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Virginia Nurses Association Chapter 5
January 17, 2013
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN Senior Director, Galloway Consulting Research Associate Professor, University of Virginia, School of Nursing Editor in Chief, American Nurse Today
National Quality Strategy (2011) National Strategy for Quality Improvement in Health Care (HHS) Better Care: Improve the overall quality--more
patient-centered, reliable, accessible, and safe.
Healthy People/Healthy Communities: address behavioral, social and, environmental determinants of health; deliver higher-quality care
Affordable Care: reduce the cost of quality health care
for individuals, families, employers, and government
Partnership for Patients (2011) Better Care, Lower Costs Public-private partnership that will help improve the quality, safety and affordability of health care for all Americans
• Keep patients from getting injured or sicker.
By the end of 2013, preventable hospital-acquired
conditions would decrease by 40% compared to 2010.
• Help patients heal without complication.
By the end of 2013, a 20% decrease in hospital
readmissions from 2010 (related to a complication
during a transition across care settings)
Condition of Affordable Care Act
Effective October 1, 2012 AMI, Heart Failure, Pneumonia
2,211 hospitals penalized $280 Million—maximum of
1% of Medicare base payments
October 1, 2013 can rise to 2% base payments
Additional diagnoses
Source Kaiser Health News
Estimated impact:
1 out of 5 Medicare patients readmitted in 30 days = 2.6 Million people
Cost = $26 billion annually (additional impact on Medicaid and private insurance)
Hospitals with higher proportion of poor and/or African American patients had higher rates
Reflects complications or poor transitions threatening safety and survival
Patient characteristics Demographics Socioeconomic status Behaviors Disease status
Activities and events associated with hospital care Environmental factors Terminal illness and multiple chronic medical and
mental health conditions Poor support systems and services in community such as
housing, transportation, other assistance
Meet three of the Institute of Medicine’s 6 aims of care Safe
Effective
Efficient
Patient-centered
Timely
Equitable Achieved from provider to provider and setting
to setting
Reduce risk of readmission Providers of all disciplines cooperate
Patient Centered
Plan of Care
Health care providers
Patient Preferences
Community resources
Social
Services
Across time And settings
Involve patients and families as the most consistent element
Training for activation and self care skills
Patient-centered care plan:
▪ Negotiated
▪ Responsive to medical and social situation
▪ Assures services available
▪ Shared across settings
Standardized, accurate, and timely communication and information exchange between transferring and receiving provider
Medication reconciliation Safe transportation Timely DME Hand off means sending provider relinquishes
responsibility for care only after patient received by clinician at new location
Affordable Care Act (section 3026) implemented April 2011 by Centers for Medicare and Medicaid (CMS)
Aim: to improve patient transitions from hospitals to other settings 5 year program; $500 million Opportunity for hospitals with high readmission
rates to partner with community-based organizations (CBO) and CBOs that provide transition services
Test models for improving care transitions for high risk Medicare patients; focus on preventable complications
Services Offered: Care transition services: 24+ hours before
discharge Post discharge education so patients
understand potential problems and signs of changing/deteriorating condition Timely
Culturally appropriate
Linguistically competent
Services offered (continued) Timely interactions between patients and
post acute and other outpatient providers Patient centered self management
support Complete medication review and
management
Rationale: align incentives for providers by bundling payments for services across an episode of care
4 models Reduce fragmentation Improve coordination across providers and
settings
Retrospective Payment Bundling—set a target payment with discount to Medicare rate (may be able to share savings) #1 Hospital stay only—discounts Inpatient
Prospective Payment rate; MD fees stable #2 Inpatient stay and post acute care to include +30
to +90 days #3 starts at discharge from hospital then +30 days
post discharge #2 and #3 both include discounts for hospital and
MD/other provider fees; includes lab, DME, prosthetics/orthotics, supplies, Part B drugs
Prospective Payment Bundling—set a target payment with discount to Medicare rate (may be able to share savings) continued
#4 Single payment to hospital for all services of inpatient stay including MD/other providers
All models incentivize avoidance of readmissions
Care Transitions Intervention
Eric Coleman, MD, MPH
University of Colorado
Transitional Care Model
Mary Naylor, PhD, RN, FAAN
New Courtland center for Transitions and Health
University of Pennsylvania
BOOST—Better Outcomes for Older adults
through Safe Transitions
Society of Hospital Medicine
Project RED—Re-engineered Discharge
Boston University
Intervention focuses on 4 pillars Medication self management
Understand medications and have system to ensure correct intake at home
Dynamic patient centered record Understand and manage personal health record (PHR)
Follow-up Patient schedules and completes follow up with primary and specialist care
Red Flags Knows how to recognize signs of condition decline and how to respond
Tools Patient centered record (PHR) Structured discharge preparation checklist Patient self-activation and management
session with Transitions Coach® Transitions Coach® follow up visit at SNF or
home plus phone calls
34 of 47 Community-based Care Transitions Model sites are using this intervention
7 strategies—collectively create effective care transitions (↓ 30 day readmissions 20-50%) Greater engagement of patient and family care givers Acknowledge essential status of family care givers as
essential care team members Implement performance measures Define accountability during transitions Build professional competency in care coordination Explore and implement technological solutions to
improve exchange of information/communication across settings
Align financial incentives to promote cross setting collaboration
Targets older adults with 2+ risk factors History of recent hospitalization
Multiple chronic conditions or medications
Poor self-health ratings Managing transitions across settings and
changes in condition ↓readmissions 28% first 24 weeks and 13%
within a year (Kaiser Permanente patients) Reduced costs 39% per patient ($5,000)
within year after hospitalization
Transitional Care Nurse (TCN) Advanced practice nurse with a masters
degree in nursing with advanced knowledge and skills in the care of older adults
Caseload of 15-20 patients In-hospital visit Home visit Nurse visit with physician
Key components Patient and caregiver understanding
Patient education
“Translating” information Medication reconciliation and management Transitional care (not ongoing case management)
Help patient and family develop knowledge, skills, and resources to prevent decline and/or re-hospitalization
Facilitate connections to needed care
Goal: improve hospital discharge process
30 day readmission rate (older adults; general medicine)
Improve patient satisfaction and H-CAHPS scores related to discharge
Improve flow of information between inpatient and outpatient providers and settings
Identify high risk patients and specific tailored interventions to lower risk for adverse events
Improve patient and family preparation for discharge
Key elements Mentoring to customize interventions Comprehensive implementation guide—
many tools available to public Longitudinal technical assistance BOOST collaboration BOOST data enter
Combination of tools for interventions shown to decrease readmissions BOOST mentors hospital teams
Map current processes and create and implement action plans for organizational change.
Provides a suite of evidence-based clinical interventions that can be easily adapted and integrated into each unique hospital environment
105+ sites enrolled in year long mentoring ↓30 day readmission rate 21%
Goal: reduce readmissions and yield high patient satisfaction Key Factors
Educate patient about diagnosis throughout stay
Patient involved in setting follow up appointments
Patient knows what tests were not completed in the hospital
Post discharge services are organized
Medication plan confirmed
Key factors (continued)
Discharge plan reconciled with national guidelines and critical pathways
Care provider reviews with patient actions to take if a problem develops
Discharge summary has expedited transmission to post acute providers
Care providers assess patient understanding of plan
Patient received written discharge plan
Patient receives phone follow up 2-3 days post discharge to discuss plan or any problems
Unique feature
Louise—virtual discharge advocate
74% of patients preferred the virtual nurse
Results in development phase
34% lower costs
30% lower rate of hospital utilization
15-20% reduction in 30 day readmission rate
16-24% reduction in ED use
Keep focus on all safety and quality improvement initiatives
Recognize transitions as times of vulnerability
Assess vulnerable populations for risk factors including health care disparities
Take action to improve overall care that prevents adverse events and mitigates risk factors
New evidence: Improving education, environment, and
workload can lead to lower readmission rates (in addition to evidence on lower RN overtime hours)
Hospital Nursing and 30-Day Readmissions Among Medicare Patients With Heart Failure, Acute Myocardial Infarction, and Pneumonia
McHugh, Matthew D. PhD, JD, MPH, RN; Ma, Chenjuan PhD, RN
Medical Care 2013;51: 52-9
Participate in the Partnership for Patients Follow trends in reimbursement for quality
and penalties for “off-quality” Champion the use of tools to improve
transitions in care Celebrate successful reduction of
readmissions and improved patient experiences
Community-based Care Transitions Program http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html?itemID=CMS1239313 Roadmap to Better Care Transitions and Fewer
Readmissions (Partnership for Patients) http://www.healthcare.gov/compare/partnership-for-patients/safety/transitions.html#BackgroundonCareTransitions Care Transitions Intervention (Coleman) http://www.caretransitions.org/overview.asp Project BOOST http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=27659 Project RED http://www.bu.edu/fammed/projectred/
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