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Ensuring Patient Safety at Home

Mary Ann Christopher, MSN, RN, FAANPresident & Chief Executive Officer Visiting Nurse Service of New York

5th Annual Lorraine Tregde Patient SafetyLeadership ConferenceJune 14, 2012

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VNSNY: Who We Are

The Visiting Nurse Service of New York

• Founded in 1893 by Lillian D. Wald, VNSNY is the largest non-profit community-based health care agency in the U.S.

• Serves all five boroughs of NYC, plus Westchester, Nassau, and Suffolk Counties

• Plans a statewide expansion

• Provides a range of services to an average daily census of 31,000 patients, from newborns to seniors

• 16,000 employees – most are field staff providing direct care

• Serve a socio-economically diverse population (36% speak a foreign language)

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Presentation Framework

• Industry perspective

• Magnitude of Problem

• Patient Anecdotal

• Interventional strategies with qualitative and quantitative outcomes

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Safety Issues at Home

• Falls Prevention

• Non-Healing Wounds

• Depression

• Transitions of Patients Across the Continuum

• Adverse events related to medication administration

• Patient Preference

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Falls Prevention

1 in 3 adults over 65 will suffer a serious fall this year

70% of these falls occur at home

1 in 2 adults 85 and older fall

Falls are the leading cause of fatal and non-fatal injury in older adults

Every 17 seconds, an elderly person is taken to the ER because of a fall

High likelihood of a fall within 48 hrs of changes or additions to medications

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Risk Factors for Falls

Medical and Falls History

EnvironmentSafety

MultipleMedications

Vision

Muscle Weakness

Balance & Mobility

footwear & devices FALLS

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Strong Foundations: Background

“Strong Foundations” is a multidisciplinary initiative aimed at patients at high-risk for falls. Falls interventions combine skilled nursing care and physical therapy in a 4-part course of treatment

Data will be obtained from patient self-report and VNSNY administrative and clinical systems on:

– Incidence of falls and hospitalizations– Quality of Life– Satisfaction with Care– Ambulation– Sustainability of exercise plan

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Strong Foundations: Risk Assessment Tool

The RN assesses the first 5 factors on the patient’s first visit using OASIS measures

For the remaining measures, the physical therapist performs a number of standardized, quantitative assessments:

1) Medical History 4) Home Environment 7) Strength

2) Medications 5) Footwear 8) Gait

3) Vision 6) Balance

Nurse and a physical therapist assess the following 8 factors for falls, as consistent with the American Geriatrics Society guidelines on falls prevention:

Timed Up and Go Functional Reach

Single Leg Stance Falls Efficacy Scale

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Non-Healing Wounds

Affect over 1 million people, exceeding $11 billion in all settings

Wound infection rates increased 27% from 2000 – 2005

30% of patients have wounds and 42% have multiple wounds

Unacknowledged impact of patient preference on quality outcomes

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Non-Healing Wounds (cont.)

Communication reminders to clinicians improve patient safety

Management guidelines include WOCN (Wound Ostomy Continence Nurse) Consultation

New Jersey Hospital Association:

Cross continuum collaborative involving 150 organizations

Use of Braden Scale and implementation of 3 preventive measures:

Manage moisture

Optimize nutrition and hydration

Minimize pressure

Outcomes: 70% reduction in decubitus ulcers

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Depression

Affects more than 6.5 million (or 18%) of the 35 million Americans aged 65 years or older

major depression is twice as common in elderly patients receiving home care than in those receiving primary care

chronic illness is the most common factor associated with depression (prevalence of depression can rise from 10% to 30%)

Even if diagnosed, roughly 18% of the elderly are on the wrong meds or have an ineffective dose; thus receiving inadequate therapy

If untreated, depression can lead to: poorer outcomes for hip fractures, heart attacks & cancer decline of cognitive abilities avoidable hospitalizations increased risk of suicide

Of those elderly who attempt suicide, 80 percent are reported to have major depression

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VNSNY Behavioral Health Program

Employs psychiatric nurses, psychiatric nurse practitioners and in-home visiting psychiatrists and receives referrals from community primary care physicians, hospitals and family members

In 2011, 1100 patients were admitted to the VNSNY Behavioral Health Program with the following 5 top diagnoses:

depression anxiety dementia (early onset) bipolar disorders schizophrenia

VNSNY Behavioral health specialists employ:

PHQ-9 assessment tool

Evidence-based practice treatments, using anti-depressive medication and Cognitive Behavioral Therapy (CBT)

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Rehospitalizations are costly and avoidable

1 in 5 Medicare patients are rehospitalized in 30 days

34% are rehospitalized within 90 days

Half never see an outpatient doctor within 30 days after discharge

Costs $17.4B*

*Coleman, Williams, et al. NE Journal of Medicine

Transitions of Patients Across the Continuum

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Drivers of Hospitalization Risk

Higher hospitalization risk is associated with:

PreviousHospitalization

Illness &SymptomSeverity

UnhealedPressure &

Stasis Ulcers

UrinaryIncontinence &

Catheters

RespiratorySymptoms

DiagnosisType

MedicationUse

ITAC 2012

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Transitional Care Model

1) Predictive Algorithm with alerts to clinicians

2) Short and long-term transitions of care program

3) Adapted Brenner Model

4) Continuity of Care Challenges

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Transitional Care ProgramResults: 30 Day Readmission Rates

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Opportunities for Improved Outcomes

Continuityof Care +

-

ERVisit

HospitalReadmission

ADLFunctioning

-

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Medication Management

Patients who did not take medications as prescribed cost the health care system $290B in available medical spending

– 2009 (New England Health Care Institute)

In a study of patients, 1/5 had adverse events due to inadequate medical care after returning home, with Rx drugs accounting for most injuries after discharge

Some medications get discontinued inadvertently (mostly statins and anticoagulants) with a resultant adverse impact on patient safety and hospital recidivism

Non-geriatric friendly medications can result in unnecessary falls and motor vehicle accidents

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Components of an Effective Medication Program

• Care Coordination

• Utilization Management

• A well thought out formulary structure

• E-prescribing

• Basing pharmacists and nurses at neighborhood and senior centers

• Automatic medication dispensers

• Involvement of PharmD in interprofessional team

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VNSNY CHOICE Model has Produced Measurable Outcomes• Hospital Admissions: Utilization data for a cohort of 573

members enrolled in our care coordination program for 24 months showed significant reductions:

– 54% decrease in hospital admissions– 24% decrease in readmits within 30 days to 16%– 27% decrease in ER visits

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Vulnerable Patient Study

Background:

• VNAA, in collaboration with the VNSNY Center for Home Care Policy & Research, initiated a patient study in 2010 to collect data on a range of patients and their associated costs

Initiated by 9 VNAs across the country

Now being replicated nationally with 50 home care organizations

Adequacy of Risk Adjustment:

• Identified variables: health literacy, stasis or pressure ulcers, presence of caregiver, access to primary care, clinically complex conditions, functional disability with poor rehabilitation potential