Ideal Patient Care Across the Continuum: Reducing Preventable

ReadmissionsApril 17 IHS ForumPeg Bradke RN MA St. Luke’s Hospital

Director of Heart and Vascular Services

Where We Have Been• Engaged Cross Continuum Teams• Condition focused• Learned about patients who are readmitted

– By condition, 3 readmissions in 180 days• Used IHI Change Package for hospital-

based transitions• Learned to see and solve at the front line

– Started to see from another care site perspective

Where We Are Going2012 Clinical Priorities

Clinic Hospital Home Health Quality Patient Experience

Adherence to

Diabetes Bundle

Reduce

Readmissions

Reduce Acute

Hospitalization

Improve

Press Ganey Scores

Improve HCAHPS Scores

Improve HHCAHPS

Scores

2011 Results

Transition from Hospital to Home

Post-Acute Care Activated

Alternative or Supplemental Care for High-Risk Patients ** Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Health Information Exchange and Shared Care Plans

Evidence-based Care in Community Care Settings(Better Models of Care)

Hospitals

• Perform an enhanced assessment of post-hospital needs

• Provide effective teaching and facilitate enhanced learning

• Ensure post-hospital care follow-up

• Provide real-time handover communications

Office Practices

• Provide timely access to care following a hospitalization

• Prior to the visit: prepare patient and clinical team

• During the visit: assess patient and initiate new care plan or revise existing plan

• At the conclusion of the visit: communicate and coordinate ongoing care plan

Home Care

• Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan

• Assess the patient, initiate plan of care, and reinforce patient self-management at first post-discharge home care visit

• Engage, coordinate, and communicate with the entire clinical team

Skilled Nursing Facilities

• Ensure that SNF staff are ready and capable to care for the resident patient’s needs

• Reconcile the Treatment Plan and Medication List

• Engage the resident and their family or caregiver in a partnership to create an overall place of care

• Obtain a timely consultation when the resident’s condition changes

Co-designing Processes to Improve Transitions

Analysis of Results to Date• Reducing readmissions is dependent on highly

functional cross-continuum teams and a focus on the patient’s journey over time.

• Explicit focus on patient and family-centered work.• Importance of engaged Executive Leadership and

Physician Leadership.• Improving transitions in care requires co-design of

transitional care processes among “senders and receivers”. Frontline clinicians and staff involvement in developing the process improvements.

• Stories are as important as data.• Providing intensive care management services for

targeted high-risk patients is critical.• Reliable implementation of changes in pilot units or

pilot populations requires 18 to 24 months.• Information Technology design is part of the work.

Barriers to Improving Care Transitions and Reducing Rehospitalizations

• Cost of copayments for medications and follow-up visits.• Lack of coverage for home health services if patients did

not meet regulatory requirements.• Lack of reimbursement for transitional care services such

as post-discharge phone calls, coaches and dedicated clinicians to provide extra support for patients and family caregivers.

• Limitations of the electronic medical record to capture and transmit information.

• Access to physician offices for follow-up visits. • Complexity of patients with multiple co-morbidities.• Challenges to completing reliable medication

reconciliation.

PLA-MLA Joint Meeting: February 2012

How, exactly, does IHS deliver on the Triple Aim?

• Align providers with a common quality agenda

• Use Analytics to identify at-risk patients for clinical intervention

• Design a care management infrastructure to follow the patient across a highly integrated provider network into all care settings

• Deliver comprehensive care aimed to attain and maintain health in the outpatient setting

Linking the Patient Experience and Reducing Readmissions

Patient/Family as Full Partner

• Partner with patient/family in the way they want to be

• They will speak up more if involved • Look for the patient/family clues• With their input look at what you

specifically do at each transition• The patient is not discharging from

the Army – they need a transition (K. White)

Key Changes to Improve the Transition from Hospital to Home

1. Perform an Enhanced Assessment of Post-Hospital Needs

2. Provide Effective Teaching and Facilitate Enhanced Learning

3. Ensure Post-Hospital Care Follow-Up 4. Provide Real-Time Handover

Communications

Understanding of the comprehensive assessment of the post-discharge needs of patients

• Streamline paperwork for nurses and enhance the work environment to free up time for nurses to spend more time with patients (TCAB changes: move laptops to patient rooms; admission nurse; bedside change-of-shift report)

• Front-line nurses complete a more comprehensive assessment of home-going needs (need to specify the open-ended questions); bring this information plus “what the patient is worried about” to daily Care Rounds

• How best to use white boards in patient rooms to assess comprehensive needs of patients?

• Develop standardized processes for getting information from family caregivers and community providers

Patient and family caregiver understanding and comprehension of clinical condition, plan and

self-care at home• Create standard process to involve family caregivers

• Ensure that all nurses, hospitalists and residents are competent to facilitate health literacy teaching sessions (Ask Me 3 and Teach Back)

• Incorporate patient teaching into routine daily processes such as the bedside change-of-shift report

• Change documentation fields in EMR from “what has been taught” to “what is the patient’s understanding of……?”

Post-acute Follow-up Care

• No universally agreed-upon risk assessment tools;may be difficult to mitigate some medical

and social risks• Continue to assess utility of assessing patient’s

understanding of home care and meds (using Teach Back); look at agenda of Patient Care rounds

• Appropriate and timely FU care is dependent on availability and payment for services

• Plan post-discharge follow-up care taking into consideration assessed needs and capabilities of the patient and family caregiver;

• Chronic Disease Management/ Advance Medical Team

Proposed Agenda for “Patient Care Rounds”

1. What are the goals/reasons for this admission? Are the health care team’s goals and the patient/families’ goals in synch?

2. What needs to happen during this hospitalization? What are the criteria for the discharge readiness?

3. What is the likelihood that this patient will be readmitted in 30 days? Why (predictions re: potential problems)?

4. What post-acute care plan should be put in place to meet the patient’s level of activation and to mitigate potential problems?

5. Activate and communicate real-time post-acute care plans to patients, family caregivers and community providers

Handover Communications• Co-design of communication and

information needed for next level of care• After care summary • Agenda for f/u office visit

• Utilizing Interact tools for Nursing Facilities• Utilizing Health Coaches/Navigators• Determining who is the most appropriate

individual to make the follow up calls.• Don’t confuse information with

communication 

Scale-up and Spread• Spread: Taking a system or intervention and replicating it in an

independent site– Replication without new learning or structural changes.– Ex: A pilot unit at a hospital implements changes to reduce patient injury from

falls >> successes are shared with nurses in an educational forum and changes are promoted and spread hospital-wide

• Scale-up: The progressive design of a system of interrelated parts; moving from one setting to a larger setting and then an even larger setting within an interrelated system – Expect new learning and structural changes to achieve results at scale.– Ex: A pilot unit at a hospital successfully implements TeachBack as the

standard approach to patient education >> TeachBack is an annual core competency for all nurses and residents in the hospital and EHR has fields where nurses and doctors document “patient understanding…”

Source: API and IHI Retreats

Critical Capabilities for Care Redesign Include:

• Cross-continuum participation and alignment • The development and use of standardized tools

and compatible information infrastructure• Horizontal Leaderships and executive

sponsorship; and engaged physicians• Effective external and internal learning

Scale up changes cannot be a “project”, they must become the new way to do work, built into the culture

20

Reducing Readmissions with Integrated Chronic Care Disease

Management

Vicki Wildman, RN, MSN, EduIowa Health Home Care

“Patients can undo a month’s worth of

expensive and intensive care just

going home and going about

their normal routines.”

John Charde, MDVP Strategic Development, Enhanced Care

Initiatives, Inc (April 2006)

Cause of Crisis: Poor Management

Before

Informed,

Activated

Patients

•Motivation•Information•Skills•Confidence

PreparedPractice Team

•Patient information•Decision support•Resources

Prepared

PracticeTeam

Home-Based Chronic Care Model

High Touch Delivery

Self-Management Support

Specialist Oversight

Technology

After

Lesson’s LearnedCommitmentEducationCompetency performance testingHardwiring evidence-based practices

Future Opportunities• Expansion of the curriculum cross

continuum• Sustaining the education, training,

and competency• Evidence based medicine

implementation project• Hardwiring best practices related to

chronic conditions• Individual employee outcome

scorecards

The Future• Rehospitalizations are frequent, costly and many are

avoidable;

• Successful pilots, local programs and research studies demonstrate that rehospitalization rates can be reduced;

• Individual successes exist where financial incentives are aligned;

• Improving transitions state-wide requires action beyond the level of the individual provider; systemic barriers must be addressed;

• Leadership at the provider, association, community and state levels are essential assets in a state-wide effort to improve care coordination across settings and over time.