The Care Coordination and Management Series: Discharge Planning

Comprehensive Care for Joint Replacement Model

May 4, 2017

Comprehensive Care for Joint Replacement Model

Audio available through device speakers OR by dialing (800)832-0736

Conference Room:*8713107#Access Code: 050417#

Webinar Agenda

• Welcome• Announcements & Logistics• Presentations

– Hurley Medical Center– Froedtert & Medical College of Wisconsin

• Discussion• Updates & Next Steps

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Comprehensive Care for Joint Replacement Model

Introduction to Adobe Connect

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Download Available Resources

Closed Captioning

Comprehensive Care for Joint Replacement Model

To Ask Questions

or Send Messages

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To Dial In via

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Introduction to Adobe Connect (Cont.)

• Use the Chat pod to submit any questions or comments

• Please use “@” if your question/comment is directed to a specific presenter

• Submit your question/comment by clicking the chat bubble icon

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Group Chat Introductions

• Name• Hospital• A challenge you face in discharge planning

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TANA BRANDT RN, BSNJOINT NURSE NAVIGATOR

CENTER FOR JOINT REPLACEMENT

HURLEY MEDICAL CENTER

• Located in Flint, Michigan• 443 Bed Public Teaching Hospital• 20,000 Inpatients Annually• Region’s Only

– Level 1 Trauma Center– PICU– NICU– Burn Center– Pediatric ED

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HURLEY – JOINT REPLACEMENT

• Specialized Center for Joint Replacement Unit• Specially trained orthopedic nurses• 350 elective hip and knee replacements per year• 120 CJR cases per year• Orthopedic surgeons from single private group servicing

neighboring hospitals• 6 Outpatient physical therapy locations to provide continuum• Participate in Michigan Arthroplasty Registry Collaborative

Quality Initiative (MARCQI)

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DISCHARGE PLANNING

• Begins the moment the patient is scheduled for Surgery – Schedule for Pre-Surgical Joint Class

• Meet 1-on-1 with a Physical Therapist• Receive pre-surgical education, folder, PT exercises, etc. • Offer 6 free aquatic visits

– Assess Discharge Needs• Goal of Assessing Discharge needs 3-4 weeks prior to surgery is to ensure a

smooth transition between services, educate patient on expectations of care, and identify potential causes of readmission and prevent those when possible

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ASSESSING DISCHARGE NEEDS

• Narcotic Use– If taking prescription pain medication prior to surgery, patients are

encouraged to fill prescriptions prior to discharge at our outpatient pharmacy in case authorization is required

• Discharge Plan (Outpatient PT, SAR, Homecare)– Outpatient PT location

• Instructed to schedule outpatient PT evaluation prior to coming in for surgery– Homecare preference– SAR – List and patient tours

• Anticoagulation • Prescription Coverage

– Discount cards• Walker

– Prescription– Loaner closet list – fitted at preop class

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ASSESSING DISCHARGE NEEDS CONTINUED…

• Location of Bedroom/Bathroom in their home• Steps in home (if significant, Inpatient PT notified)• Support Person

– Who is your support person(s)– What level of assistance can they provide after discharge– How much time can they contribute– Can they provide transport to and from Physical therapy appointments

• Mobility Assessment– Are assistive devices used prior to surgery– How far are you able to ambulate– Are you currently able to go up and down stairs

• Beneficiary incentives

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BARRIERS TO DISCHARGING HOME

– No Family/Support Person– No transportation

• Unable to drive post-op• No reliable/cost effective transportation in our community

– Afraid to be alone– Meals– Stairs– Mobility

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BENEFICIARY INCENTIVES

• Transportation to Outpatient Physical Therapy and Post-op Appointments– Door-to-Door – Typically 2-4 weeks in duration

• LifeAlert• Delivered Meals• Personal Care assistant

– Showers, cleaning, meals, laundry, etc.

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INPATIENT ASSESSMENT

• Each patient reassessed once admitted • Discharge plan confirmed• Follow PT evaluation and modify discharge plan as needed• Collaborate with Social Work to set up PAC needs • If patient discharging to SAR/Home Care

– Notify SAR patient is CJR– Call detailed report to PT– Request prompt progress reports

• Patients educated about – Navigator access; given my work cell number– 24/7 contact number in case of concerns or emergencies

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POST-DISCHARGE PHONE CALLS

• Faxed updates– Weekly from Home Health Care companies– Every 4 days from SAR

• 24-48 hours after discharge home– If concerns or issues, additional call placed 3-5 days later to follow-up

• Pain• Swelling/Bruising• ACE/Bandage Removal• Medications• Bowel Movements• Physical Therapy• Follow up appointments with Orthopedic Surgeon

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Questions & Answers

• Use the Chat pod to submit any questions

• Please use “@” if question is directed to a specific presenter

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Poll 1

Are you using the beneficiary incentives in discharge planning, to address post-discharge needs? [select one option]• Yes• No• I don’t know

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Poll 2

Who drives your discharge planning? [select one option]• Care Navigators• Case Managers• Physical Therapists• A multidisciplinary team• Other (please type into chat pod)

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Comprehensive Care for Joint Replacement Model

Discharge Planning & Care Coordination in the Post-Acute

Portion of the CJR Bundle

Jamie Schounard, PTDirector, Joint Preservation and

Replacement ProgramFroedtert & Medical College of

Wisconsin

Froedtert & Medical College of Wisconsin

• Milwaukee & Suburbs, SE Wisconsin• Academic Medical Center + 2 Community

Hospitals• TJR Hub @ larger Community Hospital• 1,000 Elective TJR’s annually• 415 CJR-qualifying TJR’s annually• 15% Fracture

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TJR Team Makeup• 10 Surgeons 50/50 Academic/Community

– Collaborate on Protocols, Standardization, Team-building

• IP NP’s on Nursing Unit– Medicine/Hospitalist background– Ortho Surgeon Extension

• Program Navigators– 1 month pre-op through CJR window

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Successes in PAC

1. Increasing Discharge Disposition to Home via Consistent Patient Messaging

2. IP Care Coordination Rounds3. Post-Acute Care Provider

Committee

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1. Increasing Discharge Disposition to Home via

Consistent Patient Messaging• Use SNF when Medically Necessary

– Goal of 20% or less (all Patients)– Pt’s going to SNF will be ABOVE the $ target– 2014: 43%, 2016: 15% (CJR = 24%)

• Avoid SNF for Social Necessity and Patient Preference reasons

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Mitigating Patient Preferencefor SNF Transfer

• Why it Happens– Fear of Patient / Family– Lack of Preparedness– “This is easier”– Past History with SNF

• Previous TJR• Spouse/Friend/Neighbor/Relative

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Dr: “I Expect You to Go HOME”• See Above: Surgeon directive is KEY• Advances in the procedure, pain

management, therapy allow for faster recovery and better function after surgery

• You are better off at home recovering in your own environment

• Lower risk of infection and readmission• Post-op Pain and Function are often

similar to Pre-op25

2. IP Care Coordination Rounds• Every Morning• Entire Team: Nursing, Navigator, NP, PT,

OT, Pharmacy, CM, SW• Coordinate Care• Discuss Issues & Resolve Them• Discharge Planning Optimization• “We are ALL on the Same Page”• Consistent Messaging to Patient

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3. Post-Acute Care Provider Committee

• Hospitals: Director, Navigators, Nursing, Therapy, Case Management, Quality

• Local SNF Leadership (top 3; 75%+ volume)

• Primary Home Health Agency• Focus on Collaboration and Quality• “Referrals will decrease, but you can earn

a higher % of referrals”27

PAC Committee Projects• Develop Common Clinical Pathway for

SNF, based on aggressive Therapy BID• Drive Shorter LOS• Readmission Reduction via 3-day

“Stoplight Report” Check-ins• Developed Success Metrics and Report

Card (Pt. Satisfaction, LOS, Readmit)

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Questions?Thank you

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Questions & Answers

• Use the Chat pod to submit any questions

• Please use “@” if question is directed to a specific presenter

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Comprehensive Care for Joint Replacement Model

Poll 3

Does your hospital use a rounding process similar to the care coordination rounds? [select one option]• Yes• No• I don’t know

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Ideas to Try

Please type into the chat pod one thing you’ve heard today that you would like to try in your hospital to enhance discharge planning.

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Poll 4

Does your hospital have any helpful tips or strategies to share regarding effective use of care navigators? [select one option]• Yes• No• Maybe

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Updates & Next Steps

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CJR Upcoming Events Schedule

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Upcoming Events

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If you have any questions about these events, send an email to LS-CJR@lewin.com

Follow-Up Q&A Session: Comprehensive Care for Joint Replacement (CJR) Model Performance Year One Reconciliation

May 11, 20172:00 – 3:00 PM EDT

Register Here

Patient Engagement Affinity Group Session 2May 17, 2017

2:00 – 3:00 PM EDTRegister Here

The Care Coordination and Management Series: Effective Use of Care Navigators

June 1, 20172:00 – 3:00 PM EDT

Register Here

CJR Connect: Searching for Chatter by Topic

CJR Connect is an online forum for CJR participants to ask questions of and share lessons learned, helpful resources with their peers via “Chatter.”

Quick tips to find Chatter posts and comments by topic:1. Log into CJR Connect using your username and password2. On the left column of the screen, click on Topics3. Search for topics using the Topic Search Box

or browse the list of topics

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To request a CJR Connect account, go to: https://app.innovation.cms.gov/CJRConnect/CommunityLoginand click “New User? Click Here.”

Next Steps

• Send any questions to CJRSupport@cms.hhs.gov• Please take a few minutes to complete the Post-

Event Survey

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