A Rehospitalization Reduction Program on a Geriatric Skilled

Nursing Unit

Randi Berkowitz, MD

Hebrew SeniorLife

Why decrease readmissions?

I. Excellence in care– errors

– patient satisfaction

– staff satisfaction

II. Financial– referrals

– subacute beds long-term care

– census

– reimbursement/patient

Learning Objectives

• Define the scope of the issue of rehospitalization in subacute care nationally

• Describe innovative programs to reduce transfer out to the hospital

• Show how CQI process involving transfer can lower hospital readmission rates whole improving patient safety and quality of care

Large geographic variation

Hospital Readmissions within 30 days from SNFs are common

Of ~1.8 million SNF admissions in the U.S. in 2006, 23.5% were re-admitted to an acute hospital within 30 days

In Massachusetts the rate is 26% Cost of these readmissions = $4.3 billion

Common Reasons for Transfers

Medical instability Availability of:

On-site primary care providers Stat tests, IVs

Inadequate assessments to identify early changes Communication gaps Family issues/preferences Lack of advance directives (DNR, DNH)

Do They Have to Go?

As many as 45% of admissions of nursing home residents to acute hospitals may be

inappropriateSaliba et al, J Amer Geriatr Soc

48:154-163, 2000

In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive

diagnoses” Grabowski et al, Health Affairs

26: 1753-1761, 2007

Adverse Events Common Coming and Going

• 46% of hospitalized patients have 1 or more regularly taken medications omitted without explanation. Potential for harm estimated at 39%.– Cornish Arch Int Med 2005; 165: 424-9

• Transfers from NH to hospital have an average of 3 med changes. 20% lead to adverse drug events.– Boockvar Arch Int Med 2004 (164) 545-50

Conclusion

• Rehospitalizations are going to be a prime focus coming years

• New system paradigm will be needed to meet the demand for prevention of readmissions

• Focus of enhancing care in the SNF and community treatment will take precedence

It’s a new world Obamacare!

• Center for Medicare Medicaid Innovation• $10 billion• Triple aim

– better health– better care– lower cost

• Innovation Advisors Program - Current fellow

How?

1. Admission2. Stay on unit3. Discharge

Bucket #1: Problems on Admission

• Ineffective communication of prognosis / options

• PCP out of loop• Inadequate care plans for

recurrent symptoms

Reduce AVOIDABLE hospital transfers

Approach to the Problem: Admission

• MD standardized discussions

• Communication family and PCP

• High risk patients– Automatic Palliative Care consult– Flag for entire team

Bucket #2: Stay on Unit:Problems With Team Operation

• Disciplines operating in silos

• Failure to identify problems early

• Failure to learn from mistakes

Reduce AVOIDABLE hospital transfers

Approach to the Problem: Stay on the Unit

• Team Improvement for the Patient and Safety (TIPS) conference

• Call to hospital

• Root cause analysis

Bucket #3: Problems With Home Discharge

• Poor hand off to next team

• No teach back with patient/HCP

• No standardized discharge summary/ nursing process

Reduce AVOIDABLE hospital transfers

Approach to the Problem: Home Discharge

• Project RED– Written home care plan from electronic medical

record– Making specific for geriatric use

• E.g. advance directives, diet, VNA, assistive devices

• Standardized discharge summaries

Target Population

• All admissions to the RSU subacute unit

• 1000 admissions a year

• 3NP/3MD- geriatric and palliative care certified

Process and Outcome Measures

• Admission– 90% patients have discussion with MD

• Prognosis

• Rehospitalizations past 6 months

• Communication family and PCP

– Patient/ family satisfaction survey

Advisory Committee

• Family Involvement - Daughter• Outside institutions - Director Subacute Care-

Partners• Biostatistician• Information Technologist• Continuum - homecare• Senior leadership at HSL• Rabbi from palliative care• Staff nurse, unit coordinator, therapy, social work,

aide, administration

Process and Outcome Measures

• Middle - Stay on the unit– Unplanned discharge rates – Benchmarked staff safety survey for staff AHRQ – Attendance TIPS

Process and Outcome Measures

Discharge Home

• 30 day readmission rates after discharge from SNF

• Satisfaction survey of discharge preparedness

Perceived Facilitators/Barriers

• Pt acceptance of less aggressive approaches• Increased liability • Increase cost keeping sicker patients• Difficulty obtaining information from hospital• Time needed to engage primary care • Lack of practitioner access to computer systems in

key referral sites• Limited IT resources for Project RED

RSU Acute Transfer/Total Discharges

Data Unplanned Transfers

• January 2008- June 2009 compared with post TIPS July 2009-November 2009

• Massachusetts 30 day 22-28%Pre-intervention 16.5%Post-intervention 13.3%Rate Reduction -20%

Pre and Post Discharge Dispositions

• Pre N=862• Community 68.6%• Died 1.2%• LTC 13.8%• Hospital 16.5%

• Post N=8863• 73%• 2.2%• 11.6%• 13.3%

When staff report something that could harm a resident, someone takes care of it

Agree and Strongly Agree

On this unit, we talk about ways to keep incidents from happening again

Agree and Strongly Agree

Staff ideas and suggestions are valued on this unitAgree and Strongly Agree

It is easy for staff to speak up about problems on this unit

Agree and Strongly Agree

Staff feel like they are part of a team

Agree and Strongly Agree

Staff are blamed when a resident is harmedDisagree and Strongly Disagree

Implications for HSL

• Family/patient involvement• Create culture of system management rather than

blame• Share knowledge learned across sites/teams• True multidisciplinary team- swarm the problem

and front line solutions which can be used organizational wide

• Use of run/control charts to guide CQI into frontlines and understand common cause variability

Why take on this pain financially? Census, census, census

• Hospital care!

• CMS demonstration project

• Preferred provider network

RED

• Computerized After Hospital Care Plan– Code status, meds, VNA info, PCP info, speech

and therapy directions– Is Meditech good for something?– Phone number to call with questions with

picture care coordinator and name– Give at first care plan meeting and on discharge

update

RED

• Change culture patient/family empowerment

• Involvement of front line staff- NASA comparison

• Culture of QA and monthly feedback

• Clear numerical goals for entire team

Project RED Empowering the Patient

Setting goals of January, 2011How are we doing?

How good EXACTLY do we want to be?

Respondents Reached

• 305 patients

• 96%

• 30 days after discharge RSU

Rehospitalization Once Home

• 56/302 patients

• 18.5%

• GOAL- We will reduce this to 15% or 2.7%

How many see PCP in 30 days?

• 171/282

• 60.6%

• GOAL - We will increase this to 75%.

Understood Medications Very Well or Extremely Well

• 216/279

• 77.4%

• GOAL- We will increase this to 80%

Understood Medications Very Well or Extremely Well

• 216/279

• 77.4%

• GOAL- We will increase this to 80%

How would you rate HSL?

• Respondents 263

• Mean number scale 1-10 (10 the best)

• 8.55

• GOAL- We will increase this to 9

The life of a RED packet

• Given to patient approximately 1 week after admission (“rough draft”)

• Nurses use RED as a tool to help educate patients about their illness, meds, etc.

• “Final draft” is given to patient on discharge

RED Data – How are we doing?

• 90% of patients have been reached

• 13% of the intervention patients have been readmitted to a hospital or had a visit to the ER compared to 17.4% of the non-intervention patients

Data (cont.)

• 73.2% or RED patients saw their PCP within 30 days compared with 45.8% non-RED

• 92.5% understood their medications compared to 60.5%

Data (cont.)

• 56.5% of patients were told of side effects for new medications, compared with 16.6%

RED Problems

• Original plan was to for social workers give RED to patients

• Current plan is to have nurses deliver and teach RED to each patient

What are you all doing?

• Identify high risk patients

• Assessment versus actual interventions- all assessed and no where to go

• Sharing between systems- STAAR et al

• Communicating across continuum– Talking, data, funding