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Transitional Care and Ventilator Program Benefits and ... · Transitional Care and Ventilator ... o Provide patient written discharge plan as well as patient’s ... Comparison of

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The information contained in this document may be privileged and confidential and protected from disclosure and may not be copied or distributed without permission

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Transitional Care and Ventilator Program Benefits and Scope of Program

Purpose:

Understand the gaps in quality and patient safety that exists in post-acute care literature and essential components of Transitional Care Program that attempts to address these gaps and promote high quality, patient centered cost-effective care that incorporates the latest medical knowledge, evidence based guidelines, best practices in communication, collaboration, and care coordination through highly functioning well trained teams. In addition, it is important to understand how these programs will also positively impact the disparity of healthcare that exists in rural communities and skilled nursing facilities. Objectives:

Understand some of the key factors that are associated with poor post-acute care clinical outcomes and excessive hospitals costs

Understand the factors that influence staff and patient satisfaction and relationship to clinical outcomes and patient safety

Understand how Transitional Care Program utilizes swing beds in critical access hospitals and positively impacts:

o Clinical outcomes and patient satisfaction o Revenues and resources for transitional care patients, inpatients and outpatients o Long term viability of these facilities o Jobs and access to healthcare.

Understand the essential clinical components of Transitional Care Program and impact of effective communication, collaboration and care coordination on the following:

o Patient and staff satisfaction o Hospital readmissions o Financial impact

Background and Medical Literature Excessive Acute Care Hospital Costs

Healthcare expenditures in the United States in 2009 was 2.49 Trillion dollars o Hospital costs accounted for approximately 30% of total expenditures o Hospital costs in 2009 was 759 billion dollars

There is an approximate $80 billion cost shift from Medicare and Medicaid to commercial payers (Fox)

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o Many of these patients require post-acute services and inadequate pathways to meet demands impacts excessive acute care hospitals costs that are not reimbursed by Medicare and Medicaid

o In addition, perceived and real drop off in quality of care in post-acute care settings by patients, families, and providers results in significant obstacles to timely acute care hospital discharge and contributes to long lengths of stay and uncompensated care

o Small percent of patients account for a high percent of bed days and resources Weissman reported that patients who stayed for more than 14 days in a

medical surgical ICU accounted for 7.3% of admissions but 40% of total patient days

Patients on mechanical ventilation may account for less than 10% of admissions to intensive care units but account for over 30% of bed days and resources

o Patients with chronic disease contribute to growing hospital costs, readmissions and patients requiring post-acute care.

o Ability to establish high quality post-acute care pathways, promote a seamless continuum of care is an essential strategy to maximize the cost avoidance opportunity for acute care hospitals and healthcare systems and reduce overall cost of care

Hospital Readmissions

The costs and clinical consequences of hospital readmissions is staggering o Nearly one in five Medicare patients are readmitted to acute care hospitals o Associated costs are around $ 15 billion.

Friedman reported on rate and cost of preventable readmissions o Included residents in New York, Wisconsin, Pennsylvania, and Tennessee over a 6

month period in 1999 o Estimated hospital cost of preventable readmission was over

$700 million during the 6 month period Skilled Nursing Facility Outcomes

Garibaldi reported that poor clinical outcomes that include urinary and lower respiratory tract infections, decubitus ulcers and other poor outcomes can be attributed to high staff turnover, lack of attention to infection control practices and other factors

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Cook reported that 45% of patients discharged from a Surgical ICU to an extended care facility died within two years

Carey reported that over 13% of coronary artery bypass patients transferred to other healthcare facilities died

Ankrom reported from a nursing home ventilator program that 15% of patients were liberated from the ventilator and 19% of patients were alive at one year

Staffing Levels

Staffing levels was one of the three top priority areas for improvement identified from AHRQ 2012 Data Base

o Only 56% of respondents reported a positive response to the following: there are enough staff to handle the workload and work hours are appropriate to provide best care for patients

Poor nurse staffing levels have been linked to the following clinical outcomes (Needleman):

o Increased Mortality o Poor patient outcomes including pneumonia, shock, gastrointestinal

bleeding, and urinary tract infections o Longer hospital stays

Staff Turnover

Hospital and skilled nursing facility staff turnover can be much higher than other industries. Decker reported that nurse assistant turnover can be as high as 100% in some skilled nursing facilities

The average hospital may lose approximately $300,000 per year for each percentage increase in nurse turnover

Factors that may contribute to nursing turnover include: o Adequate staffing levels o Feeling overworked o Poor communication and collaboration with co-workers and management o Not receiving recognition o Disengaged or unappreciated o Not feeling respected o Lack of career opportunities

Nurse turnover may impact healthcare in a number of ways including: quality of care, increased staffing costs, increased absenteeism, and loss of patients

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Impact of Ineffective Communication and Culture

Communication problems were identified in more than half of sentinel events reported in 2011

Knaus reported in a study of 13 ICUs that higher mortality rate was linked to nurses and physicians who were less collaborative

Dysfunctional nurse-physician communication has been linked to the following: o Medication error o Patient harm o Patient deaths

Culture and other factors that may contribute to communication failures leading to errors include:

o Hierarchy Traditionally physicians at higher level of hierarchy may perceive

environment as more collaborative than nurses Can create barriers for people lower in the hierarchy reporting concerns to

people with decision making authority o Avoidance of disagreement o Disruptive physician behavior o Healthcare providers may display different priorities caring for patients

Disparity of Healthcare in Rural Communities

It is well recognized that there are significant disparities in healthcare provided to rural communities. Rural residents are more likely than urban residents:

o To suffer from chronic disease such as diabetes or heart disease o Less likely to receive preventative services o Poorer access to healthcare o Fewer physicians

Almost 1/5th of residents in United States live in rural communities Less than 1/10th of physicians live in rural communities

Excessive Acute Care Hospital Costs Ventilator Patients:

Patients requiring prolonged mechanical ventilation are increasing with significant resource utilization (Zilderberg)

o Projections are for a doubling of patient population by 2020

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o Costs are anticipated to be around 60 billion dollars

Patients requiring prolonged mechanical ventilation frequently require extensive post-acute care services, have multiple transitions, fair to poor outcomes and costs for care that are significant. (Unroe)

o Patients surviving to discharge had a median of 4 transitions of care following acute care hospitalization

o 67% of patient in their cohort had a hospital readmission o During 1 year follow-up, surviving patients spent an average of 74% of all days in a

hospital, post-acute care facility, or requiring home health services o Mean cost per patient was $306,135 o Cost per independently functioning survivor was $3.5 million at one year

Weaning or liberation success from mechanical ventilation from hospital based units vary o Gracey reported 60% of patients were liberated from invasive mechanical

ventilation, 75% of patients were postoperative in his report o Scheinhorn reported that 56% of patients were liberated from ventilator and 71%

of patients survived to discharge o Bagley reported that 38% of patients were liberated and 53% survived to discharge

There are fewer outcome reports from skilled nursing facilities on prolonged mechanical ventilation

o Ankrom reported 15% of patients were liberated from mechanical ventilation with 19% survival at one year

o Report from a skilled nursing facility in Wisconsin, more than 60% of patients were liberated from mechanical ventilation with 70% survival at one year (Lindsay)

Respiratory therapy and nurse directed weaning protocols are effective in the following: o More rapid liberation from mechanical ventilation o Reducing length of stay in ICU

Successful Interventions Applied to Transitional and Post-Acute Care:

Naylor and colleagues developed Transitional Care Model (TCM) which emphasizes care coordination for high risk elderly patients with chronic disease. Transitional Care Model demonstrated reduction in overall health care costs, improved patient satisfaction and fewer rehospitalizations. Key components of the program include:

o Transitional Care Nurse coordinates care across an episode of illness. o Home follow-up visits for average of two months which includes telephone support. o Early identification and response to health risks with efforts to avoid harm and

events that lead to readmission

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o Engagement of patients, families, caregivers, and healthcare providers with emphasis on communication and education.

Dr. Eric Coleman and colleagues from University of Colorado developed The Care

Transitions Program. They demonstrated significantly reduced patient rehospitalization rates at 30, 90 and 180 days compared to controls. Key elements of The Care Transition Program include:

o Patient centered record or Personal Health Record (PHR) o Follow-up with physician o Knowledge of “red flags” or warning signs and symptoms and how to respond o Medication self-management

Dr. Brian Jack and colleagues at Boston University Medical Center developed an improved

discharge coordination process called Project Re-Engineered Discharge (RED). They demonstrated significantly reduced hospital utilization. Key elements of the intervention included:

o Educating patient throughout hospital stay o Follow-up appointments in place with clinician with discharge summary o Provide patient written discharge plan as well as patient’s understanding of plan,

and what to do if problem arises o Follow-up call 2-3 days after discharge. o Confirmation of medication plan

Other efforts that have demonstrated reduced rehospitalization have included: o Nurse Practitioners as care managers o Remote patient telemonitoring o Multidisciplinary chronic care team interventions o Enhanced admission assessment for post-discharge needs

Mayo Ventilator and Transitional Care Program Ventilator Program

Ventilator Program was established in Chippewa Falls, Wisconsin Key elements of the program included:

o Bedside rounds with patients and families o Respiratory therapy and nurse directed weaning protocols o Establishment of key roles

Medical Director Respiratory Therapy Director Nursing Leadership Role

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o Conversion from invasive mechanical ventilation to noninvasive ventilation o Emphasis on socialization o Data base

Program has cared for over 60,000 ventilator patient days with more than 50% of all patients liberated from ventilator

o More than 50 patients converted directly from invasive ventilation to noninvasive ventilation

o Better outcomes at reduced costs relative to other reports in the literature (Lindsay) Figure: Outcomes from Wisconsin Ventilator Program

Vent Unit % Weaned % Neuro Wi Program* 67% 27% Scheinhorn 56% 7.8% Mayo (Gracey) 60% NR Bagley 97 38% 19%

Figure: Comparison of Ventilator Programs in Skilled Nursing Facilities

NH Vent Unit %weaned %alive 1yr Johns Hopkins 15% 19% Geriatric Center Wi Program* 67% >70% *Lindsay JCJQS 04

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Mayo Transitional Care Programs

Transitional Care Units were initially established in critical access hospitals in Bloomer and Osseo, Wisconsin

The program was expanded successfully to include 11 critical access hospitals in Minnesota, Wisconsin and Iowa

Key components of the program included: o Bedside rounds with patients and families o Medical Director and Nurse Leadership positions established o Patient centered and clinical outcome measures

Focused on rehabilitative care for patients recovering from variety of surgery and medical conditions

o Complex medical (respiratory, cardiac, neurologic, renal, bariatric, diabetes, infectious disease)

o Trauma o Wounds o Post-surgical patients

Orthopedics Cardiac surgery Neurosurgery General Surgery

o Other Benefits of Transitional Care Program included:

o Patient Centered Outcomes More than 90% of patients: “would recommend the program to others” More than 90% of patients: “rated their overall care as very good” Vast majority of patients are discharged home or to their prior care setting

with low 30 day readmission rates o High employee satisfaction

Rural Community and Critical Access Hospital

Maintain and improve access to healthcare Prevention of critical access hospital closures in rural communities Addition of new services not only benefitting transitional care patients but also inpatients

and outpatients. Few examples include: Respiratory and Therapy (Speech, Physical and Occupational Therapy services)

o Outpatient pulmonary rehab and pulmonary function testing

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o Tracheostomy care, noninvasive ventilation, continuous positive airway pressure, cough assist device support and other services

o Expansion of hours and breadth of services o Outpatient cardiac rehabilitation

Maintain and improve revenues:

o Critical Access Hospitals are certified to receive cost-based reimbursement, cost +

1%, from Medicare with intent to improve their financial status and prevent hospital closures.

o The 1997 Balanced Budget Act was intended to strengthen rural healthcare. Critical Access Hospitals must maintain an annual length of stay of 96 hours or less for acute care admissions.

o There is no limit on length of stay limit for swing bed patients as long as they have a skilled nursing or therapy need.

Strengthening connections with acute care hospitals

o Referrals o Telemedicine o Quality and Patent Safety Collaboration o Optimizing Continuum of Care

Financial Impact of Program

o 20/1 Return on investment o Acute Care Hospital and Health System cost savings in millions of dollars per year o Cost-based +1% reimbursement for critical access hospitals creates a long-term

viability program for these facilities with significant positive impact on revenues and stability

o Positively impacting readmissions reduces overall cost of care benefitting payers including Medicare and Medicaid

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Transitional Care Guidelines and Program Components:

Transitional Care and Ventilator Program Overall Description and Scope of Program

Transitional Care Admission Guideline

Transitional Care Discharge Guideline

Transitional Care Bedside Rounds with Patient and Family

Transitional Care Implementation Guideline

Interdisciplinary Care Team and Transitional Care Patient

Transitional and Ventilator Care Quality Program, Outcome Metrics, Benchmarking and Transparency

Transitional Care Patient Safety Program

Frontline A3 Problem Solving, Meeting the Needs of Patients and Care Team

Patient Engagement Guideline

Ventilator Patient and Transitional Care Team Guideline

Respiratory Therapy and Nurse Directed Weaning for Ventilator Patient

Conversion to Noninvasive Ventilation Guideline

Transitional Care and Ventilator Patient Mobility Guideline

Transitional Care Bundle

Checklists for high risk processes

Rehab Therapy Measures and Guideline Operational Guidelines:

Descriptions identifying specific clinical competencies for key personnel positions

Staffing model guidelines for each of the key personnel positions, including On-site and On-Call requirements

Listing of recommended Program equipment and medical supplies Allevant On-Site Supported Activities:

Allevant Medical Director, Respiratory Therapy and Nurse Leader facilitated implementation

Initial On-Site Assessment Allevant Supported Activities: (Includes combination of on-site and conference call/ telecommunication meetings):

Participation in Interdisciplinary Care Team Meetings

Monthly Respiratory Care Director Meetings

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Monthly Nurse Care Coordinator Meetings

Quarterly Leadership Team Meetings

Medical Director, Nurse Lead, Respiratory Therapy Director availability as needed by phone or telecommunication

Quarterly Audits

Facilitate working with payers on establishing competitive rates (includes working with State Medicaid to establish rates for ventilator rate in skilled nursing facilities

Marketing and Promotion:

Marketing materials to support Transitional Care and Ventilator Program

Allevant Medical Director, Nurse Leader and Respiratory Therapy Director will help facilitate marketing with Acute Care Hospital and Long Term Acute Care Hospital Referral Site Targets

Sample PowerPoint Marketing Templates will be provided Database and Reports:

Web based tool will be provided with the following features:

Administrative Data Collection Tool and Database

Quality Indicators and Outcome Tracking Database

Benchmarking and Trending Reports

Definition of Metrics Training and Education:

Training materials for key Hospital personnel related to Transitional Care and Ventilator Program

Training materials on the use of recommended equipment and supplies

Training materials for Hospital personnel in the marketing of the Program

Training materials for web based Database and Reports Clinical Training and Education Programs:

Select Modified Programs

Speaking Valves

Wound Care Introduction

Spasticity

Obesity Metabolic Syndrome

Neurogenic Bladder

Hypertensions 1

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Hypertensions 2

Dealing with Difficult People 1

Dealing with Difficult People 2 New Material:

Medication Safety

Fundamentals of Transitional Care

Fundamentals of Respiratory Patient

Fundamentals of Ventilator Care

Basics of Renal Patient

Heart Failure

Behavioral Health Basics

Diabetes

Anticoagulation

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Updated 2/5/13 (mel)

Jordan TenenbaumVice President

Allevant SolutionsPost Acute Care Solutions

Developed by Mayo Clinic and Select Medicalwww.Allevant.com(m) 314-302-5373

[email protected]

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