September 11, 2018
Learning Session Six Webinar #4
Nursing Home Strategies to Reduce Avoidable Hospitalizations, Part 2
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Objectives
• Describe strategies nursing homes are using to prevent hospital admissions
• Describe measures nursing homes are using to identify if strategies resulted in improvement
National Nursing Home Quality Care Collaborative CHANGE PACKAGE
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Strategy 6Provide exceptional compassionate clinical care that treats the whole person
Change Concept 6.c Transition with care (between shifts, departments, and all care settings)
https://www.lsqin.org/wp-content/uploads/2015/03/C2_Change_Package_20170425_508.pdf
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Luther Haven
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Speakers
• Diane Landmark, RN
• PIPP Coordinator
• Luther Haven, Montevideo, MN
• Cindy Stinson RN
• DON
• Luther Haven, Montevideo, MN
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Luther Haven
• Located in west central Minnesota
• Church-sponsored; not-for-profit
• Purpose: Serve the elderly and disabled and promote their physical, social, emotional, and spiritual needs in a Christian atmosphere
• Bed capacity is 90, average census is 80
• 24 hour staff: RN, LPN, TMA, CNA
• Activities staff 7 days a week and evenings
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Luther Haven
• Contract for SLP, PT & OT therapies
• A clinic NP rounds 2x/week to assist with resident needs and non emergency orders
• Chippewa County Montevideo Hospital (CCMH) Lab comes to facility 2x/week for lab work
• CCMH Physicians round monthly in facility
• Physically connected to CCMH hospital - no 911 or ambulance services needed for our ED transfers
• .
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Performance-Based Incentive Payment Program (PIPP) Project
PIPP: Reducing re-hospitalizations, developing an effective discharge planning process and follow-up post discharge
• MN PIPP supports provider-initiated projects aimed at improving the quality and efficiency of nursing home care
• Provider-initiated projects that are tied to state nursing home performance measures are selected through a competitive process and funded for up to 5% of the weighted average operating payment rate
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Reducing Re-Hospitalizations
• Were aware of our use of the ED and knew this was a measure that was going to be identified and used in all facilities
• Residents were being seen in the ED by a provider that wasn’t familiar with them
• Had a significant number of ED visits and hospitalization especially after hours identified via:
― Minnesota Quality Indicators
― Discharge and hospital leave reports
― Achieve Matrix admission
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What Are You Trying to Accomplish?
• Decrease ED visits and re-hospitalizations by 10% over 2 years
• Improve quality of life/care by reducing re-hospitalizations
• Develop effective discharge planning processes for residents who are discharged to the community
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How Will You Know That Change Is an Improvement?
PIPP Outcome Measure One
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How Will You Know That Change Is an Improvement?
PIPP Outcome Measure Two
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How Will You Know That Change Is an Improvement?
Measures:
• Minnesota Quality Indicators
• CMS Casper/Quality Measures
• Achieve Matrix Software
• Admission, Discharge and Hospital Leave Reports
• Review of each ED visit and hospitalization including the residents’ progress notes to determine trends
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Changes Made That Resulted in Improvement
• Education and communication with the medical director, clinic staff, ED staff, hospital staff, our staff, residents, and their family members.
• Met with staff from all areas, identified problems, developed a plan, and initiated it.
• Identified the need for ongoing constant communication
• Continue to meet at least quarterly to review and revise the plan as needed.
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Changes Made That Resulted in Improvement
January 1, 2017 through December 31, 2018 Activities:• Education to staff and families on project and goals
• Regular communication to all involved regarding goals and progress
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Changes Made That Resulted in Improvement
January 1, 2017 through December 31, 2018 Activities
• Auditing and monitoring of these strategies:• Patient/caregiver introduced to the educational process upon
admission.
• Educational sessions for a successful discharge identified by the IDT and the patient/caregiver.
• Patient/caregiver participate in educational sessions.
• Patient/caregiver learning is validated.
• Weekly calls are made to all residents discharged to the community to follow up on their status and any needs/education they may need
• Determination of successful or failed transition is made.
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Changes Made That Resulted in Improvement
January 1, 2017 through December 31, 2018 Activities:
• Auditing and monitoring of these strategies:• Identify residents who discharge quickly and successfully and compare
their recovery to those that have similar circumstances but a longer stay.
• Continual research and literature review to assist with all programs and interventions
• Meet with outside agencies to share progress on project goals and identify barriers and necessary changes
• Collect, organize, and analyze data collected on all goals (ongoing throughout the project).
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Changes Made That Resulted in Improvement
January 1, 2017 through December 31, 2018 Activities:
• Auditing and monitoring of these strategies:• Compliance audits on all programs and document action taken
throughout the project.
• Ongoing education to staff and residents re: Lean Process, reducing re-admissions to hospital and discharge planning goals and protocol
• Refine Care Coordination for residents upon admission and discharge to identify resident needs for a successful and efficient discharge to home and transition to independence
• Provide outcomes to staff, residents, partners and providers
• Make appropriate changes to ensure sustainability of program
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Progress-to-Date
• 7/1/2017 - 12/31/2017: 19 discharges to the community with 1 hospital readmission within 30 days; we were unable to track any ED visits.
• 1/1/2018 – 7/31/2018 : 32 discharges to the community with 1 ED visit and 5 re-admitted within 30 days.
• Positive communication from staff
• Constant communication and ongoing education is necessary to be successful
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Progress-to-Date
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Progress-to-Date
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Progress-to-Date
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Resources That Have Contributed to Our Success
• Reports from Matrix, our Electronic Medical Record, QI/QM, and Casper reports.
• Manual review of hospitalizations and ED visits.
• 4 RN Managers attended Pathways Interact Training.
• All facility staff attended Lean training to improve our discharge planning process.
• Partner buy-in:
• Hospital HIS staff alert PIPP Program Manager of any ER visits or hospitalizations occurring with our community discharges
• Clinic, Hospital, and ER Managers
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Dove Healthcare
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Speaker
Kris Modl
• ACBSW Director of Social Services / Admissions
• 715-895-9032
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Dove Healthcare
• Dove Healthcare includes six skilled nursing and rehab facilities and five assisted living residences within a 60-mile radius of Eau Claire, WI
• Core services include rehabilitation, post-acute care, ventilator / tracheostomy care, skilled nursing, long-term and end-of-life care, assisted living, and memory care.
• Workforce of 1000+ employees serves an average of 425 residents and patients daily
• Owns and operates Transitions Rehabilitation which employs over 90 physical, occupational, and speech therapists
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Chippewa Valley Continuum of Care Coalition
• Formed in 2010 as a result of strategic planning
• Initially comprised of two hospitals, five Skilled Nursing Facilities (SNF), and a Family Care organization
• Focus was to improve the continuum of care process as patients transitioned from the acute care setting to an SNF in a timely manner
• The Coalition has grown to include 4 hospitals, hospice, and home care agencies, Community Based Residential Facilities, and multiple SNFs
• Open to any organization or individual interested in fostering the vision by actively engaging in the work and planning of the Coalition
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Our Purpose
• To focus on improving care transitions
• To encourage person-centered and person-directed models of care
• To reduce the number of re-hospitalizations and patient care transitions
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Our Commitment
As members we join in a commitment to:
• Share best practices and knowledge with each other
• Mentor our partners and providers
• Share data and support analyses related to care transitions
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Improvement Goals
• Minimize transitions between entities and ensure timely and consistent transitions (reduce re-hospitalizations)
• Improve the well-being of the community through collaborative processes that promoted optimal care and services
• Ensure resident needs could be met including behavioral needs
• Share data across providers
• Improve transportation
• Develop tools and resources
• Education
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Identified Gaps
Some of our initial work identified gaps that have an impact in transitioning patients.
Examples include:
• SNFs with various capabilities
• Regulatory differences between acute care setting and SNF setting
• Placement challenges related to behavioral issues
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Identified Gaps
• Inconsistent / incomplete information from the acute care setting
• Lack of education / lack of earlier education regarding advance care planning
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How Will You Know That Change Is an Improvement?
• Transitions (re-hospitalizations) will be reduced
• Appropriate patient placements
• More timely discharges
• Collaboration amongst providers
• Improved transportation
• Improved overall collaboration / communication
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Changes Made That Resulted in Improvement
• Transfer Communication Tool – EMR / paper
• Standardized acute care referral summary
• Standardized acute care discharge information
• Standardized Physicians Plan of Care (PPOC)
• Accompaniment to appointments, tests, etc.
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Changes Made That Resulted in Improvement
• Timelier receipt of DC summaries
• Facility capabilities
• RN to RN Handoff / Handover
• Formation of subcommittees – Education, Transitions, and Transportation
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Sub-Committee Focus
Provider and Community Education• Identify knowledge gaps regarding care
transitions
• Identify opportunities to improve communication, knowledge and quality of care with transitions
• Provide education to healthcare providers and community regarding health care resources and support along the continuum of care
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Sub-Committee Focus
Transitions of Care• Monitors transitions from both the acute
setting and SNF setting
• Improve the continuum of care process as patients transition
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Sub-Committee Focus
Transportation
• Centralized compilation of transportation resources to allow for multi-organizational access
• Collaboration with local and state levels to ensure services are available no matter the need or payer source
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Next Steps
• Implement multi-directional flow of information
• Educate receivers of this information – what to do with it
• Educate medical providers using health care resource utilization data
• Sponsor a community event to focus on advance care planning and facilitation of setting goals
• Ongoing collaboration with MetaStar – focus on reducing all cause admission / readmission rates
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Resources/Tools
• Add as needed to share
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Colonial Acres Health Care Center at Covenant Village
of Golden Valley
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Speaker
Christine DeLander - MS, RN
• Director of Nursing
• Colonial Acres of Golden Valley at Covenant Village of Golden Valley. A Covenant Retirement Community.
• Direct line: 763.732.1412
• Email address: [email protected]
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Colonial Acres HCC at Covenant Village of Golden Valley
• Located in Golden Valley, MN• Part of a Continuing Care Retirement Community
(CCRC) of Covenant Retirement Communities (14 communities across 8 states)
• Not-for-profit, faith-based community as a part of the Evangelical Covenant Church
• Colonial Acres is the Skilled Nursing Facility campus:― 88 bed capacity: 38 Medicare Certified, 50 Private
Pay― Rehabilitation, LTC, and Memory Care services
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Reducing Avoidable Hospitalizations at Colonial Acres
• Covenant Retirement Community’s goal: reduce the readmission rate to hospitals to 10% by the end of 2018
• Current rate (Nursing Home Compare Q4 2016 to Q3 2017) is 29.4%
• Other reasons why this project is important to us:
• Improve health care outcomes for our population
• Decrease/avoid financial penalties associated with readmissions within 30 days.
• Be a responsible partner to our hospital systems
• Improve systems that help increase staff confidence, efficiency, morale, and effectiveness
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How Colonial Acres Will Measure Improvement
• A reduction in the Hospital Readmission QM to gain 20 or more points.
• Better and longer transition of our residents in the community through increase in QM – successful community DC (Short Stay) – our goal is 65%. We are currently at 58.3%.
• Internal measure - Reduction in avoidable readmissions through Interact QI tool (will impact QMs when out)
• Increased employee satisfaction regarding nursing system
• Increased employee recognition through Inspire to Serve
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Changes Made That Will Result in Improvement
• Re-Introduced INTERACT to the facility after strategically coming up with a flow chart on how a change in condition will be orchestrated.
• Utilization of INTERACT tools – embedded in our EMR
• Worked with Lake Superior QIN to come up with a plan
• Re-educated all facility staff on the new plan/process
• Completing a root cause analysis/RCA on all hospital transfers by using the INTERACT QI tool and reviewing at IDT meetings daily
• Re-education/resource planned review review is ongoing and based on identified RCA/trend review/advice by QAPI committee monthly
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Change of Condition Process Map
https://www.lsqin.org/wp-content/uploads/2018/09/Change-of-Condition-Comm-Process-Eval-Tool.docx
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Progress-to-Date at Colonial Acres
Data from May-August 2018 shows:
• 12 readmissions to hospital after entry to facility from highest ranking falls then CHF – identified through Interact QI RCA tool
• Current rate is 29.4% (CMS claims data that generates our QM) So far, from 5/1/18 to present, internal data shows our number to be –17%.
• Internal goal is to reduce to 10%
• Areas of focus to reduce hospitalization rates include falls and CHF
• Working on building orders sets for CHF into the EMR for all new admits with CHF
• Implementation of FSI to ensure RCA matches fall – prevents recurrent falls and staff/resident/family education on fall prevention
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Progress-to-Date at Colonial Acres
• Looking at partnerships with home care agencies with readmission rates of 15% or below to increase LOS in the community
• Held nursing meetings in August and INTERACT re-discussed. Staff report feeling better about what they are doing.
• Formal surveys to occur in September 2018 to gauge feelings about progress
• Nursing staff recognition by HCP from Allina, NMMC and Methodist hospital – comments “your nurses know what they are doing”
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Resources/Tools
INTERACT® Version 4.0 Tools:
http://www.pathway-interact.com/interact-tools/interact-tools-library/interact-version-4-0-tools-for-nursing-homes/
Data.Medicare.gov:
https://data.medicare.gov/Nursing-Home-Compare/Star-Ratings/ax9d-vq6k/data
Questions via phone or chat….
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Next Steps: Participate in These Webinars:
• Watch this pre-recorded 24-minute webinar: • Reducing Hospital Admissions to Improve Resident Outcomes,
Quality, and Financial Incentives
• https://youtu.be/PcMcyoYpWD8
• Watch these recorded webinars:• Using QAPI to Reduce Readmissions:
https://youtu.be/7irxuOWtZec
• Nursing Home Strategies to Reduce Avoidable Hospitalizations, Part 2:
• (YouTube link will be available shortly)
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Next Steps: Participate in These Webinars:
Register for the last webinar in this series:
• September 20, 2018: Nursing Home Strategies to Reduce Avoidable Hospitalizations, Part 3
More information, including registration link: https://www.lsqin.org/initiatives/nursing-home-quality/ls6/
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Lake Superior QIN
Michigan: Holly Standhardt • 248-912-6709 • [email protected]
Minnesota: Kristi Wergin • 952-853-8561 • [email protected]
Wisconsin: Toni Kettner • 608-441-8290 • [email protected]
This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-18-159 090618
