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Coordination of Care InitiativeNorth East MN Area Community

Community Meeting

May 28, 2019

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Download meeting agenda and slide handout:

• Agenda

• Handout

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Welcome&

Introductions

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Meeting Agenda and Objectives

Describe coordination of care efforts across Minnesota

and review updated North East MN

community data

Understand improvements in care transitions in

delirium prevention and management

Recognize initiative participation and celebrate

community accomplishments to improve care

transitions

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Coordination of Care Initiative Update

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Coordination of Care Initiative Goals

• Improve quality of care for Medicare beneficiaries

who transition among care settings

• Reduce 30-day hospital readmission rates and

admission by 20% by 2019

• Increase the number of days at home

• Establish sustainable, transferrable transition

practices across the spectrum of care

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Coordination of Care Communities

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Success Stories Webinar Series

Successful Strategies for Sustained

Community Improvement

Tuesday, January 22, 2019, 12–1:00pm – More

At Your Service: Benefits of Home

Health Agencies Working with their QIN

Tuesday, February 26, 2019, 12–1:00pm – More

Using Data to Drive Community

Quality Improvement Efforts

Tuesday, March 26, 2018, 12–1:00pm – More

Home-based Innovative Strategies

to Prevent Readmissions

Tuesday, April 23, 2019, 12–1:00pm – More

Changing the Culture: Improving

Recognition and Management of Sepsis

Thursday, May 30, 2019, 12–1:00pm – More

Achieving Community Goals by Partnering

with Aging and Disability Resource Centers

Tuesday, June 25, 2019, 12–1:00pm – Register

This six-webinar series highlights the innovative work the Lake Superior QIN COC partners have done across care settings and in the community to improve transitions of care and reduce readmissions.

Download the webinar series flier

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Community Scorecard

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The Community

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Admissions (community)

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Admissions (comparative)

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Admissions (vs. goal)

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Number of Fewer Admissions Needed to Meet Goal

• This community had 8,660 admissions in the most

recent 12 months (Q4 2017 – Q3 2018).

• Need to be at 7,855 admissions for final

measurement (Q4 2017 – Q 3 2018), which is 805

fewer admissions than the target rate.

• That’s 67 less admissions/month.

• Congratulations NE MN community on maintaining a

lower than average national/state admissions rate!

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Readmissions (community)

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Readmissions (comparative)

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Readmissions (vs. goal)

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Number of Readmissions Needed to Meet Goal

• This community had 1,438 readmissions in the most

recent 12 months (Q4 2017 – Q3 2018).

• Need to be at 1,162 readmissions for final

measurement (Q4 2017 – Q 3 2018), which is

276 fewer readmissions than the target rate.

• That’s 23 less readmissions/month.

• Congratulations NE MN community on maintaining a

lower than average national/state readmissions rate!

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ED Visits (community)

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ED Visits (comparative)

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Workgroup Updates

Medication SafetyCommunication

Resources/Patient Engagement

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Featured Presentation

—

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Place picture here

MHA Delirium Discharge Order Bundle

Charisse Coulombe, MS, MBA, CPHQ, CPPSMinnesota Hospital Association

Aminata Cham, APRN, MSN, ACNS-BCFairview/Health East Care System

May 28, 2019

Agenda/Outline

1. Introduction

2. MHA Quality and Patient Safety Committee Structure

3. Delirium Committee 2019 priorities and tools

4. Clinical review

5. Discharge Order Bundle deep dive

6. Questions

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Minnesota Hospital Association

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MHA Overview

MHA Quality & Patient Safety Division

Dedicated QPS staff for over 19 years

13 expert committees

Partnership for Patients contractor for the last 7 years

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Quality and Patient Safety Committee Structure

2019 Delirium Committee Priorities

Priority 1: Road Map Implementation and Adherence

Priority 2: Re-evaluating and updating delirium process and outcome metrics

Priority 3: Early mobilization during hospitalization

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Place picture hereMHA Delirium Committee 2019WorkPlan Priority 1

Priority 1: Delirium Road Map

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Road map design

Operational definitions

(what yes means)

Organized by section to address specific aspects of care

Audit-style format for key

elements

Line by line references (active links at the end

of each document)

Mapped resources with live links

Fundamental or advanced strategies to help with prioritization

Why use the Delirium Road Map?

It is a step-by-step guide to building a delirium program.

Infrastructure Detection Prevention MedicationsManagement of Behaviors

ICU/Ventilated Patients/the

ED

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Delirium Road Map

MHA Delirium Road Map (PDF)

https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Delirium/Delirium%20Road%20Map.pdf (URL)

Now that we’ve updated our website, I would add the new look, which shows an icon of the road map directly on the webpage.

What does the road map data tell us?

2018

1. Education for nurses

2. Education for physicians/residents

3. Reaching the executive team

4. Coordination of care

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Delirium Learning Cohort (Nurses)

Purpose

• Provide education about delirium identification, prevention, and management to nurse leaders and educators via a train-the-trainer model.

Objectives

• Provide education, resources, and tools for nurse leaders to learn about delirium awareness.

• Train nurse leaders/clinical educators on how to bring the delirium awareness presentation and resources back to their nursing units.

Resources & Activities

• 6 monthly calls

• Delirium Awareness Presentation-Nurses

• Case Studies

• Videos

• Patient stories

• Delirium Road Map

• Data collection

• Learning Collaboration Network Events

Delirium Learning Cohort Clinical Education Modules

Module 6 Patient and Family Engagement

Module 5 Management: First Lines of Treatment

Module 4 Identification and Presentation of Delirium

Module 3 Prevention

Module 2 Data: Current State and Collection

Module 1 Introduction to Delirium: Definition, Cost, and Mortality

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Delirium Learning Cohort Example Toolkit

Delirium Fact Sheet (Physicians and Residents)

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SBAR(Executives and Leadership)

Place picture here

Delirium Discharge Order Bundle

Aminata Cham, APRN, MSN, ACNS-BCFairview/Health East Care System

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Delirium Discharge Order Bundle

Goal: Coordinate with post-acute organizations to identify and address areas of opportunity in delirium prevention and management to prevent delirium related readmissions

Delirium

An acute disorder of attention and cognition.

Common, serious, costly, under recognized and often

fatal.

Current approach to diagnosis and treatment of delirium

remains a clinical diagnosis.

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Diagnosis

Underrecognized and easily overlooked.

Only 12 to 35% of delirium cases are recognized.

Current reference standard diagnostic criteria are:• DSM-5

• ICD-10

Over 24 delirium instruments have been used in published studies.

CAM-most widely used instrument.

Currently, there are at least 11 diagnostic codes for delirium in ICD-9 and 23 codes in ICD-10.

Only 3% of delirium cases are coded in medical records.

DSM V

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness.

Change in cognition (e.g., memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a preexisting, established, or evolving dementia.

The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.

There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.

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Significance

In the united states, >2.6million adults 65years and older each year develop delirium

Total cost range from $16,303 to $64,421 per patient

Accounts for >$164 billion in annual healthcare expenditure

Included on the pt. safety agenda

Targeted as an indicator of healthcare quality for seniors

Hold significant societal implications

Key Clinical Predisposing Factors

Advanced Age- 65 and

older

Cognitive impairment,

such as dementia

Multiple co-morbidities

History of delirium 5

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Key Clinical Precipitating Factors

Higher severity of

illnessSurgery

Dehydration or

constipation

PainExposure to

multiple medications

Hip Fractures5

Forms of Delirium

1. HYPERACTIVE2. HYPOACTIVE3. MIXED The hypoactive form is more

common among older adults• Often unrecognized• Associated with higher rates

of complications and mortality

Delirium was found in ~90% of patients in the last days of life in a 2013 systematic review.• Hypoactive delirium was the

most prevalent delirium subtype in the palliative care population (68%–86% of cases).

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Delirium Superimposed on Dementia

Older adults with dementia are at greatest risk for delirium.

89% experience delirium when hospitalized and between 24% and 76% die within one year of the index episode.

Delirium or Dementia?

Characteristic Delirium Dementia

Onset Acute, abrupt Insidious, steady decline

Attention Inattention present Usually no change

Course

Fluctuating and resolves over

time, may not resolve

without discharge

Steady decline with

Alzheimer’s

Stepwise decline with

vascular dementia

Duration Hours to days, may last

months Months to years

Level of consciousness Changes-vigilant to lethargic Usually no change

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Delirium or Dementia?

Characteristic Delirium Dementia

Perception Hallucinations (visual and

auditory) may occur

Usually do not occur

Lewy Body dementia-

hallucination do occur

Sleep/wake cycle Impaired, sleep schedule can

become reversed

Fragmented; may awaken

frequently or sleep more

Psychomotor behavior Hypoactive, Hyperactive, or

Mixed No change

Mood/affect Rapid swings; paranoid May be apathetic,

depressed

Adverse Outcomes of Delirium

1. Most common adverse health events for older adults.

2. Independently associated with an increased risk of death.

3. Potent risk factor for complications: falls, increase LOS, pressure ulcers, functional decline, and Institutionalization.

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MHA Delirium Discharge Order Bundle

Clinician Section

Clinician Section

Continue to assess for signs of delirium, such as: disturbance in attention and awareness; change in cognition that is not accounted for by dementia, develops over a short period, and fluctuates throughout the day.

Minimize high-risk medications and other medications with high anti-cholinergic effects:

• Opioids (e.g., Meperidine, Morphine, Fentanyl, Hydromorphone)

• Benzodiazepines (e.g., Diazepam, Lorazepam, Alprazolam)

• First Generation Antihistamines (e.g., Diphenhydramine, Hydroxyzine, Meclizine)

• Muscle Relaxants (e.g. Cyclobenaprine, Chlorzoxazone, Metaxalone)

• Hypnotics (e.g., Zolpidem, Eszopiclone, Zopiclone)

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Ensure Patients Have Sensory Aids

Address sensory impairment by: • Determining which, if any, sensory

aids are used by the patient • Ensuring sensory aids are

available and in reach of patient • Resolving reversible cause of the

impairment, such as impacted ear wax

Sensory aids include: • Hearing aids • Eyeglasses• Amplifiers• Dentures

Assess and Manage Pain

How

Assess for pain regularly using objective scale 6

Look for nonverbal signs of pains, especially for patients with

communication difficulties or ventilated patients 6

Why

Pain is a risk factor for delirium 26

When pain is not properly assessed and treated, patient

may receive sedatives and narcotics that place them at risk

for delirium 26

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Encourage Mobility

Patients with early mobility protocol are:

• Out of bed earlier

• Out of the ICU and hospital earlier

• Less likely to be readmitted to the hospital in 12 months following discharge

• Less likely to die in 12 months following discharge

Sleep Promotion and Environment

Sleep promotion

• Low-level lighting at night 9

• Avoid nursing or medical procedures during sleeping hours 6

• Schedule medication rounds to avoid disturbing sleep 6

• Reduce noise during sleeping hours 6

Environment

• Clock or calendar in view of patient 6

• Normal day/night variation in illumination 6

• Limit room and staff changes 9

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Hydration and Nutrition

Encourage patient to drink adequate fluids

Screen for comorbidities that would affect fluid balance (congestive heart failure, chronic kidney disease)

Promote Cognitive Stimulation

Encourage hobbies

Puzzles

Reading

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Questions

Contact Information

Charisse Coulombe

• ccoulombe@mnhospitals.org

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References

1. Adamis, D. et. al., Delirium scales: A review of current evidence. Journal of Aging and Mental Health, 2010. 14(5): p.543- 555.

2. Angle, C. (2016). Standardizing management of adults with delirium hospitalized on medical-surgical units. The Permanente Journal. doi:10.7812/tpp/16-002

3. Brummel, N. E., & Girard, T. D. (2013). Preventing delirium in the intensive care unit. Critical Care Clinics, 29(1), 51-65. doi:10.1016/j.ccc.2012.10.007

4. Confusion Assessment Method (CAM). (n.d.). Retrieved from http://www.medscape.com/viewarticle/481726

5. Waszynski, C. M. (2012). The Confusion Assessment Method (CAM). Best Practices in Nursing Care to Older Adults, (13). Retrieved from https://consultgeri.org/try-this/general-assessment/issue-13.pdf

6. Delirium: prevention, diagnosis and management (2010). https://www.nice.org.uk/guidance/cg103/chapter/1-guidance

7. Ely, E. W., Inouye, S. K., Bernard, G. R., Gordon, S., Francis, J., May, L., … Dittus, R. (2001). Delirium in mechanically ventilated patients. JAMA, 286(21), 2703. doi:10.1001/jama.286.21.2703

8. Family Engagement and Empowerment (n.d.). http://www.icudelirium.org/family.html

9. Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology, 5(4), 210-220. doi:10.1038/nrneurol.2009.24

10. Girard, T. D., Jackson, J. C., Pandharipande, P. P., Pun, B. T., Thompson, J. L., Shintani, A. K., … Wesley Ely, E. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7), 1513-1520. doi:10.1097/ccm.0b013e3181e47be1

11. Gleason, O. (n.d.). Delirium - American Family Physician. http://www.aafp.org/afp/2003/0301/p1027.html

References

12. Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911-922. doi:10.1016/s0140-6736(13)60688-1

13. Leslie, D. L., & Inouye, S. K. (2011). The importance of delirium: Economic and societal costs. Journal of the American Geriatrics Society, 59, S241-S243. doi:10.1111/j.1532-5415.2011.03671.x

14. Managing delirium among elderly patients in the ED. (n.d.). Retrieved from http://www.physiciansweekly.com/managing-delirium-elderly-patients/

15. Pandharipande, P., Girard, T., Jackson, J., Morandi, A., Thompson, J., Pun, B., … Brummel, N. (2013). Long-term cognitive impairment after critical illness. New England Journal of Medicine, 369(3), 1306-1316. doi:10.1056/NEJMoa1301372

16. Rudolph, J. L., & Marcantonio, E. R. (2011). Postoperative delirium. Anesthesia & Analgesia, 112(5), 1202-1211. doi:10.1213/ane.0b013e3182147f6d

17. Sessler, C. N., Gosnell, M. S., Grap, M. J., Brophy, G. M., O'Neal, P. V., Keane, K. A., … Elswick, R. K. (2002). The Richmond agitation–sedation scale. American Journal of Respiratory and Critical Care Medicine, 166(10), 1338-1344. doi:10.1164/rccm.2107138

18. Schweickert WD, et al. Lancet. 2009;373:1874-1882.

19. Vasilevskis, E. E., Han, J. H., Hughes, C. G., & Ely, E. W. (2012). Epidemiology and risk factors for delirium across hospital settings. Best Practice & Research Clinical Anaesthesiology, 26(3), 277-287. doi:10.1016/j.bpa.2012.07.003.

20. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

21. Agarwal, V., O’Neill, P. J., Cotton, B. A., Pun, B. T., Haney, S., Thompson, J., … Pandharipande, P. (2010). Prevalence and risk factors for development of delirium in burn intensive care unit patients. Journal of Burn Care & Research: Official Publication of the American Burn Association, 31(5), 706–715. http://doi.org/10.1097/BCR.0b013e3181eebee9

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References

22. DeCrane, S. K., Sands, L., Ashland, M., Lim, E., Tsai, T. L., Paul, S., & Leung, J. M. (2011). Factors Associated with Recovery from Early Postoperative Delirium. Journal of Perianesthesia Nursing : Official Journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia Nurses, 26(4), 231–241. http://doi.org/10.1016/j.jopan.2011.03.001

23. Tomlinson, E. J., Phillips, N. M., Mohebbi, M., & Hutchinson, A. M. (2016). Risk factors for incident delirium in an acute general medical setting: a retrospective case-control study. Journal of Clinical Nursing, 26(5-6), 658-667. doi:10.1111/jocn.13529

24. Watkins, C. C., & Treisman, G. J. (2015). Cognitive impairment in patients with AIDS – prevalence and severity. HIV/AIDS (Auckland, N.Z.), 7, 35–47. http://doi.org/10.2147/HIV.S39665

25. Elsamadicy, A. A., Wang, T. Y., Back, A. G., Lydon, E., Reddy, G. B., Karikari, I. O., & Gottfried, O. N. (2017). Post-operative delirium is an independent predictor of 30-day hospital readmission after spine surgery in the elderly (≥65 years old): A study of 453 consecutive elderly spine surgery patients. Journal of Clinical Neuroscience, 41, 128-131. doi:10.1016/j.jocn.2017.02.040

26. Kalish, V. B., Gillham, J. E., & Unwin, B. K. (2014). Delirium in Older Persons: Evaluation and Management. American Family Physician, 1(90), 150-158. Retrieved from http://www.aafp.org/afp/2014/0801/p150.html#commenting

27. Hipp, D. M., & Ely, E. W. (2012). Pharmacological and Nonpharmacological Management of Delirium in Critically Ill Patients. Neurotherapeutics, 9(1), 158–175. http://doi.org/10.1007/s13311-011-0102-9

28. Freter, S., Dunbar, M., Koller, K., MacKnight, C., & Rockwood, K. (2015). Risk of Pre-and Post-Operative Delirium and the Delirium Elderly At Risk (DEAR) Tool in Hip Fracture Patients. Canadian Geriatrics Journal, 18(4), 212–216. http://doi.org.aurarialibrary.idm.oclc.org/10.5770/cgj.18.185

References

29. Kuczmarska, A., Ngo, L. H., Guess, J., O’Connor, M. A., Branford-White, L., Palihnich, K., … Marcantonio, E. R. (2015).Detection of Delirium in Hospitalized Older General Medicine Patients: A Comparison of the 3D-CAM and CAM-ICU. Journal of General Internal Medicine, 31(3), 297-303. doi:10.1007/s11606-015-3514-0

30. Han, J. H., Wilson, A., Vasilevskis, E. E., Shintani, A., Schnelle, J. F., Dittus, R. S., … Ely, E. W. (2013). Diagnosing Delirium in Older Emergency Department Patients: Validity and Reliability of the Delirium Triage Screen and the Brief Confusion Assessment Method. Annals of Emergency Medicine, 62(5), 457-465. doi:10.1016/j.annemergmed.2013.05.003

31. Sarutzki-Tucker, A., & Ferry, R. (2014). Beware of Delirium. The Journal for Nurse Practitioners, 10(8), 575-581. doi:10.1016/j.nurpra.2014.07.003

32. Scheffer, A. C., Van Munster, B. C., Schuurmans, M. J., & De Rooij, S. E. (2011). Assessing severity of delirium by the delirium observation screening scale. International Journal of Geriatric Psychiatry, 26(3), 284-291. doi:10.1002/gps.2526

33. Gaudreau, J., Gagnon, P., Harel, F., Tremblay, A., & Roy, M. (2005). Fast, Systematic, and Continuous Delirium Assessment in Hospitalized Patients: The Nursing Delirium Screening Scale. Journal of Pain and Symptom Management, 29(4), 368-375. doi:10.1016/j.jpainsymman.2004.07.009

34. Clegg, A. & Young, B. Which medications to avoid in people at risk for delirium: systematic review. Age and Aging, 2011. 40(1): p. 23-29.

35. Rosenbloom-Brunton, D., Henneman,E. and Inouye, S. (2010). Feasibility of family participation in delirium prevention program for the older hospitalized patient. Journal of Gerontological Nursing. 36(9). p. 22-25. 36. Mailhat, T., Cossette, S., Bourbonnds, A. et. al. (2014). Evaluation of a nurse mentoring intervention to family caregivers in the management of delirium after cardiac surgery (MENTOR _ D): a study protocol for a randomized controlled pilot trial. BioMedCentral. https://doi.org/10.1186/1745-6215-15-306.37. Halloway, S. (2014). A family approach to delirium: a review of literature. Age & Mental Health. 18(2).38. ICU Delirium for Patients and Families. www.icudelirium.org/family.html

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Appreciation!

Recognition!

Celebration!

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National/Regional Accomplishments

National

• 90,961 hospital readmissions avoided

• 388 communities

• 1.1 billion dollars cost avoided

Regional (Lake Superior QIN – MI, MN, WI)

• 15,500 hospital readmissions avoided

• 26 communities

• 199 million dollars cost avoided

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North East MNAccomplishments

Participation:

• 232 individual participants

• 78 different organizations

• Assisted Living Facilities

• Clinics

• Community organizations

• Government groups

• Health plans

• Health Systems

• Home Health Agencies

• Hospice programs

• Hospitals

• Nursing Homes

• Pharmacy Groups

• University

• Resource suppliers

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North East MNAccomplishments

Workgroups:

Started summer 2015

• Communication – Duluth area

• Exacerbation of Chronic Conditions (CHF/COPD)

– Virginia area

• Medications-related issues – Duluth area

• Resources/Patient Engagement – Duluth area

• Social Support – Virginia Area

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North East MN Accomplishments

What changes has your organization

made to improve care transitions,

care coordination or reduce

unnecessary hospital readmissions

in the past four years?

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Recognition

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Celebration!

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Contact Info

Janelle Shearer, Stratis Health

jshearer@stratishealth.org

952-853-8553 or 877-787-2847

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This material was prepared by the Lake Superior

Quality Innovation Network, under contract with the

Centers for Medicare & Medicaid Services (CMS), an

agency of the U.S. Department of Health and Human Services.

The materials do not necessarily reflect CMS policy.

11SOW-MN-C3-19-114 052319