Optimizing Transitions of Care: Redesigning Nursing Roles to

Improve Quality and Reduce CostSuneela Nayak, MS, RN,

Clinical Quality Improvement Specialist, Center for Quality and Safety

David Bachman, MD Senior Medical Director, Clinical Integration

Learning Points

• Preventable Readmissions in the context of Transitions of Care

• Why now? Where to Start?

• MaineHealth Transitions of Care Program

• Leading with Innovation: Redesigning Roles, Competencies

Case Study : Mr. S

• 76 year old male, living independently, limited social supports

• Past Medical History– Congestive heart failure– 6 routine medications including Coumadin

• Admitted for evaluation of syncopal episode

Mr. S: Hospital Course

• Cardiac monitoring and diagnostic testing• Developed urinary retention

– Urology consultation– Urologic procedure performed

• Discharged on Coumadin, new antibiotic, with urinary catheter

Mr. S: One week later

• Developed hematuria, urinary retention• ED Visit

– Dramatic hematuria with catheter obstruction– INR 9.6 (ideal range 2 –3)– More urological intervention

• Readmitted– Reversal of anticoagulation

• Transfused 6 units of blood

Questions to Consider

• Was this readmission predictable?

• Was this readmission preventable?

• What went wrong with the transitions of care?

• How can we do better?

Why now?

2007 MedPac Report

• Medicare Payment Advisory Committee• Readmissions

– “sometimes indicators of poor care or missed opportunities to better coordinate care”

– 17.6% of Medicare patients readmitted within 30 days– $15 billion in annual spending– 76% of readmissions potentially avoidable

• Recommended public reporting, payment reform

Jencks S et al. N Engl J Med 2009;360:1418-1428

Rates of Rehospitalization within 30 Days after Hospital Discharge

Health Care Reform: Hospitals

• Reduce reimbursement for hospitals with high risk-adjusted rates of readmission by 1% a year beginning in 2012 (up to 5% total)– 2012 : CHF, pneumonia, AMI– 2013: Add COPD, CABG, PTCA, Other vascular

procedures, potentially global readmission rate

• Reduce reimbursement to SNF, Home Health when patient under their care readmitted

Health Care Reform: Physicians

• Create new payment code for patient visit within one week of discharge

• Apply payment reductions for physicians who treat a patient during an admission that results in a readmission

Payment Reform: MaineCare

• Reimburse for only one hospitalization when MaineCare patient readmitted to same hospital within 72 hours for the same diagnosis.

Why Now?

• Frequent & costly

• Issue of quality of care and patient safety

• Source of patient & provider dissatisfaction

• Waste increasingly scarce clinical resources such as nursing care

• Integral to movement towards Accountable Care Organizations

Where to start?

Lots of Data and Toolsat your fingertips

MaineHealth: Efforts to Date

Transitions of Care Pilots

• Supported by funding from the Cardinal Health Foundation

• Three pilot sites selected from MaineHealth hospitals

Transitions of Care Pilots Key Outcomes

MaineHealth Transition of Care Bundle

Implications for Role Redesign

MaineHealth Transitions of Care Bundle

1. Risk stratification for readmission

2. Transition Checklist

3. Medication reconciliation

4. Patient/family health education

5. Timely communication among hospital and post-hospital providers

6.Timely follow-up of patients

Leading with Innovation:

What are implications for

Redesigning

Nursing Roles and Competencies?

National Summit of Advancing Health Through Nursing..

Key Messages from Institute of Medicine and the Robert Wood Johnson Foundation

Nurses should practice to the full extent of their education and training.

Nurses should be full partners with physicians and other professionals in redesigning health care

Washington DC, October 2010

Focus on Reduced Readmissions

Findings from MaineHealth Pilots:

1. Advocacy for patient’s agenda for care

2. Focus on safety, improved outcomes

3.  Fully engage clinical skills, scope of practice

4.  Develop ability to network across continuum

…Offers Abundant Opportunities for Clinicians, Educators, & Leaders to Redesign Roles and Competencies

Roles and CompetenciesKey Roles Clinicians Educators Leaders

1. Advocacy for patient’s agenda for care

2. Focus on safety, improved outcomes

Skilled Patient Centered Care Practices

Skilled Hand-Off

Communication all levels of care

Instill: Patient/ Family

as central members of the care team

Comfort with transparent Communication

Innovate for improved outcomes and reduced costs

Sustain an environment of knowledge sharing(translate knowledge from individual to system)

Roles and CompetenciesKey Roles Clinicians Educators Leaders 3. Fully

engage clinical skills, scope of practice

Assessment skills & related actions

Develop comfort with “Teach back”

Knowledge access : -continuum networks -electronic media

Quality through measured outcomes

Assessment & related actions

Focus on what is learned; skilled use of “teach back”

Refine networking skills

Operationalize roles to optimize practice and scope

Sustain the gain through visible and engaged continuum leadership.

Facilitate knowledge exchange across continuum

•Facilitate knowledge exchange between providers (Teach back)•Sustain the gain through visible engaged leadership.

Roles and CompetenciesKey Roles Clinicians Educators Leaders

4. Develop ability to network across continuum

Establish networks with -continuum

-payers -patient groups Develop

transition plans that ensure right care, at the right level.

“Admit to home”

Instill Continuum

Navigation skills

Optimal use of EMR to enhance hand-offs

Shape pressing agenda of reimbursement reform

-Lead early ACO work

-Build and sustain networks to reduce downstream spending

Mr. S, revisited

Admitted for syncopal episode

Hospital Course:- Cardiac evaluation

- urologic procedure - Discharged on Coumadin, new antibiotic, with catheter

One week later: - ED Visit - Dramatic hematuria, obstruction

- INR = 9.6 - Readmitted

- Reversal of anticoagulation - 6 units of blood transfused

Mr S: Risk for Readmission (8P‘s)

• Prior hospitalization: in last 6 monthsProblem medications: anticoagulantsPolypharmacy: > 5 routine medications Principal diagnosis: heart failure• Psychological: PHQ2 screen• Poor health literacy: unable to Teach BackPatient support: lives alone• Palliative care: advanced illness

Case Study: The New Post Hospital Scenario

• Home support services– Monitoring of

anticoagulant status

• Follow-up phone call

• Office visit within 5 to 7 days

* No ED visit

* No readmission

* Decreased morbidity

* Decreased cost

* Increased patient satisfaction

Summary

Focus on Reduced Readmissions offers Abundant Opportunities for Nurse Educators, Clinicians and Leaders

Innovative redesign of roles, competencies to- Improve clinical outcomes, quality,

satisfaction- reduce cost

Questions?

Thank-you!