Chronic Disease Management class

Patient and family members on our Patient-Family Advisory Council

Feedback from follow-up phone calls Feedback from Cardiopulmonary Rehab

participants Feedback from High-Risk Clinic Patients

CROSS-CONTINUUM TEAM

Meets monthly Reviews readmissions for each month

related to core diagnosis to assess causes and opportunities for improvement

Reviews process and outcome measures Continually testing and improving,

aggregating the experiences of patients, families and caregivers

Each facility reports in testing occurring in their area

SEVERAL SUBGROUPS REPORT INTO THE LARGER TRANSITION TO HOME TEAM

Data Management Patient Education processes Home Care SNF/Nursing Facilities work processes Physician Clinic processesCase Management/Social Work/Care Coordination

Several members of the Transition to Home team are members of the hospital ACO and Population Health Management work. Information is bidirectional between these teams.

Continuum of Care Process Standardized care through order sets. Use of the clinical indicator sheet as a

checklist for evidence-based care being met. Report developed to identified key core

measure patients – (e.g. BNP, Troponin etc) Teaching:

• Utilizing Universal Health Literacy Concepts• Enhanced teaching materials• Teach back

Utilization of whiteboard to individualize patient’s plan of care and communicate to team.

Continuum of Care (2)

Bedside report to involve patient and family caregivers as partners in care.

Daily huddles are facilitated with the patient care nurse, charge nurse, and care coordinator. Daily goals are reviewed providing opportunity to review plan for the day, available support for patient, discharge goals, and determine what it will take to get the patient home safely. Assessment of palliative care referral is part of discussion.

Standardized Disease specific on-line discharge instructions.

Continuum of Care (3)Touch points post discharge: Home Care - care coordination visit 24 to 48 hours

post discharge on high risk patients Physician Clinic follow up appointment made prior to

discharge for 3-7 days after returning home Follow-up phone call set up based on post discharge

needs at 5-9 days Standardized tool for transfer of information to nursing

facilities for next level of care . Telehealth monitor available through Home Care Chronic Disease Management Program for patients

In addition staff participate in Integrated Chronic Disease Management class

ENHANCED ADMISSION ASSESSMENT During Admission Assessment, the patient and family

are asked, “Who would you like to have present when we provide your discharge information?”

Information added to the whiteboard RN and physician do medication reconciliation

Concentrated effort for Admission. Dedicated Admission Center RN’s complete home medication list and prepare an appropriate list for physician to address. At times, the pharmacy or physician offices need to be called to get additional information. If the patient is a home care patient, the home care agency is called to get the current list of medications

ENHANCED ADMISSION ASSESSMENT (2)

Referral to Palliative Care for patient with advanced stages of disease - the referrals have consistently increased. Team rounds daily on units

Bedside report to involve the patient and family caregivers as partners in their care. Daily discharge huddle is facilitated daily with the RN caring for the patient, the charge nurse, and unit-based case manager

Take 5 completed on patient at start of shift. Daily goals are reviewed and written on the whiteboards in each room, providing the opportunity to review the plan for the day, anticipate discharge needs, and determine what it will take to get the patient home safely

Interview QuestionsFor patients that are readmitted within 30 days of

lastadmission: Can you tell me in your own words why you think

you ended up sick enough to be readmitted again?

Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night?

Have you seen your doctor since you were discharged from the hospital?

Do you have all of your medications? How do you set up your pills every day?

Were there any appointments that kept you from taking any of your pills?

“The patient is noncompliant.” vs.

Asking, “What is our responsibility as the sender of the information?”

PARADIGM SHIFT

ENHANCED TEACHING AND LEARNING

The patient education materials facilitate the use of Teach Back, and the same materials are used across the continuum: in the hospital, with home care, long-term care settings and the clinic.

Short, succinct material developed for each Core Measure DRG. Teach Back question part of packet for staff and patient reference.

Patient teaching flowsheets set up to address Teach Back and assure the documentation and use of Teachback.

TEACH BACK WITH DISCHARGE INSTRUCTIONS Can you show me on these instructions:

How you find your doctors’ office appointment?

What other tests you have scheduled and when?

Is there anything on these instructions that could be difficult for you to do?

Have we missed anything? Who will you call if you have questions?

ENHANCE TEACHING AND FACILITATE LEARNINGUse Teach Back: In the hospital During home visits and follow-up phone calls To assess the patient’s and family caregiver’s understanding of

discharge instructions and ability to do self-care

Building Teach Back into our work Session in Nursing Orientation Session in Nursing Residency Program Net Learning module, competency validation, and in-house

prepared instructional DVD with Teach Back demonstration Closing staff meetings, walking the talk Staffs participate in Chronic Disease Management

HEART FAILURE MAGNET

LOW SODIUM EATING PLAN BROCHURE

Cover page Back page

LOW SODIUM EATING PLAN BROCHURE

LOW SODIUM EATING PLAN BROCHURE

LOW SODIUM EATING PLAN BROCHURE

Heart Failure Workshop

Saturdays 9:00 a.m. to Noon

St. Luke’s Hospital Nassif Heart Center

Third Floor

This workshop is taught by a registered nurse and registered dietitian.

You will learn about: ♥ Causes of heart failure ♥ Activity and exercise ♥ Low Sodium eating plan ♥ Guidelines for dining out ♥ Reading food labels ♥ Medications ♥ Living with heart failure

There will be displays of health information to look at and a packet of heart failure information for you to take home.

This is an excellent program for people who have had heart failure or have a heart problem that puts you at risk for heart failure. Learning more about your heart failure is essential in controlling your heart failure symptoms and preventing problems. Family members and caregivers are encouraged to attend also.

This program is FREE No registration necessary Walk-ins welcome!

To learn more, call St. Luke’s Heart Care Services (319) 369-7736

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Where To Start? Go to the Unresolved

Education Tab Select the topic you

educated on Begin charting on the

right side of the screen

What you taught on

Additional comments

DISCHARGE ASSESSMENT - SMART TEXT

POST-ACUTE CARE FOLLOW-UP

Home Care Visit set up for 24-48 hours after discharge. Home Care liaison in-house. Teach Back questions part of visit .

Partnership with physicians’ offices resulted in redesign of scheduling follow-7p visits to allow office visits within seven days for patients.

Appointments are scheduled prior to discharge and noted on discharge instructions.

Advanced Medical Team Pilot in Pulmonology Clinic with High Risk/High Resource patients.

Consistent Care Plan Program in Emergency Dept.

3W TEST OF CHANGE

EMERGENCY DEPARTMENT CONSISTENT CARE PLAN Consistent Care Program (EDCCP) for patients who had

visited the ED 12 or more times in the previous 12 months.

103 Care Plans were developed, mailed, and implemented.

Care Plans are a communication tool that provide data specific to that patient’s medical history and current medical needs, along with Goals of Care for when patients present in the Emergency Dept.

Using care plans and with intervention by a social work case manager, there has been a reduction in patient’s Emergency Department use.

CONSISTENT CARE PROGRAM

REAL-TIME HANDOVER COMMUNICATIONS

Medication Reconciliation is a joint physician and nurse accountability.

Patients going home are offered a care coordination visit with Home Care in the first 24-48 hours after discharge. The home care does a certified content visit including medication reconciliation and determines eligibility.

St. Luke’s partnered with the hospital’s home care agency (VNA) and two long-term care facilities to standardize and enhance the quality of the handoff communication process. A new interagency transfer form is now used. Warm handover with those patients with complex issues.

Provided education for home care and long-term and skilled care RNs and CNAs on HF, MI and Pneumonia and continuity processes.

Home; 718; 58.6%

SNF; 195; 15.9%

ICF; 27; 2.2%

Home Care; 200; 16.3%

Court; 1; 0.1%

Hospice Home; 11; 0.9%

Hospice Facility; 8; 0.7%

MC Swing ; 12; 1.0%

Rehab; 20; 1.6%

LTAC; 6; 0.5%

Psych Hospital; 26; 2.1% Other Institution; 2;

0.2%

Base Event Discharge DispositionHousewide Acute Inpatient Readmissions wi 30 Days

Jul 2012 - Jun 2013

Different Hospital; 23; 1.9%

Skilled/ICF; 72; 5.9%

Court/Law; 6; 0.5%

Hospice Facility; 5; 0.4%

One Distinct Unit to Another; 30; 2.4%

Home & Clinic; 1092; 88.9%

Readmit Admit SourceHousewide Acute Inpatient Readmissions wi 30 Days

Jul 2012- Jun 2013

302724211815129630-3-6

12

10

8

6

4

2

0

Number of Days Between Admissions

Fre

qu

ency

Mean 10.36StDev 8.389N 56

Normal Histogram of Days Between Admissions (with Outlier removed)

363024181260-6

12

11

10

9

8

7

6

5

4

3

2

1

0

Days between

Frequency

7 14 30 Mean 15.10StDev 8.773N 49

Histogram of Days between Initial Discharge Date and Readmission DateHeart Failure as Initial Admission

• Incomplete medical management• Wrong site of post- acute care

• Socio-economic factors• Physician follow-up • Med problems

• Patient compliance with regime• Disease trajectory

HCAHPS RESULTSDISCHARGE INFORMATION (% YES)

2009 2010 2011 Jan-Sep 2012

78

80

82

84

86

88

90 89

87 8788

82 82

84 84

St. Luke's NationalThe following questions make up this composite measure:#19 – During hospital stay, did doctors, nurses or other hospital staff talk about whether you would have the help you needed when you left the hospital?#20 - During hospital stay, did you get the information in writing about what symptoms or health problems to look out for after you left the hospital?

GOOD

Prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI) http://www.mitre.org/work/health/news/bundled_payments/St_Lukes_Case_Study.pdf

CRITICAL CAPABILITIES FOR CARE REDESIGN INCLUDE: Cross-continuum participation and

alignment The development and use of

standardized tools and compatible information infrastructure

Horizontal leaderships and executive sponsorship and engaged physicians

Effective external and internal learning

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LESSONS LEARNED Importance of engaged executive leaders and

physicians. Patients and families help transform care in

profound ways. The patient and family home environment must

be understood. Involving front-line staff in the changes helps

them understand why they are important and grows ownership by engaging them in redesign.

The power of relationship building and collaboration of the cross-continuum team builds new ideas to work and removes many of the “silos’ in the care.

LESSONS LEARNED (CONT)

The role of Information Technology in the process should be addressed simultaneously with the work.

Ongoing monitoring of Process and Outcome Measures is important to hardwiring best practices.

Using patient stories unleashes energy and participation that becomes evident in process and outcome results.

QUESTIONS:

Peg Bradke RN, MAVice President, Post Acute Care Services UnityPoint Health St. Luke’s Cedar Rapids, IA Peg.bradke@unitypoint.org