enhancing the continuum of care - ministry of healthenhancing the continuum of care report of the...

Enhancing the Continuum of Care

Report of the Avoidable Hospitalization Advisory Panel

Submitted to the Ministry of Health and Long-Term careNovember 2011

Table of Contents

Executive Summary .................................................................................................. 6

Introduction ............................................................................................................. 81.1 TheExcellentCareforAllStrategy.................................................................................. 8

1.2 ProvincialFocusonAvoidableHospitalization............................................................... 8

1.3 TheRoleoftheAdvisoryPanel...................................................................................... 10

1.4 Methodology....................................................................................................................... 12

The Current State and Evidence for Intervention ......................................................142.1 TheCausesofUnplannedReadmissions........................................................................ 14

2.2 InterventionstoReduceUnplannedReadmissions...................................................... 15

The Context for Change in Ontario ...........................................................................22

Panel Recommendations ..........................................................................................24

Appendices ..............................................................................................................29Appendix1. SummaryReportfromtheMay31,2010LeadershipForum..................... 30

Appendix2. AvoidableHospitalizationAdvisoryPanelTermsofReference................ 38

Appendix3. SafeDischargePracticesChecklist.............................................................. 39

Appendix4. MeasuresandEvaluation.............................................................................. 48

Appendix5. References....................................................................................................... 50

Executive Summary

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Executive Summary

TheExcellentCareforAllStrategy(ECAS)aimstoimprovethequalityandvalueofthehealthcarereceivedbyOntarians.Improvingqualityofcareandsustainabilityofthehealthsystembyreducingavoidablehospitalizationsisakeyareaoffocusofthestrategy.SystemexpertsataMay31,2010AdvisoryForumonAvoidableHospitalizationsrecommendedinitialeffortstoreduceavoidablehospitalizationsfocusonsafe,effectivetransitionsincaretoreducereadmissionstohospital,whilebuildingthesystem’scapacitytoincreasetheareaoffocusinsubsequentyears.

TheMinistryofHealthandLong-TermCare(MOHLTC)establishedanAvoidableHospitalizationAdvisoryPaneltoprovideadviceandrecommendationsonappropriatemeasures,targetsandtimelines,validationofbestpracticeguidanceforOntarioandleadingcaretransitionpracticesinOntario.TheadviceandrecommendationsofthePanelwillinformprovincialinitiativestosupporthealthserviceprovidersinprovidingsafe,effectivetransitionsincaretoreduceavoidablereadmissionstohospital.

ReducingavoidablereadmissionsofpatientsdischargedfromhospitalisanimportantareaforimprovingthequalityandsafetyofhealthcareandmakingmoreeffectiveuseofhealthcareresourcesinOntario.

Evidenceindicatessuccessfulinterventionsusedtoimprovecaretransitionsandreduceavoidablerehospitalizationsincludeseveralcommonelements.Effectivecaretransitionsincorporatebetterplanningfordischarge,improvedcommunicationbetweencliniciansindifferentsettingsaswellasbetweencliniciansandpatients,medicationreconciliationandmanagementwhenthepatientreturnshome,patientandcaregivereducation,andtimelyprimarycarefollow-upinthecommunity.

Strategiestoimprovecaretransitionsmayrequireadditionalresourcestoreducethelikelihoodofrehospitalization,sohospitalsshouldscreenpatientswithtoolsliketheLACEIndex(detailedinChapter2.2)toidentifythoseathighriskofreadmissionandthentargettheireffortstothesepatients.

Improvementsincaretransitionwillrequireclinicalandstrategicpartnershipsacrossthehealthcaresystem.Collaborationacrossorganizationalboundariesisessentialforreducingpooroutcomes.

Areviewofcurrentpoliciesandsystemconstraintsonimprovedcollaboration,includingfundingformulae,shouldbelaunchedinparallelwithorganizationalandsysteminterventionstoimprovecaretransitions.

AvarietyofsmallscaledemonstrationprojectsareunderwayinOntariotoimprovecaretransitions.TheseeffortsneedtobefullyevaluatedtoassesstheirimpactandthentestedinothersettingsinOntariowithdifferingresourcesandpatternsofhealthcaredelivery.An“improvementcollaborative”projectthatrecruitscross-continuumteamsfromdifferentpartsoftheprovincecouldteststrategiesforimprovingcaretransitions.HealthQualityOntariocouldleadsuchaproject.

Effortstoimprovecaretransitionsneedtobeintegratedintothecurrentsystemwithoutaddingunnecessarycomplexityorintroducingduplication.Effectivescreeningofpatientsatriskofreadmission,targetingadditionalservicestothesepatientsandimprovingcommunicationsbetweenhospitals,homeandcommunityservicesandprimarycareproviderswillenablereductionsinreadmissions.ThePanel’svisionforanenhancedsystemseeshigherqualitycareforOntariopatientsanddoesnotnecessarilyimplyincreasedcostsforthesystemasaresultoftheseimprovements.

Introduction

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Introduction

1.1 The Excellent Care for All Strategy HighqualityhealthcareisimportanttoeveryOntarian.Assuch,thegovernmenthastakenimportantstepstoimprovethequalityofOntario’shealthcaresystemandmakesureeveryhealthcaredollarisusedtoprovidethebestpossiblecare.

TheExcellent Care for All Act(ECFAA),whichreceivedRoyalAssentonJune8,2010,strengthenstheorganizationalfocusonqualityanditscontinuousimprovementandputspatientsfirstbyimprovingthequalityandvalueofthepatientexperiencethroughtheapplicationofevidence-basedhealthcare.TheActsetsoutanumberofrequirementsfromhealthcareorganizations,includingthedevelopmentofQualityCommitteesandannualqualityimprovementplans.ThesechangeswilloccurfirstinOntariohospitalsandthenspreadtoallhealthcareorganizationsthroughouttheprovince.

ECFAAalsoestablishedHQOastheagencyresponsibleforpromotinganddisseminatingevidence-basedrecommendations,supportinghealthcareprovidersinqualityimprovementandadoptionofbestpractices,andreportingtothepubliconthequalityofhealthcareinOntario.

Ontario’sECASisdesignedtoimprovethequalityandvalueofthehealthcarereceivedbyOntarians.Thestrategyisbasedonfourguidingprinciples:caremustbecentredaroundthepatienttosupporthisorherhealth;continuousqualityimprovementisacriticalgoal;policy,planningandpaymentmustsupportboththequalityofhealthcareandtheefficientuseofresources;andqualitycaremustbeinformedandsupportedbytheverybestevidenceandstandardsofcare.

1.2 Provincial Focus on Avoidable HospitalizationAspartofECAS,theMOHLTCispursuingprovincialinitiativestocontributetosystemsustainabilitybyimprovingqualityofcare,addressinggapsbetweenevidenceandpracticeandsupportingevidence-basedcare.ReducingavoidablehospitalizationshasbeenidentifiedasanareaofprovincialpriorityintheECAS,whereimprovementsinqualityofcareforOntariansarealsoexpectedtocontributetothesustainabilityofthehealthcaresystem.

TheMOHLTCheldaLeadershipForumofclinicalandhealthsystemexpertsonMay31,2010todiscussthedriversandpatternsofhospitalizationsintheprovinceandtoidentifyareasofopportunityforfurtherwork,areaswheresupportforevidence-basedcarewouldimprovequalityofcare,patientoutcomesandreducesystemcosts.Theforumfocusedonopportunitiesinthreekeyareas:reducingavoidableprimaryhospitalizations,reducingavoidablehospitaldays,andreducingreadmissionstohospital,asoutlinedinfigure1onpage9.

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Figure 1

Reducing Avoidable Hospitalizations

Fewerpreventableadverseevents

Moreeffectivecaretransitions

Betterchronicdiseasepreventionandmanagement

Hospitalstays(admissions,readmissionsandhospitaldays)thatcouldbeavoidedthroughenhancedsafetypracticesinhospitalorcommunity.

Potentialoutcomemeasures:Expected/actuallengthofstay(LOS),Readmission(72hours),NosocomialInfection,Falls,PressureUlcers,MedicationErrors,CriticalIncidents.

Admissionsandreadmissionsthatcouldbeavoidedthroughenhancedhospitaldischargepracticesandmoreeffectivecaretransitions.

Potentialoutcomemeasures:Readmission(7,30,90days);multiplepsychiatricreadmissions.

Admissionsandreadmissionsthatcouldbepreventedthroughmoreeffectivechronicdiseasemanagementandpatientself-management.

Potentialoutcomemeasures:AmbulatoryCareSensitiveConditions(ACSC)hospitalization.

SettingsforIntervention

•Hospital•Long-TermCareHomes•Community(CCAC/CSS)

•Hospital•Community(CCAC/CSS,

Pharmacy)•PrimaryCare•Long-TermCareHomes•MentalHealthandAddictions

•PrimaryCare•PublicHealth

AlignedStrategies

•MostResponsiblePhysicianCollaborativeFunding

•PatientSafetyReporting•ResidentsFirst

•ER/ALCStrategies•IntegratedClientCare•MentalHealthandAddictions•MedicationReconciliation/

MedsCheck

•ChronicDiseasePreventionandManagement

•DiabetesStrategy•FamilyHealthCareforAll

TherewasstrongalignmentandconsensusattheLeadershipForuminanumberofareas,including:• AvoidableHospitalizationsisanimportantissuetofocuson,butcoversaverybroadscope.• Givensubstantialworkandfocusacrosstheprovincealreadyunderwayonreducingadverseeventsand

improvingpatientsafetywithinhospitals,safeandeffectivedischargeandtransitiontothenextcarelocationtoreduceavoidablereadmissiontohospitalwouldbeanappropriateinitialareaforprovincialfocus.Thebroadercontextofeffectivechronicdiseasepreventionandmanagementinprimarycaretoreduceavoidablehospitalizationscouldbeconsideredamediumtermareaoffocus.

• Focusoftheseeffortsshouldbeontargetpopulations,notspecificconditions/diseasesinisolation.• Keypopulationsofinterestidentified:firstandforemostthefrailelderlypopulation,thenthosewith

multipleco-morbidities,clientswithmentalhealthissuesandcomplexchildren.• Specifictargetsshouldbevalidatedthroughadditionalexpertpaneldiscussion.

OneoftheoutcomesoftheforumwasarecommendationtoestablishanadvisorypaneltoprovideguidancetotheprovinceoninitiativesfocusedonreducingreadmissionsandavoidablehospitalizationsaspartoftheECAS.

MaterialsrelatedtotheForumareincludedasAppendix1.

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1.3 The Role of the Advisory Panel TheMOHLTCestablishedtheAvoidableHospitalizationAdvisoryPanel(“thePanel”)inSeptember2010,withamandateto:

• provideadviceonthemostappropriatemeasures,targetsandtimelinesforinitiativesfocusedonreducingreadmissions/avoidablehospitalizationsaspartoftheECAS;

• provideadviceonevidence-basedpracticesthatensureefficient,effective,safeandpatient-centredcaretransitions;

• provideadviceonstrategiesforidentificationandselectionofleadingcaretransitionpracticesinOntariotobecompiledinaninventoryor“LivingLab”ofinnovativemodelsofcarethatreducereadmissions/avoidablehospitalizations;

• provideadviceonlocalevidencecriteriaforleadingpracticesinOntario;• provideadviceonthescalabilityandspreadofleadingpracticesinOntario;• monitortheoutcomesofcaretransitionsinitiatives,andassesstheirimpactsonhospitalreadmission;and• identifypolicyorsystemicbarriersandenablerstosafe,effectiveandpatient-centredcaretransitions,

includingfundingpolicy,andfundingincentivesordisincentives.

TheAdvisoryPanelTermsofReferenceareincludedasAppendix2.

ThePanelwaschairedbyDr.G.RossBaker,ProfessorofHealthPolicy,ManagementandEvaluationattheUniversityofToronto.Itincludedmembershipfrommultipledisciplinesandacrossseveralhealthcaresectors,includingprimarycarephysicians,hospitalists,nursepractitioners,researchers,pharmacists,academics,andLHINandhospitaladministrators,toensurethatmanyproviderandstakeholderperspectiveswererepresentedinthePanel’sdiscussions,deliberationsandconsiderations.

Members of the Advisory PanelAdvisory Panel Chair Dr. G. Ross Baker, ProfessorHealthPolicy,ManagementandEvaluation(HPME),UniversityofToronto

Dr. Howard B. AbramsDivisionHead,GeneralInternalMedicine,UniversityHealthNetworkandMountSinaiHospitalExecutiveDirector,CentreforInnovationinComplexCare

Dr. Chaim BellChairinPatientSafetyandContinuityofCare,CIHR/CPSI;PhysicianandScientist,St.Michael’sHospitalandKeenanResearchCentre;AdjunctScientist,ICES

Paula Blackstien-HirschSeniorDirector,Ontario,CanadianPatientSafetyInstitute

Dr. Glenn BrownHead,DepartmentofFamilyMedicine,Queen’sUniversity

Patti A. CochraneVicePresident,PatientServices&QualityandChiefNursingOfficer,TrilliumHealthCentre

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Dr. Fionnella CrombieChiefofFamilyMedicine,St.Joseph’sHealthcare,Hamilton

Stacey DaubCEO,TorontoCentralCommunityCareAccessCentre

Dr. Irfan DhallaStaffPhysicianandScientist,LiKaShingKnowledgeInstitute,St.Michael’sHospital;AssistantProfessor,MedicineandHPME,UniversityofToronto;AdjunctScientist,ICES

Dr. Alan ForsterCo-Director,OttawaHospitalCentreforPatientSafety;AssociateProfessorofMedicine,UniversityofOttawa;ScientistintheClinicalEpidemiologyProgram,OttawaHospitalResearchInstitute

Lori FramptonSeniorQualityImprovementConsultant,HealthQualityOntario

Dr. Joseph LeeChairandLeadPhysician,CentreforFamilyMedicineFHT(WaterlooRegion)

Bill MacLeodCEO,MississaugaHaltonLHIN

Cynthia MajewskiExecutiveDirector,QualityHealthcareNetwork

David MurrayCEOandPresident,SiouxLookoutMenoYaWinHealthCentre

Emily Lap Sum MusingExecutiveDirectorofPharmacy,ClinicalRiskandQualityandPatientSafetyOfficerfortheUniversityHealthNetwork

Dr. Peter NordVPMedicalAffairsandChiefofStaff,ProvidenceHealthcare

Dr. Tia PhamVirtualWardPhysicianLead,SouthEastTorontoFamilyHealthTeam

Dr. Walter WodchisAssociateProfessor,HPME,UniversityofToronto;Co-LeadHealthSystemPerformanceResearchNetwork;AdjunctScientist,InstituteforClinicalEvaluativeSciences(ICES)

Dr. Vandad YousefiChiefandMedicalDirectorforQuality,SafetyandPatientExperience,LakeridgeHealth

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Inaddition,thefollowingindividualsfromMOHLTCparticipatedasmembersofthePanel,andsupportedthePanelincarryingoutitsmandate:

• FredrikaScarth,Manager,HealthQualityBranch;Lead,EvidenceBasedCareStream,ExcellentCareforAllStrategy

• StenArdal,Director,HealthAnalyticsBranch• JillianPaul,Manager,HealthQualityBranch;Lead,PerformanceandResults,

ExcellentCareforAllStrategy• RoyWyman,MedicalConsultant,ImplementationBranch

1.4 MethodologyTocompleteitstasks,thePanelcommissionedliteratureandjurisdictionalreviewsoninterventionstoreducereadmissiontohospital.ThePanelalsoreviewedadministrativedataonreadmissionsandresearchliteratureonreadmissioninitiativesandmeasures.

ThePanelestablishedthreeworkinggroupstodeveloprecommendationsandguidanceonspecifictopics:

1. Reviewingandrecommendingmeasuresandtargetstomonitorreductionsinreadmissions2. Identifyingpotentialclinicalandorganizationalbestpracticeguidancetoreducereadmissions3. CreatinganinventoryofleadingpracticesinOntario,andtools/approachestosupportpeerlearningby

healthserviceproviders

ThereportandrecommendationsbelowreflecttheoutcomesoftheworkinggroupsandthedeliberationsofthePanelmembers.

The Current State and Evidence for Intervention

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The Current State and Evidence for Intervention

Avoidablehospitalizationsincludehospitalizationswhichcouldhavebeenpreventedwithcomprehensiveprimarycarefocusedonchronicdiseasemanagementandprevention(forpatientswithwhataresometimesreferredtoasambulatory-caresensitiveconditions);hospitaldaysduetopreventableadverseeventsinhospital;andreadmissionstohospital,whichcouldhavebeenavoidedifthecareinhospitalorthecareafterdischargewasoptimized.Severalcontributingfactorsleadtoahighnumberofavoidablehospitalizations,rehospitalizationsandadditionalhospitaldays.Avoidingpreventablehospitalizationsrepresentsbetterqualityofcareforpatientsaswellasbettervalueandsustainabilityforthesystem.Whilerecognizingtheimportanceofallthreecontributingcausestoreadmissions,thePanelfocusedonstrategiestoreducereadmissionsfollowingtransferfromhospitaltocommunitysettings.

2.1 The Causes of Unplanned ReadmissionsHospitalreadmissionscanbeseenasasignalofsystemfailure:theyoftenoccurbecauseofgapsincareandcommunicationsaspatientstransitionfromthehospitalsettingtothenextsettingofcare(home,communitycare,long-termcarehome,etc.),andreflectthecomplexitiesofthetransitionsinahealthcaresysteminwhichcareisdeliveredbymultiplehealthserviceproviderswithdifferentaccountabilities.

Unplanned30-dayreadmissionsaccountedforanestimated$705millioninOntariohospitalcostsin2008/09,andmanyofthesehospitalizationsmayhavebeenavoidable.Ontario’s30-dayreadmissionrateof15percentishighincomparisontosomeleadinghealthsystems.Evenmoretelling,significantvariationacrossthe14LHINs,rangingfrom13percentto18percent,exists,whichsuggeststhatthereisroomforimprovementinOntario.

Analysisofprovincialadministrativedatademonstratesthatreadmissionsaremostcommonamongtheelderlywithcomplexconditions,andthattherearesomespecificconditionsordiagnosesforwhichratesofreadmissionareconsistentlyhigheracrosstheprovince.ThesediagnosesincludeChronicObstructivePulmonaryDisease(COPD)andCongestiveHeartFailure(CHF).However,nooneconditionordiagnosticcategorymakesupamajorityofreadmissions,andreadmissionsoftenoccurforreasonsunrelatedtotheoriginaladmission,andtohospitalsthatarenottheoriginatinghospital,suggestingthatmoregeneralpopulation-focusedstrategies,aswellasdisease-focusedstrategies,maybenecessarytoaddresstheproblem.

Exactlywhatproportionofcurrentreadmissionstohospitalmaybeavoidableisdifficulttodetermine.Itisunderstoodandexpectedthatsomereadmissionswillalwaysoccurforclinicallycomplexpatients,andasaresultnotallreadmissionstohospitalcanbeconsideredavoidable.Arecentreviewof34studiesthatmeasuredtheproportionofreadmissionsconsideredtobeavoidablefoundthatthemedianproportionofreadmissionsdeemedavoidablewas27.1percentbutvariedfrom5percentto79percent(Walravenetal.,2011).

Researchersassessingavoidablereadmissionsoftenrestrictthemselvestoexaminingclinicalcauses,whichmayresultinanarrowfocusonthecausesofpreventablereadmissions.Arandomizedclinicaltrialhasshownthatreadmissionstohospitaloccursnotjustforclinicalreasons,butcanalsooccurforsocioeconomicandadministrativereasons(Nayloretal.1999).2007datafromtheUnitedStatessuggest

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that76percentof30-dayreadmissionswerepotentiallypreventable(MedPAC2007).Hospitalreadmissionsareoftentheresultofdeficienciesincoordinationandcommunicationwithinthehealthcaresystem,suchasfailuretoensurethatapatienthasafollow-upvisitscheduledwithhisorherprimarycarephysicianatthetimeofdischarge(Goldfield,2011).Theentirehealthcareteam,withcooperationfromcommunity-basedcareproviders,needstoworktogethertoreducereadmissionsresultingfromnon-clinicalcauses.Avoidablereadmissionsarenotlinkedsolelytohospitalactivity,whichmeansthereisagreatneedtoensureeffectivecommunicationandcoordinationtosupportsafe,effectivetransitionsacrossallsectorsofthecarecontinuum.

2.2 Interventions to Reduce Unplanned ReadmissionsThereisgrowing,butstillonlylimited,evidenceontheeffectivenessofinterventionsaimedatreducingavoidablehospitalizations.Interventionsmaybefocusedatdifferentstagesalongthepatientjourney,frompreventivemanagementofpeopleathighriskofadmission,servicesthatmanageacuteillness(orexacerbationsofchronicillness)withoutresortingtohospitaladmission,throughtointerventionstoimprovepatientdischargeandtransitionfromhospital(Purdy,2010).

Intermsofpreventingunplannedreadmissionsinparticular,thereissomeevidencethattherateofreadmissionscanbereducedbyattentiontosomekeybestpracticesduringhospitaldischargeandtransitiontothenextsettingofcare.MuchoftheevidencethatexistsondischargeandtransitioninterventionshasbeenincorporatedintoguidancedevelopedbytheCommonwealthFundinpartnershipwiththeInstituteforHealthcareImprovement(Nielsen,2009).TheIHI’sguidanceisgroupedinfourcategories:

I.EnhancedAdmissionAssessmentforPost-HospitalNeeds; II.EnhancedTeachingandLearning;III.PatientandFamily-CenteredHandoffCommunication;IV.Post-HospitalCareFollow-up.

TheIHIGuidancedocumentsareavailableathttp://www.ihi.org

Severalinterventionsinotherjurisdictionshaveshownpromisingresultsinreducingunplannedreadmissions.Severalofthemostpromisingaresummarizedbelow:

TheTransitional CareinterventionwasdevelopedtotargetpatientswhoarehospitalizedforCongestiveHeartFailure(CHF)anduseshighlytrainedadvancedpracticenurses(APN)toadministertheintervention.TheAPNsmetwithpatientsinthehospitalandintheirhomeshortlyafterdischargetoprovideintensecoachingandeducationonmedications,self-care,andsymptomidentification.Duringtheyearfollowingthehospitaldischarge,thenumberofhospitalreadmissionsperpatientyearinthetreatmentgroupwas34percentlowerthaninthecontrolgroup(Nayloretal.,2004).Inaddition,hospitalreadmissionratesinthetreatmentgroupwere44.9percentcomparedto55.4percentinthecontrolgroup,adecreaseof10.5percentagepoints.Atoneyear,treatmentgrouppatientsalsohadmeantotalcosts39percentlowerthanthecontrolgrouppatients(Nayloretal.,2004).TheTransitionalCareinitiativehasnowbeenexpandedtofocusmorebroadlyonallpatientsatriskofreadmission.

TheCare Transitions Interventionisafour-weekinterventionthatfocusesonimprovingcaretransitionsbyfosteringimprovedself-managementskillsforcommunity-dwellingpatientsage65andolder.Thefourmaincomponentsoftheinterventionaremedicationself-management;apatient-centredhealthrecord(PHR);

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follow-upwithaphysician;andknowledgeofthewarningsigns/symptomsandhowtorespond(Colemanetal.2006).ATransitionCoach(nurse)conductsahomevisitwithin72hoursofdischargeandspeakswiththepatientbyphoneonpost-dischargedays2,7,and14.TheCoachpreparesthepatientforupcomingencounterswithhealthcareprovidersandhelpsthepatienttoreconcileoridentifydiscrepanciesinmedicationsandservesasasinglepointofcontact.AnevaluationofpatientsadmittedwithoneoftenconditionswasconductedbyDr.EricColemanandcolleagues.PatientswhoparticipatedintheCareTransitionsProgramweresignificantlylesslikelytoberehospitalizedthancontrolsat30,90and180daysafterdischarge.ThetimetohospitalreadmissionwassignificantlylongerfortheCareTransitionsProgramgroupthanthecontrols(225.5daysvs.217.0days).Ithasbeenestimatedthatthecostsavingsassociatedwiththeinterventionfor350patientswouldbeUS$296,000over12months(Colemanetal.2006).

Project Re-Engineered Discharge(RED)isaprocessforimproveddischargecoordination.Theprojectislocatedatanurbanhospitalthatservesalow-income,ethnicallydiversepopulation.TheinterventionincludesanumberofcomponentswhicharefacilitatedbyaspeciallytrainednursecalledaDischargeAdvocatewhodoesthefollowing:educatespatientsaboutdiagnosisthroughoutthehospitalstay;makesappointmentsforclinicianfollow-up,testresultfollow-upandpost-dischargetesting;organizespost-dischargeservices;confirmsthemedicationplan;reconcilesthedischargeplanwiththenationalguidelinesandclinicalpathways;givesthepatientawrittendischargeplan,assessesthepatient’sunderstandingoftheplan;reviewswhattodoifaproblemarises;expeditestransmissionofthedischargesummarytooutpatientproviders;andcallstoreinforcethedischargeplanandofferproblemsolving2-3daysafterdischarge.Theinterventionsignificantlyreducedhospitalutilization(Jacketal.2009ascitedinBoutwelletal.2009).

MassachusettsGeneralHospitalandtheUniversityofCalifornia,SanFrancisco,developedanurse-guided, patient-centred approachthatcombinesongoingpeersupportfromatrainedelderwithhomevisitsandfollow-upphonecallsfromanadvancedpracticenurseforun-partneredelderlypatientswhoaredischargedfromhospitalafteraheartattackorbypasssurgery.Theprogramisintendedtoencouragecompliancewithmedicationregimensandrecommendedlifestylechanges,withthegoalofreducinghospitaladmissions.A24/7patientrandomizedcontrolledtrialfoundthattheprogramimprovedadherencetomedicalrecommendationsandreducedhospitalizationsduetocardiac-relatedcomplications,butfailedtoreduceoverallhospitalreadmissions(Carrolletal.2007ascitedinAHRQ2008a).

Apost-discharge,interdisciplinarycaremanagementprogramintegratesmedicalandsocialcareforlow-incomeelderlypatientswithchronicillnesses.Theprograminvolvesthedevelopmentandreviewofacareplan,homevisits,andpatienteducation.Abefore-and-afterpilotstudyconductedatSummaCareinAkron,Ohio,foundthattheprogramachievedsavingsofapproximately$600to$1,000perpatientpermonthasaresultoffewerhospitalizations(Wrightetal.2007ascitedinAHRQ2008b).

TheTransition Home for Patients with Heart Failure programatSt.Luke’sHospitalinCedarRapids,Iowa,incorporatesanumberofcomponentstoensureapatient’ssafetransitiontohomeoranotherhealthcaresetting.Thesecomponentsincludeenhancedassessmentofpost-dischargeneedsatadmission,thoroughpatientandcaregivereducation,patient-centredcommunicationwithsubsequentcaregiversathandoffs,andastandardizedprocessforpost-acutecarefollow-up.Abefore-and-aftercomparisonfoundthattheprogramreducedthe30-dayreadmissionrateforheartfailurepatientsfrom14percentto6percent(TheInstituteforHealthcareImprovementandtheRobertWoodJohnsonFoundationascitedinAHRQ2009c).

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TheHome Healthcare Telemedicine programservespatientsrecentlydischargedwithcongestiveheartfailureorCOPD.Theinterventionreliesontwokeyelements:nursesspecializinginprovidingtelehealthcare;andtelemonitoringtechnologies.Atprograminitiation,ahomehealthnurseconductstwoin-homevisitsduringthepatient’sfirstweekathome.Atechnicianinstallsthenecessaryhardwareforthetelehealthsystem.Subsequently,atelemedicinenurseprovidesanintroductoryvideoencounterduringfirstweekafterdischargeandvisitsthepatientremotelyviavideofeedonetothreetimesperweek.Thetraditionalhomehealthnursevisitsthetelehealthpatientonceaweek.Measurementsaretransmittedtothetelehealthnurse.DataisfeddirectlyintotheITsystem;abnormalparameterstriggeranalerttothenurse,whocanreinitiatehomecareinanefforttopreventhospitalization.Outcomesindicatethatthere-hospitalizationrateforpatientswithcongestiveheartfailuredecreasedfrom6percentbeforetheprogramtoabout1percentafterprograminitiation.Thecostofthetelemedicineunits(approximately$5,500)islessthanonehospitaladmission,demonstratingthereturnoninvestmentfortheorganization(Boutwelletal.2009).

Transforming Care at the Bedside(TCAB)wasanationalprogramoftheRobertWoodJohnsonFoundation(RWJF)andIHI.OneofthemostpromisingchangesdevelopedwithinTCABis“creatinganidealtransitionhome”forpatientsdischargedfrommedicalandsurgicalunitswithinhospitals.Theinitialfocusoftheinterventionwasimprovingtransitionshomeforpatientswithcongestiveheartfailure.Thefourcoreelementsoftheinterventionare:enhancedadmissionassessmentforpost-dischargeneeds;enhancedteachingandlearning;patientandfamily-centredhandoffcommunication;andearlypost-acutecarefollow-up.StaffatSt.Luke’sHospitalinCedarRapids,Iowa,documenteda50percentreductioninrehospitalizations,fromanaverageof14percenttoacurrentaverageof7percent(Neilsonetal.2008ascitedinBoutwelletal.2009).

Senior Clinician Review in the Emergency Department:TheKing’sFundreportsthatwhenpatientsinemergencydepartmentsarereviewedbyaseniorclinician,inpatientadmissionscanbereducedbyover10percentandadmissionstotheacutemedicalassessmentunitbyover20percent(Ham,2010).

Continuity of Care with a Family Doctor:TheKing’sFundreportsthatpatientswhohavehighcontinuityofcarewiththeirfamilydoctorarelesslikelytobereadmittedtohospitalforambulatorycaresensitiveconditions(asthma,angina,CHF,hypertension,epilepsy,diabetes,COPDandpneumonia)(Ham,2010).

Hospital at Home:TheKing’sFundreportsthatwhenspecialservicesdevelopedtoprovidepatientswithhospitalcareintheirhomesareexecuted,theycandeliversimilaroutcomestoadmissionatequivalentorlowercost(Ham,2010).

Assertive Case Management for People with Mental Health Problems:TheKing’sFundreportsthatwhenassertiveandintensivecasemanagementisperformedbyamultidisciplinaryteamforpeoplewithmentalhealthproblems,reductionsinthelikelihoodoftheiradmissiontohospitalisachievable(Ham,2010).

Structured Discharge Planning:TheKing’sFundreportsthatwhenastructureddischargeplan,tailoredtotheindividualpatient,isdeveloped,areductioninlengthofstayandreadmissionrates,alongwithanincreaseinpatientsatisfaction,isachievable(Ham,2010).

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Strongevidencealsosuggeststhatmanyinterventions,whichmightbeexpectedtoavoidhospitalreadmissions,donotaffectreadmissionoutcomes(Ham,2010).Theseinclude:

• intermediatecareandrehabilitationprograms• casemanagementoffrailelderlypeople(asmayidentifyadditionalat-riskindividuals)• telephonefollow-upafterdischarge

ThesestudiesweredoneinanumberofsettingsintheUSandUK.Thereareseveralcommonelementsintheinterventionstargetedtoimprovingcaretransitionsandreducingtheincidenceofrehospitalizationsamongthetargetedpopulations.Theseelementsincludebetterplanningfordischarge,improvedcommunicationbetweencliniciansindifferentsettingsaswellasbetweencliniciansandpatients,medicationreconciliationandmanagementafterthepatientreturnshome,patientandcaregivereducationandtimelyprimarycarefollow-upinthecommunity.

Arecentreviewofcaretransitioninterventions,includingstudiesofindividualinterventionstoimprovetransitionssuchasimproveddischargeplanning(Hansen,etal.,2011),foundlimitedevidencefortheeffectivenessoftheseinterventions.However,anumberofstudiesthathaveimplementeda“bundle”ofinterventions(suchasuseofanadvancedpracticenursevisitingpatientsbeforehospitaldischargeandafterreturnhome,alongwithmedicationreconciliationandappropriateambulatoryfollow-up)haveachievedsignificantresults.Thisreviewsuggeststheneedtodevelopcaretransitionsstrategiesthatincludemultiplecomponents,totestandrefinethesestrategiesinthefield(ratherthanjustadoptingpracticesusedelsewhere)andtocarefullyevaluatetheirimpacttoassesstheireffectivenessandefficiency.

SomepromisingpracticesandinterventionsdevelopedinothersettingstoreducereadmissionshavebeenidentifiedandarebeingpilotedinOntario.Keyamongtheseare:

1. The Virtual WardisaninnovativepartnershipbetweenSt.Michael’sHospital,TorontoCentralCommunityCareAccessCentre(CCAC),Women’sCollegeHospital,theUniversityHealthNetworkandSunnybrookHospital.Inthisprogrampatientsdeemedtobehighriskforhospitalreadmission(accordingtoariskassessment,theLACEIndex–describedbelow)are“admitted”totheVirtualWardonthedayofhospitaldischarge.TheyreceivecareathomefromaninterdisciplinaryteamthatprovidesCCACcasemanagementandhospitalistmedicalsupport,integratingpost-acute,primaryandhomecare.TheVirtualWardteamsharesacommonsetofnotes,meetsdaily,has24/7physicianavailability,andhasitsownCCACwardclerkwhocantakemessagesandcoordinateactivity.

ResultsinotherjurisdictionssuggestthattheVirtualWardiscapableofreducing30-dayand90-dayreadmissionratesby33percentto50percent.WhetherVirtualWardscanrealizecostsavingsdependonseveralfactorsincludingthenumberofpatientsserved,theriskprofileofthepatientpopulation,theproportionofreadmissionsthatcanbeprevented,andtheincrementalcostofprovidingcarethroughtheVirtualWard.PreliminaryestimatessuggestthatapproximatelyonethirdofreadmissionsmustbeavertedforaVirtualWardtobecost-saving.TheVirtualWardhasalsobeensuccessfulindemonstratinginter-organizationalandsectorintegrationatthepointofcare.

AsecondVirtualWarddemonstrationprojectisalsounderwayforpatientsfromtheTorontoEastGeneralHospitalandtheSouthEastTorontoFamilyHealthTeam.

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2. Improving Quality and Safety in Care TransitionsisapilotprojectadaptingEricColeman’sCareTransitionsIntervention.ItfocusesontheroleofaCareTransitionCoachwhovisitsat-riskpatientspriortohospitaldischargeandagainfollowingtheirreturnhome.TheCareTransitionsCoachisanursepractitionerwhoprovidespatienteducation,ensuresthatfollow-upappointmentsaremadeandreconcilesthepatient’smedicationsathome.Theprogramaimstoenhancepatientoutcomes,reduceadverseeventsand,particularly,toreducereadmissions.Thetargetpopulationincludespatientswithcomplexmedicalconditionsadmittedtothegeneralmedicalwardintwositesofateachinghospital.Thesepatientsarelikelytorequirehomehealthservicesandarehighriskforreadmissions.

Inadditiontoassessingtheimpactoftheintervention,thestudyisexaminingtheimpactofpolicyandhealthsystemcontextonthesuccessoftheinterventionandhowtheinterventionneedstobeadaptedtofitlocalservicedeliverypatterns.WorkingintwositesinsouthwesternOntarioaCCACnursepractitionervisitspatientsbeforeandafteracutedischargetocompleteacareplanandcarryoutmedicationreconciliationinthepatient’shome.Thenursepractitionerwasabletoaccessthehospitaldatabase,includingalistofconditionsandmedicationstoenablemedicationreconciliation,educationandmanagementinthehome.

Medicationreconciliationuncovereddiscrepanciesformanypatients.Infollow-uptelephoneinterviews,clientsindicatedalackofunderstandingofmedicationsideeffects,warningsign/symptomsandwhattowatchfor.Earlydataonfollow-upappointmentswithprimarycarephysiciansalsoindicatedifficultiesinarrangingfollow-upcare.Theinterventionandevaluationarecontinuingwithatargetinterventionpopulationof150clientsbytheendof2011.

3. TheLACE Indexisaneasy-to-usetooldesignedtopredicttheriskofdeathorunplannedreadmissionofcognitivelyintactmedicalorsurgicalpatientsafterdischargefromthehospitaltothecommunity.TheLACEtoolhasbeenpilotedinseveralsettings,includingTrilliumHealthCentre,andascoreof10ormore(outof18)isusedtodeterminepatienteligibilityfortheVirtualWardandImprovingQualityandSafetyinCareTransitionsprojects.TheLACEIndexiscomposedoffourelements:lengthofstay(L),acuityofadmission(A),patientcomorbidity(C)andnumberofvisitstotheemergencyroom(E).Unlikesomeotherriskassessmenttools,theLACEIndexiseasysincemostofthedataarereadilyaccessibletocliniciansthroughpatientrecordsorfrominterviewingpatients.

TocomputetheLACEIndex,theChargeNurse(orTeamLead)reviewsthepatient’schartandcompletestheLACEIndexScoreCardgivingpatientsascoreforeachofthefourfactors.Dependingonthepatient’sLACEscore,enhancedservicesfocusedonimprovingtransitionsofcare,includingpost-acutecaresupport,arearrangedaccordingly.PatientswhoachieveaLACEof10ormorehavea30-dayriskofreadmissionof19.1percentanda90-dayriskofreadmissionof31.7percent.

4. TheUniversity of Ottawa Heart Institute’s Telehealth programisahometelehealthmonitoringprogramthatcutshospitalreadmission.Bysupervisingpatientsthroughdailyremotecontact,qualityoflifeandqualityofcareisimproved,patientsareabletostayhomeandparticipateintheirowncareandhealthdollarsaresaved.

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Patientsarecloselyfollowedforuptothreemonthsaftertheyaredischargedusingaportablehomemonitoringsystem.Patientsaretaughttomeasureandreporttheirownvitalsignsdaily.ThedataistransmittedviatelephonetotheCentralMonitoringStationattheHeartInstitute.Ifanyinformationisquestionableorifapatientasksforhelp,anursewillcallbackimmediately(thestaffingratioofnursetopatientis1to30-40).

Anevaluationoftheprogramhasidentifiedthat30-dayhospitalreadmissionratesforheartfailurepatientshavebeenreducedby54percentto14.8percentinthesix-monthperiodafterthepatientsweretrackedviatelehealthmonitoring.Savingsupto$20,000havebeendemonstratedforeachpatientsafelydivertedfromanemergencydepartmentvisit,readmissionandhospitalstay.

The Context for Change in Ontario

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The Context for Change in Ontario

Currentdatasuggestthatthereareopportunitiestostrengthenaprovincialfocusonreadmissionsreductionsbyaligningthedisseminationofbestpracticeguidancewithattentiontoothersignificantchangelevers,includingfundingincentivesandhealthserviceproviderandlocalhealthintegrationnetwork(LHIN)accountabilities.

Ontario’scurrentfundingstructuresdonotprovidehospitalswithstrongincentivestoinvestinimprovedcaretransitionprocessestoreducepatientreadmissions;onceapatientisdischarged,thehospitalisnolongeraccountablefortheircare.

APatient-basedPaymentImplementationAdvisoryCommitteewasestablishedbytheMOHLTCtoofferadviceonthedevelopmentofapolicyframeworktoguidethedesignofthenewfundingsystemandsupportingmethodology.TheCommitteerecommendedareadmissionfundingpolicybeimplementedinparallelwithotherprovincialinitiativestoreducereadmissions,suchasqualityimprovementsupports,communicationofbestpractices,andadoptionofpatientriskidentificationtools.

Afundingpolicytiedtohospitalreadmissionratescouldcreateincentivestoextendahospital’sepisodeofcareintothecommunityafterdischarge,creatingabusinesscasetopromoteadoptionofeffective,evidence-basedpracticestoreducereadmissions.TheMOHLTCtracks30-dayreadmissionindicatorsandtargetsforasetof25CaseMixGroups(CMG)andhighvolumeCMGsintheMinistry-LHINPerformanceAgreement(MLPA).

AnotherkeyleverforchangeistheQualityImprovementPlans(QIP)mandatedbytheECFAA.TheECFAArequiresthateveryyear,healthcareorganizations(beginningwithhospitals)developaQIPforthefollowingfiscalyearandmakethatplanavailabletothepublic.Theseplansareanopportunitytohighlightanorganization’scommitmentto:

• deliveringhighqualityhealthcare;• creatingapositivepatientexperience;• ensuringthatitisresponsiveandaccountabletothepublic;• holdingitsexecutiveteamaccountableforitsachievement;and• beingtransparent.

In2010/11,the30-dayreadmissionratewasidentifiedasanindicatorofinterestinthehospitalQIPs.

Additionally,theMOHLTCsetstargetswitheachindividualLHINfor30-dayreadmissionratesaspartoftheMLPA.Targetsaremeanttobeachievablebutalsotocreateconfidencewithinthesystembydemonstratingprogressintheperformanceoftheseindicators.Fiscal2010/11wasthefirstyearthismeasurewasincludedintheMLPA.Targetsrepresentrisk-adjustedprovincialaverageswithevidence-basedreductionsforCHFandCOPD.Readmissionratesareimportantindicatorsofthequalityofcareofinpatientandperi-dischargeservices,particularlyashospitalsmovetoshorterlengthsofstayandimprovingintegrationacrossthecontinuumofcare.The30-dayreadmissionratepromotesequalaccesstoqualitycarewithinaLHIN.

Panel Recommendations

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Panel Recommendations

ThePanelenvisionsafuturehealthsysteminwhichnon-acutecareisbetterintegratedandwherecaretransitionsaredesignedtoimprovepatientoutcomesandreducethelikelihoodofreadmission.ExceptionallocalmodelsofintegrationinOntariothatexisttoday(e.g.,TorontoCentralLHINVirtualWard)willbecommonplace.Hospitalizationwillbelargelyfocusedonpeoplewhoareacutelyillratherthanchronicallyill.Frailelderly,childrenwithcomplexneedsandothersathighriskofadmissionandreadmissiontohospitalwillhavereliableaccesstocommunity-based,multidisciplinaryandpreventivecarewhentheyneedit.Consistentwiththisvision,thePaneloffersrecommendationsforchangetothehealthsystemgenerally,totheMOHLTC,topractitionersinthefieldandtoHQO.

Overall Recommendations: 1.ThePanelrecommendsaninitial,intensivefocusonimprovingcaretransitionsfromacuteto

communitysettingstoreduceunplannedreadmissions.Importantfutureareasoffocusincludeenhancedprimarycare,andreducingthenumberandfrequencyofadmissionstohospitalsforspecificconditionssuchasambulatorycaresensitiveconditions.

2.Allsectorsofthehealthcaresystemhavearoletoplayinhighqualitytransitions,includingacutecare,familypracticeandotherprimarycareandcommunitycareproviders.Performancemeasuresmustreflectthissharedaccountabilityfortransformationofthebroaderhealthsystem,andacknowledgethatlocalvariation(betweenruralandurbansettings,forexample)isinevitableandmaybeappropriate.

3.ThePanelrecommendsahigh-levelreviewofpoliciesandothersystemconstraintsonimplementationofavoidablehospitalizationandreadmissionreductionstrategies,inparticular,withrespectto:

a) promptprimarycarefollow-upthatincludespost-hospitaldischargenursingsupportforhigh-riskpatients;

b) enhancedspecialistconsultingsupport(geriatrics,medicationreconciliation,laboratory/diagnostics,etc.)inprimarycare;and

c) paymentpolicytosupportchangesinconjunctionwithdemonstratedbestpractices.

Addressingknownsystemicconstraintsisanecessaryfirststeptoreducinghospitalreadmissions.Therefore,thePanelendorsestherecommendationofthePatientBasedPaymentImplementationAdvisoryCommitteethatareadmissionfundingpolicybeimplementedinparallelwithotherprovincialinitiativestoreducereadmissions.

4.ThePanelendorsesfocusedattentiontopopulationswhosehighriskofreadmissionhasbeendemonstrated.Underlyingissuesarenotonlyrelatedtodiagnosisorconditionbutalsothesocialcareneedsofpatientsandtheirfamilies.

5.ThePanelrecommendsthattheMOHLTCensurethateffortsaremadetostrengthenhumanresourcesinhomeandcommunitycareinordertosupportthegoalofimprovingtransitionsincare.ThisincludesstrengtheningCCACandhomecareprogramstoincludetransitionsupport.Suchprogrammingshouldconsiderarangeofprofessionalservicestoreducethelikelihoodofreadmission.

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6.Whilethereisgrowingevidenceofeffectivepracticesforimprovingtransitions,theimplementationofthesepracticesischallenginggiventheneedtocoordinatemultiplehealthserviceproviderstoensureasmoothtransitionforpatients.ThePanelrecommendsMOHLTCsupportformeasured,incrementaldiffusionofbestpracticesthroughaction-orientedimprovementprogramsthatbuildoncurrentdemonstrationprojects(e.g.,VirtualWard,CareTransitionsinitiatives).Increasedemphasisonmedicationreconciliationatdischargeandinpatients’homesfollowingtransitionsisanessentialelementofeffectivetransitions,andeffortsneedtotargetimprovementsinthisarea.

ThePanelacknowledgesthatdifferentstrategiesappropriatetolocalcontextswithvaryingresourceswillbeneededfordifferentregionsoftheprovince.TheInstituteforHealthcareImprovement(IHI)“ImprovementCollaborative”modelisthePanel’srecommendedmodelofdevelopingandassessingthepracticesandsupportsneededbyhospitals,CCACs,primarycareprovidersandotherprovidersintestingandimplementingbestpractice.ExperiencebothinOntarioandelsewhere,andresearchevidencefromanumberofstudiessuggeststhatmultipleinterventionsareneededtoimproveplanningandcarebeforedischarge,followingdischarge,andinprovidingessentialinformationacrossthetransition.Suchcomplexinterventionsaredifficulttoimplement.Asaresult,effortstoexplicitlyexaminehowtoimplementthesecomplexinterventions,incorporatingimportantbutchallengingpracticessuchasmedicationreconciliationbetweenhospitaldischargeandpatientreturntothecommunity,isessential.Evaluationoftheseinterventionsisalsoneededtoassesstheirimpact.

Recommendations to the MOHLTC regarding system-wide alignment of funding, accountabilities, measurement and reporting. 7.ThePanelrecommendscleareraccountabilityforthecareprovidedtopatientsastheytransitionfrom

onehealthserviceprovidertothenext.

8.ThePanelrecommendsalignedaccountabilitywhereprovidersshareresponsibilityforapatient’scare.Comparableorcomplementaryperformanceindicatorsshouldbeincorporatedintoeachaccountabilityagreement(MLPA,provideraccountabilityagreements,etc.),withjointresponsibilitiesdefined.

9.HealthserviceproviderscompletingannualQIPsrequiredbytheECFAshouldtargetimprovementstothecaredeliveredatandbetweentransitionpointsinapatient’sjourney.1

10.Hospitalreadmissiondatashouldbeavailableandeasilyaccessibletohealthcareprofessionalsatalocallevel(e.g.,wardordepartment).Thesedatashouldincludereadmissionstootherhospitals,notsimplythesamehospital,andshouldbeavailablepromptly(i.e.,within1-3months)tofacilitaterapidcyclequalityimprovement.

127hospitalschosethe30-dayreadmissionindicatorasaprioritywithintheir2011/12QualityImprovementPlan,andeightmoreselecteda‘readmission’indicatorotherthantherecommendedcoreindicator.Ofthisgroup,threehospitalsselectedmorethanone‘readmission’indicator(i.e.,core+non-core).

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11.ThePanelrecommendsbothoutcomeandprocessindicatorsbetrackedaspartofaprovincialfocusonreducingreadmissions.

Eightindicatorsarealreadyavailable[responsibilitynotedinbrackets]:

a) TimefromreferraltoCCACtoacutedischarge.ItisrecommendedthatallCCACreferralsoccuratleast48hourspriortodischargeforallpatientsathighriskofreadmission.[Acute]

b) TimefromreferraltoCCACassessmentwithRAI-ContactAssessmentforpatientsreferredtohomecare(onlyforhomedischarges).ItisrecommendedthatRAI-CAassessmentsbecompletedwithin24hoursafterreferralforallhigh-riskpatients.[CCAC]

c) TimefromdischargetofirstCCACnursingvisitforhigh-riskpatients[CCAC].ItisrecommendedthatCCACensureanursingvisitinhomewithinthreedaysofacutedischarge(preferablyearlier)forallhigh-riskpatients.Thisnursingvisitshouldincludeareviewofpatientmedicationstoidentifypotentialrisks.

d) Lengthofstay(LOS)inacutecare.ThisisrecommendedasabalancingmonitoringmeasuretoensurethatstaysarenotabbreviatedorelongatedandtoenableassessmentofrelationshipbetweenLOSandreadmissions.ThereisnoperformancetargetassociatedwithLOS.[Acute]

e) HealthCareConnectlinkageforunattachedpatients.ThePanelrecommendsthatallpatientswhoreportnothavingaPrimaryCareProvider(PCP)beenrolledthroughHealthCareConnect.[Acute]

f) Primarycarevisitwithinsevendaysforhigh-riskpatients[Acute,PCP]g) Primarycarevisitwithin14daysforlow-riskpatients[Acute,PCP]h) MedicationReconciliation(PharmacyMedsCheck)billingwithin14days[Pharmacy]

Dataforfiveotherindicatorsarenotyetavailableprovince-wide:

i) Fullmedicationreconciliationcompletedpriortodischargefromanyhospitaltoanothersetting[Acute/Rehab/CCC]

j) DischargeSummaryprovidedtopatientattimeofdischarge,includingfulllistofmedicationsandfollow-upappointments[Acute/Rehab/CCC](Patients at high risk of readmission only)

k) DischargeSummarysenttoprimarycarephysicianandspecialistsonthedayofdischarge,includingfulllistofmedicationsandfollow-upappointments[Acute/Rehab/CCC](Patients at

high risk of readmission only)

l) DischargeMedicationListsenttoPharmacyupondischarge,includingfulllistofmedicationsandfollow-upappointments[Acute/Rehab/CCC](Patients at high risk of readmission only)

m) Patientprovidedinformationatdischargeonwhotocontactandhowtousemedications(communicationofdischargeplantopatient)[Acute/Rehab/CCC]

Evidence Based Standards of Care and Best Practices Recommendations to the field:12.ThePanelrecommendsthefollowingtobestandardpracticeinOntario:

• Allunplannedhospitaladmissionsshouldbescreenedforriskofreadmissionusingastandardriskassessmenttool.TheLACEIndex,developedinOntarioforthispurpose,isasimple,practicaltoolappropriateforreadmissionpredictioninallhospitals.

• Standardizedelectronicdischargesummaries(similartoonesusedbySt.Michael’sHospitalandSunnybrookHealthSciencesCentre)shouldbestandardpracticeprovince-wide.

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• Anexpandedmedicationprescription/medicationlistshouldbeprovidedtothepatientorfamilymemberandsenttothefamilyphysicianand/orcommunitypharmacyupondischarge.Thelistshouldincludenotonlycurrentprescriptionsbutalsoasummaryofmedicationchangessinceadmission(i.e.,newmedications,discontinuedmedications,adjustedmedications).

13.ThePanelrecommendsspecificbestpracticesinhospitaldischargeandtransitionplanning,whicharedescribedintheSafe Discharge Practices for Hospital Patients Checklist(SeeAppendix3).

14.ThePanelrecommendsthefurthertesting,refinementandadoptionoftheChecklistandothertoolstosupportprovidersincaretransitions.Thechecklisttoolforhospital-basedproviders,attachedinAppendix3,isaninitialstepinthedevelopmentofastandardizedchecklistforprovince-widespreadandimplementation.

15.ThePanelrecommendsthefurtherrefinementandimplementationofaHospitalAvoidancePracticesInventory(HAPI)ofbestpracticestoreducereadmissionsandavoidhospitalizationsinOntario.Asearchableinventorywouldpromotesafe,effective,patient-centredhealthcaretransitions.ThePanelconsideredpotentialHAPIspecificationsanddescribeditsrecommendationstotheMOHLTCinseparatedocumentation.

Monitoring and Evaluation of Interventions Recommendations to Health Quality Ontario:16.InterventionsaimedatreducingavoidablehospitalreadmissionsshouldbeassessedbyHQO.Evaluations

oftheeffectivenessandefficacyoftheseinterventionsintheOntariocontextwillprovideevidenceoftheirimpactandguidancetodecision-makers.TheresultsshouldbemadeavailabletohealthcareprofessionalsthroughtheannualQuality Monitorreportandotherchannels.

17.WhiletheLACEIndexisanappropriatetoolforreadmissionpredictioninhospitals,additionaltoolsmustbedevelopedtoquantifyriskforavoidablehospitalizationsinthecommunity,long-termcareandothernon-acutesettings.HQOshouldseektodevelopsuchtoolsandtesttheireffectivenessinlocaldemonstrationprojects.

Appendices

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Appendix 1. Summary Report from the May 31, 2010 Leadership Forum

Avoidable Hospitalization Advisory Forum, May 31, 2010Communiqué

TheOntarioHealthQualityCouncil(OHQC)andtheMinistryofHealthandLong-TermCare(MOHLTC)collaboratedonaone-dayAvoidableHospitalizationAdvisoryForumtoseekadviceandinputfromhealthcareexpertsandleadersonhowtobestfocusqualityimprovementeffortstosupportreductionsinavoidablehospitalizationsinOntario.

Theone-dayforuminTorontoonMay31,2010wasattendedbyOHQCandministrystaff,clinicalleaders,researchers,healthcarepractitionersaswellasrepresentativesfromabroadrangeofhealthcaresectorsandorganizations.Thefullparticipantlistisattached.

Dr.BenChan,CEOoftheOHQC,openedthedaywithadiscussionoftheday’sobjectives,whichwereto:

• ReviewpatternsofOntariodataonhospitalizations• Reviewanddiscussasynthesisofliteratureonideasforimprovement• Developconsensuson‘BigDot’aimsofavoidablehospitalizationframework• Developconsensusonkeydriversthatleadtoavoidablehospitalizations• Identifykeyopportunityareastoreduceavoidablehospitalizationsbasedondataandliteraturepresented• DevelopprovincialAimStatementsforreducingavoidablehospitalizations

FredrikaScarthfromthePerformanceImprovementandComplianceBranch,MOHLTC,presentedonthestrategiccontextfortheprovincialfocusonAvoidableHospitalization:theExcellentCareforAllStrategy(ECAS).TheECAShasanoverallaimofimprovingqualityandevidence-basedpracticetosupportasustainablehealthcaresystem.FredrikapresentedabroadAvoidableHospitalizationsframeworktothegroupfordiscussion,whichisdividedintothreemainaims:fewerpreventableadverseevents,moreeffectivecaretransitionsandbetterchronicdiseasepreventionandmanagement.

DebbieGibsonandStenArdalfromtheHealthAnalyticsBranch,MOHLTC,presentedadescriptivedataanalysison30-dayreadmissions,preventableadverseeventsandambulatorycaresensitiveconditions(ACSC).Thedatashowedpotentialareasofopportunityforimprovementacrosstheseindicators.Ratesfor30-dayreadmissionsandACSChavebeenrelativelystableovertheyears,butthereisvariationacrosstheprovincesuggestingroomforimprovement.

Next,fouraccomplishedresearchersandclinicianspresentedrelevantresearchoncomponentsoftheframeworkandtheunderlyingbroaderdeterminantsofhealth.

LiisaJaakkimainen,ascientistfromICESandfamilyphysician,presentedontheroleofprimarycareinchronicdiseasemanagement.Specifically,sheidentifiedtheimportantrolethatprimarycaredeliverymodels,primarycareteams,andelectronicmedicalrecordshaveineffectivelymanagingchronicdiseasestoreduceavoidablehospitalizations.

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Reducing Avoidable Hospitalizations

Fewerpreventableadverseevents

Moreeffectivecaretransitions

Betterchronicdiseasepreventionandmanagement

Hospitalstays(admissions,readmissionsandhospitaldays)thatcouldbeavoidedthroughenhancedsafetypracticesinhospitalorcommunity.

Potentialoutcomemeasures:Expected/actuallengthofstay(LOS),Readmission(72hours),NosocomialInfection,Falls,PressureUlcers,MedicationErrors,CriticalIncidents.

Admissionsandreadmissionsthatcouldbeavoidedthroughenhancedhospitaldischargepracticesandmoreeffectivecaretransitions.

Potentialoutcomemeasures:Readmission(7,30,90days);multiplepsychiatricreadmissions.

Admissionsandreadmissionsthatcouldbepreventedthroughmoreeffectivechronicdiseasemanagementandpatientself-management.

Potentialoutcomemeasures:AmbulatoryCareSensitiveConditions(ACSC)hospitalization.

SettingsforIntervention

•Hospital•Long-TermCareHomes•Community(CCAC/CSS)

•Hospital•Community(CCAC/CSS,

Pharmacy)•PrimaryCare•Long-TermCareHomes•MentalHealthandAddictions

•PrimaryCare•PublicHealth

AlignedStrategies

•MostResponsiblePhysicianCollaborativeFunding

•PatientSafetyReporting•ResidentsFirst

•ER/ALCStrategies•IntegratedClientCare•MentalHealthandAddictions•MedicationReconciliation/

MedsCheck

•ChronicDiseasePreventionandManagement

•DiabetesStrategy•FamilyHealthCareforAll

NextWalterWodchispresentedresearchanddatafromtheHealthSystemPerformanceResearchNetworkrelatingtoimprovedintegrationandtransitionsofcare.SpecificallyWalterspokeabouthowtoidentifytargetpopulationsforsystemimprovement.

ThethirdpresenterwasRossBaker,ProfessoratHealthPolicy,ManagementandEvaluationattheUniversityofToronto.Rossspoketotheimportanceofunderstandingcontextualfactorsinimplementinginterventionstoimprovetransitionsofcare,anddescribedcurrentworktodevelopcasestudiesoftransitioninterventionsinthreedifferentcontexts,includingtheSWLHIN.Rossalsospoketothethirdareaoffocusintheframework,preventableadverseevents,andindicatedthatwhiletherehasbeensignificantprovincialfocusintheareaofpatientsafetyinacutesettings,throughbothpublicreportinginitiativesonthepartofMOHLTCandqualityimprovementinitiativesthroughprogramssuchasSaferHealthcareNow!,therearestillareasofopportunityforimprovement.Rossindicatedthatincreasedprovincialfocus(throughprovincialtargetsandpublicreporting)couldbegiventohospitalacquiredinfectionsandpressureulcersandfallspreventioninhospitals.

Finally,ArleneBiermanofStMichael’sHospitalandaboardmemberoftheOHQCbroughtanequitylenstotheavoidablehospitalizationsdiscussion.Arlenepresenteddatarelatingtohowdisparitiesinincomeandvariedgeographicalaccesstoprimarycare,aswellasage,sexandoverallmentalhealthaffecthealthoutcomesandhospitaladmission/readmissionrates.

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Afterlunch,BenChanpresentedaDriverDiagramforavoidablehospitalizationsthatdepictedcaregaps,rootcausesofgapsand30changeideastoreduceavoidablehospitalizations.TheOHQChaddevelopedthisDriverDiagramthroughconsultationwithsystemexperts.

Theremainderoftheafternoonwasbrokenintotwoworkinggroupsessions,bothofwhichproducedfruitfuldiscussionandhighlightedseveralareasthattheministryneedstoinvestigatefurther.Therewasstrongalignment/consensusthroughtheroominanumberofareas:

1. AvoidableHospitalizationsisgenerallytherightissuetofocuson,butthepositioningoftheframeworkshouldbereworkedto:

a) Havemeaningforallareasofthehealthsystem,b) Takeapatient-centredfocus,c) Focusfirstoneffortstoimprovetransitionsincare(morecouldbeachievedfirstthrough

narrowerfocus),andd) Considerreductionofadverseeventsasafoundationalissueacrossthecontinuumofcare

(notaseparatestreamofefforts).

2. Focusofeffortsshouldbeontargetpopulations,notspecificconditions/diseasesinisolation.Keypopulationsofinterestidentified:firstandforemostthefrailelderlypopulation,thenthosewithmultipleco-morbidities,mentalhealthandcomplexchildren.

3. Aligningefforts(QI,reporting,measurement,etc.)isnecessarytoachieveresults.

4. Consensusontwoperformancemetricstosupportbigdotgoal:30-dayreadmissionsandACSChospitalizations;thereisroomforimprovementprovinciallyinbothareas.Othermorespecificqualitymeasuresshouldalsobetrackedthroughinitiativesthatareimplemented.

5. 30percentimprovementmaybetherighttargetfor30-dayreadmissions;however,improvementatthesystemlevelwilllikelybeseenonlyoveramulti-yeartimeframe(suggestedover5-10years).

6. Specifictargetsshouldbevalidatedthroughadditionalexpertpaneldiscussion.

7. LearnfromsuccessesinOntarioandinternationalbestpractices.

8. Buildonexistinginitiatives,alignmeasurementandreporting.

9. Manyopportunitieshavethepotentialforhighreward,butwillalsorequirehigheffortofresources,culturechange,etc.inordertoimplementsuccessfully.

TheministryandOHQCwilljointlymoveforwardonthisimportantworkbasedonthekeyoutcomes/messagesfromthisForum:

• Reworkframeworktofocusonapatient’ssafe,effectivejourneyacrosstransitionsincare• A30percentimprovementin30-dayreadmissionsmaybeanappropriatetarget,butwouldlikelyonly

beachievedovera5-10yearperiod• AnExpertPanelshouldbeconvenedtodeterminethemostappropriatemeasure,targetandtimeline

forthiswork.

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Avoidable Hospitalizations Stakeholder Advisory Forum: Participant List May 31, 2010

Name Title Organization

AllisonCostello PerformanceImprovementPlanningLead PICB,MOHLTC

AmandaBaine ProjectCoordinator PICB,MOHLTC

ArleneS.Bierman,MD,MS

OntarioWomen’sHealthCouncilChairinWomen’sHealth

UniversityofTorontoandLiKaShingKnowledgeInstitute,St.Michael’sHospital

BenChan,MDMPHMPA

ChiefExecutiveOfficer OntarioHealthQualityCouncil

BrendaFraser ExecutiveDirector QualityImprovementandInnovationPartnership

ChaimBell,MD,PhD,FRCP(C)

ChairinPatientSafetyandContinuityofCarePhysicianandScientistAdjunctScientistAssociateProfessorofMedicineandHealthPolicyManagementandEvaluation

CIHR/CPSISt.Michael’sHospital&KeenanResearchCentreICESUniversityofToronto

CharleneSandilands Director,CardiacHealthSystem TrilliumHealthCentre

CherylHarrison VicePresidentofPatientCareServices&ChiefNursingExecutive

SoldiersMemorial

CynthiaMajewski ExecutiveDirector QualityHealthcareNetwork(QHN)

DebbieGibson SeniorHealthAnalyst HealthAnalyticsBranch,MOHLTC

EdwardEtchells,Dr.regrets

AssociateDirector,UniversityofTorontoCentreforPatientSafety

SunnybrookHealthSciencesCentre

EileenPatterson Director,QualityImprovement OntarioHealthQualityCouncil

ElliotGold Manager,StrategicPlanning&Research CIB,MOHLTC

EmilyO’Sullivan Manager,PerformanceImprovementImplementation

PICB,MOHLTC

FredrikaScarth Manager,PerformanceImprovementPlanningandEvaluation

PICB,MOHLTC

GenevieveObarski SeniorQualityImprovementConsultant CentreforHealthcareQualityImprovement

GloriaWhitson-Shea ClinicalLead WaterlooWellingtonLHIN

ImtiazDaniel ResearchDirector OntarioHealthQualityCouncil

IrfanDhalla StaffPhysicianandScientist KeenanResearchCentreintheLiKaShingKnowledgeInstitute

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JamesMelocheregrets

SeniorDirector,SystemDesign&Implementation

CentralEastLHIN

JillianPaul Lead,Performance&Results ExcellentCareforAllStrategyBranch,MOHLTC

JohnRonson Facilitator CourtyardGroup

KellyGillis SeniorDirector,Planning,IntegrationandCommunityEngagement

SouthWestLHIN

KyleJohansen HealthSystemDesignSpecialist SouthEastLHIN

LaurieBourne,MHSc Manager,SurgeryandDiagnosticImagingWaitTimes

CancerCareOntario

LiisaJaakkimainenMD,MSc,CCFP

ScientistStaffPhysicianAssociateProfessor

ICESSunnybrookHealthSciencesCentreDepartmentofFamilyandCommunityMedicine,UniversityofToronto

M.J.Marcaccio,MD,FRCSC,FACS

Professor,Dept.ofSurgeryHead,ServiceofSurgicalOncology

McMasterUniversityHamiltonHealthSciencesandJuravinskiCancerCentre

MarionEmo SeniorDirector,Planning,IntegrationandCommunityEngagement

HamiltonNiagaraHaldimandBrantLHIN

MattDrownregrets VP,HumanResources RBJSchlegelHomes

MimiLowi-Young CEO CentralWestLHIN

MonitaO’Connor Director,PerformanceImprovementandIntegration

MississaugaHaltonLHIN

NizarLadak ChiefOperatingOfficer OntarioHealthQualityCouncil

PatStoddart SeniorDirector,Performance,ContractandAllocation

CentralWestLHIN

PattiA.Cochrance VPPatientServices,Quality&CNO TrilliumHealthCentre

PaulaBlackstein-Hirsch ExecutiveDirector CentreforHealthcareQualityImprovement

PeterNord,Dr. V.P.MedicalAffairsandChiefofStaff ProvidenceHealthcare

RhonaMcGlassonRPT,MBA

ProjectDirector HollandOrthopaedic&ArthriticCentre

RomeoCercone VicePresident,Quality,Planning&PerformanceImprovement

St.Joseph’sHealthcareHamilton

RossBaker Professor,HealthPolicy,ManagementandEvaluation

UniversityofToronto

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RoyButler IntegratedVicePresident,QualityandStrategyPerformance

LondonHealthSciencesCentre/St.Joseph’sHealthCare,London

SamTirkos,Dr. Hospitalist SouthEastTorontoFamilyHealthTeam,TorontoEastGeneralHospital

StaceyBrener ResearchCoordinatorandMScCandidate St.Michael’sHospital&UniversityofToronto

StaceyDaub Sr.Director,ClientServices TorontoCentralCommunityCareAccessCentre

StenArdal Director HealthAnalyticsBranch,MOHLTC

SusanWheeler ManagerofStrategicInitiatives QualityImprovementandInnovationPartnership

SylviaHyland VicePresidentandChiefOperatingOfficer ISMPCanada

TaiHuynh Director ExcellentCareforAllStrategy,MOHLTC

TiaPham,Dr.regrets

Hospitalist SouthEastTorontoFamilyHealthTeam,TorontoEastGeneralHospital

TimBurns Director PICB,MOHLTC

VandadYousefi PhysicianLead–Quality LakeridgeHealthCorporation

VaniaSakalaris DirectorofProgramDevelopment CentralLHIN

VictoriavanHemert SeniorDirector CentralLHIN

WalterWodchis,PhD AssociateProfessorResearchScientistAdjunctScientistCo-Lead

HPME,UniversityofTorontoTorontoRehabilitationInstituteInstituteforClinicalEvaluativeSciencesHealthSystemPerformanceResearchNetwork

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Provider too busy, forgets, or is unaware of best practices for treatment

No organized monitoring system

Patients not engaged in their care or not motivated to modify behaviours

Handwriting, drug interactions, unnecessarypolypharmacy, drugs unknowingly given bymultiple MDs

Lack of multidisciplinary teams in primary care,or teams not working most effectively and efficiently as a team, or not enough providers

Delay in home care services (communication, staff scheduling, etc.)

Lack of available home care services

Handwriting, miscommunication, drug history or past medical history not shared between providers

Lack of experience, backup, too busy & miss details,poor communication, diagnostics not available


Providers delay dictating discharge summaries – too busy, no consequences if late

Discharge instructions to providers focuses on treatment at point in time rather than suggested treatment options as symptoms or illness changes

Patients do not understand medical terms, not fluent in English, cannot memorize verbal instructions, too stressed at time of illness to absorb information

Staff unaware of need to identify risk or tools to do so

Patients may be told to make appointment but forget or cannot get into see provider in a timely fashion

Specialists not available, not on-call; not accessible for simple follow-up questions

No communication mechanism between in-hospitaldoctors, specialists and primary care

Lack of leadership

Safety assessments may be missed in home care

Lack of culture of quality and safety among staff

Lack of accountability or incentives for quality

Lack of Quality Improvement skills among staff – no previous training

Patients not offered right drugs, treatments for chronic disease

Patients not regularly monitored

Patients non-adherence to recommended treatments, drugs

Primary Care

Better Chronic Disease Prevention

and Management

Fewer PreventableAdverse Events

More EffectiveCare Transitions

ED Visit

Index Hospitalization

Discharge Transition

Poor Discharge Care

All Phases of Care

Patient lifestyle (e.g., smoking)

Drug errors, adverse drug reactions

Patients unable to access primary care

Home care needed but cannot be arranged, resulting in admission

Drug prescriptions leading to adverse event after visit (e.g., drug interaction, adverse reaction, unintended change)

Missed diagnoses

Patient not getting right drugs, treatments in hospital

Patient not getting right drugs, treatments while in ED

Adverse event during hospitalization

Drug prescriptions leading to adverse event (e.g., drug interaction, adverse reaction, unintended change)

Lack of, incomplete treatment plan, or delay in transmitting it

Poor communication of discharge instructions to patient

Risk of readmission not recognized

Follow-up care not arranged (no one identified for follow-up or no appointment made)

Lack of access to specialist opinion on complex issues by primary care, home care

Disagreement among providers about the treatment plan

Accidents in home (e.g., falls) with frailty a contributing factor

Any of the care gaps under “primary care Chronic Disease Management patient”

Lack of skills to change

Lack of will to change

Avoidable hospitalizations of patients acute

care sensitive conditions and

unplanned visits to the Emergency Department (ED) or readmissions following index hospitalization

Care Gap Root CauseStandard orders, decision tools, flow sheets, flow charts, checklists, electronic reminders – primary care

Standing lab orders & recall system, titration protocols (e.g., coumadin)

Interactive voice recognition – automated phone calls to monitor symptoms, medication use

Telehomecare (devices to monitor vital signs,communicate with staff)

Patient self-management training (one-on-one or group sessions, patient goals & targets)

Electronic Medical Records – flag drug interactions, dose errors, eliminate handwriting probs

Health Human Resource solutions, increase MDs, RNs, NPs, other health professionals; promote team-based models (e.g., Family Health Teams); train teams on teamwork

Advanced access & office efficiency techniques

24/7 availability of home care staff for assessment; consider advanced access type scheduling

Consider increasing home care services, if all efficiencies maximized

Medication reviews by pharmacist

Medication reconciliation or Electronic Health Records with view of all prescriptionsStandard orders, decision tools, flow sheets, flowcharts, checklists, electronic reminders – hospital

Database-generated discharge summaries

Stepped action plans from in-hospital physicians to primary care, home care detailing steps to follow if patient symptoms change

Written discharge instructions (meds, monitoring,appointments, who to contact, etc.) in simple vocabulary, multiple languages

Apply risk scoring (e.g., LACE index) and triage patients post-discharge services

Make booked follow-up appointment at discharge the standard of care

Specialty clinics (e.g., Congestive Heart Failure clinics), poly-clinics, or virtual wards esp. for complex cases, with on-call system

Improved provider communication mechanisms (e.g., e-mail)

Falls & safety risk assessments; prevention e.g., mobility aides, handles

Governance & leadership development & Quality Improvement Plans

Anonymous individual-level provider (e.g., physician) feedback of data on compliance with best practices

Public reporting at institution or provider group level

Accountability agreements with performance target setting and consequences (e.g., pay-for-performance, sanctions, awards)

Quality Improvement skills development among staff (model for improvement, LEAN, etc.)

Change Ideas

37


No organized monitoring system

Patients not engaged in their care or not motivated to modify behaviours

Handwriting, drug interactions, unnecessarypolypharmacy, drugs unknowingly given bymultiple MDs

Lack of multidisciplinary teams in primary care,or teams not working most effectively and efficiently as a team, or not enough providers

Delay in home care services (communication, staff scheduling, etc.)

Lack of available home care services

Handwriting, miscommunication, drug history or past medical history not shared between providers

Lack of experience, backup, too busy & miss details,poor communication, diagnostics not available


Providers delay dictating discharge summaries – too busy, no consequences if late

Discharge instructions to providers focuses on treatment at point in time rather than suggested treatment options as symptoms or illness changes

Patients do not understand medical terms, not fluent in English, cannot memorize verbal instructions, too stressed at time of illness to absorb information

Staff unaware of need to identify risk or tools to do so

Patients may be told to make appointment but forget or cannot get into see provider in a timely fashion

Specialists not available, not on-call; not accessible for simple follow-up questions

No communication mechanism between in-hospitaldoctors, specialists and primary care

Lack of leadership

Safety assessments may be missed in home care

Lack of culture of quality and safety among staff

Lack of accountability or incentives for quality

Lack of Quality Improvement skills among staff – no previous training

Patients not offered right drugs, treatments for chronic disease

Patients not regularly monitored

Patients non-adherence to recommended treatments, drugs

Primary Care

Better Chronic Disease Prevention

and Management

Fewer PreventableAdverse Events

More EffectiveCare Transitions

ED Visit

Index Hospitalization

Discharge Transition

Poor Discharge Care

All Phases of Care

Patient lifestyle (e.g., smoking)

Drug errors, adverse drug reactions

Patients unable to access primary care

Home care needed but cannot be arranged, resulting in admission

Drug prescriptions leading to adverse event after visit (e.g., drug interaction, adverse reaction, unintended change)

Missed diagnoses

Patient not getting right drugs, treatments in hospital

Patient not getting right drugs, treatments while in ED

Adverse event during hospitalization

Drug prescriptions leading to adverse event (e.g., drug interaction, adverse reaction, unintended change)

Lack of, incomplete treatment plan, or delay in transmitting it

Poor communication of discharge instructions to patient

Risk of readmission not recognized

Follow-up care not arranged (no one identified for follow-up or no appointment made)

Lack of access to specialist opinion on complex issues by primary care, home care

Disagreement among providers about the treatment plan

Accidents in home (e.g., falls) with frailty a contributing factor

Any of the care gaps under “primary care Chronic Disease Management patient”

Lack of skills to change

Lack of will to change

Avoidable hospitalizations of patients acute

care sensitive conditions and

unplanned visits to the Emergency Department (ED) or readmissions following index hospitalization

Care Gap Root CauseStandard orders, decision tools, flow sheets, flow charts, checklists, electronic reminders – primary care

Standing lab orders & recall system, titration protocols (e.g., coumadin)

Interactive voice recognition – automated phone calls to monitor symptoms, medication use

Telehomecare (devices to monitor vital signs,communicate with staff)

Patient self-management training (one-on-one or group sessions, patient goals & targets)

Electronic Medical Records – flag drug interactions, dose errors, eliminate handwriting probs

Health Human Resource solutions, increase MDs, RNs, NPs, other health professionals; promote team-based models (e.g., Family Health Teams); train teams on teamwork

Advanced access & office efficiency techniques

24/7 availability of home care staff for assessment; consider advanced access type scheduling

Consider increasing home care services, if all efficiencies maximized

Medication reviews by pharmacist

Medication reconciliation or Electronic Health Records with view of all prescriptionsStandard orders, decision tools, flow sheets, flowcharts, checklists, electronic reminders – hospital

Database-generated discharge summaries

Stepped action plans from in-hospital physicians to primary care, home care detailing steps to follow if patient symptoms change

Written discharge instructions (meds, monitoring,appointments, who to contact, etc.) in simple vocabulary, multiple languages

Apply risk scoring (e.g., LACE index) and triage patients post-discharge services

Make booked follow-up appointment at discharge the standard of care

Specialty clinics (e.g., Congestive Heart Failure clinics), poly-clinics, or virtual wards esp. for complex cases, with on-call system

Improved provider communication mechanisms (e.g., e-mail)

Falls & safety risk assessments; prevention e.g., mobility aides, handles

Governance & leadership development & Quality Improvement Plans

Anonymous individual-level provider (e.g., physician) feedback of data on compliance with best practices

Public reporting at institution or provider group level

Accountability agreements with performance target setting and consequences (e.g., pay-for-performance, sanctions, awards)

Quality Improvement skills development among staff (model for improvement, LEAN, etc.)

Change Ideas

38

Appendix 2. Avoidable Hospitalization Advisory Panel Terms of Reference

Targeting Avoidable Hospitalizations through Improved (Safer, More Effective) Transitions in Care

Advisory PanelTerms of Reference

Background:• TheExcellent Care for All Strategy(Strategy)willsupportthegovernment’scommitmenttoexcellence

inthequality,value-for-moneyandevidencebaseofpatientcareasthefoundationofasustainablehealthcaresystem.Amongothergoals,theStrategywillembedtheprinciplesofqualityandsustainabilitythroughoutthehealthcaresystembysupportingthedisseminationofevidence-basedbestpracticesandtoolstohelpfront-linestaff,managersandadministratorsmakepermanentchangesintheirorganizations.

• ReducingavoidablehospitalizationisakeyresultareaofExcellentCareforAllStrategy• AtaMay31stAvoidableHospitalizations(AH)AdvisoryForumattendedbyresearchers,clinical

leadersandqualityimprovementgroupstherewasgeneralconsensusthatthereareopportunitiestoreduceavoidablehospitalizationsinOntario,andthatthefocusofinitialeffortsshouldbeonimprovingtransitionsincaretoreducereadmissionstohospital.

• Forumparticipantsagreedthat30-dayand90-dayreadmissionscouldbeanappropriatesystem-levelmeasuretoshowprogressinimprovingpatienttransitionsacrosscaresettings.However,consensuswasnotreachedonanappropriatetargetandassociatedtimelines,andothermeasuresthatcouldbeusedaspartofaperformanceframeworktosupportreductionsin30-dayand90-dayreadmissions.

• ItwassuggestedbytheparticipantsattheForumthatanAdvisoryPanelbeconvenedtoadvisetheprovinceonappropriateprovincialmeasure(s)andtargetsandonbestpracticesrelatedtoreducingreadmissionsandavoidablehospitalizations.

Mandate: TheAdvisoryPanelwill:• provideadviceonthemostappropriatemeasures,targetsandtimelinesforinitiativesfocusedon

reducingreadmissions/avoidablehospitalizationsaspartoftheExcellentCareforAllStrategy;• provideadviceonevidence-basedpracticesthatensureefficient,effective,safeandpatient-centred

caretransitions;• provideadviceonstrategiesforidentificationandselectionofleadingcaretransitionpracticesinOntario

tobecompiledinaninventoryor“LivingLab”ofinnovativemodelsofcarethatreducereadmissions/avoidablehospitalizations;

• provideadviceonlocalevidencecriteriaforleadingpracticesinOntario;• provideadviceonthescalabilityandspreadofleadingpracticesinOntario;• monitortheoutcomesofcaretransitionsinitiatives,andassesstheirimpactsonhospitalreadmission;and• identifypolicyorsystemicbarriersandenablerstosafe,effectiveandpatient-centredcaretransitions,

includingfundingpolicy,andfundingincentivesordisincentives.

39

ConfidentialityAdvisoryPanelmembersareanimportantlinkfortwo-waycommunicationbetweentheExcellentCareforAllStrategyandhealthsectorprofessionalsacrosstheprovince.Assuch,theMinistryofHealthandLong-TermCare(MOHLTC)expectsmemberstodiscusswiththeirpeerstheelementsoftheStrategythatarealreadyinthepublicdomain.

IntheirroleasadvisorstoMOHLTC,panelmemberswillalsobeprivytopreliminary,confidentialordraftmaterialsthatarenotapprovedfordistributionordiscussionoutsidethePanel.MembersagreetotreatasconfidentialallmaterialsthatMOHLTCidentifiesthisway.

Conflict of Interest1. AconflictofinterestexistswhereaMemberengagesinanyprivateorpersonalbusiness,undertaking

orotheractivityinwhichtheMember’sprivateorpersonalinterestconflictswithhisorherdutiesasaMemberorwiththeinterestoftheAdvisoryPanel.Aconflictofinterestmaybeactual,potentialorperceived.

2. Thefocusofconflictofinterestandtheseguidelinesisthe“privateorpersonalinterest”oftheMember.ThisphraseshouldbeinterpretedbroadlyandextendsbeyondadirectorindirectpecuniaryinteresttoincludeanydirectorindirectbenefittotheMember;theorganization/institution/associationwithwhichtheMemberisaffiliated;ortheMember’sspouse,children,siblingsorparents(the“Member’sfamily”).

3. Asageneralprinciple,a“personalorprivateinterest”shouldbeinterpretedasapersonalorindividualinterestinthesensethatitisnotonethatbelongstothegeneralpublicoronethatiscommontoaclassofpersons.

Declaring a Conflict4. PanelmembersshalldisclosetotheChairoftheAdvisoryPaneltheexistenceofanycircumstances

thatcouldariseorthathaveariseninwhichtheirpersonalorprivateinterestconflictswithorcouldconflictwiththeinterestoftheAdvisoryPanelorwiththeirdutiesorobligationsasaPanelMember.PanelMembersshallmakethisdisclosureassoonastheybecomeawareofanysuchcircumstances.

5. Assoonastheybecomeawareofsuchcircumstances,inadditiontoimmediatedisclosure,PanelMembersshalltakeallreasonablestepstoavoidtheconflict,havingregardtotheseguidelinesandtoanyotherconflictofinterestpoliciesthatmaybeestablishedbytheAdvisoryPanel.In particular, Panel Members shall immediately refrain from any further participation in discussions or decision-making relating to the subject matter of the possible conflict and shall not attempt to influence the discussions or decision-making or vote on the matter.OncePanelMembershavemadeadisclosuretotheChairs,theyshallfollowtheChair’sdirections.

Funding:MOHLTCwillfundtheadministrationcostsofthePanel.

Reporting:ThePanelwillreporttotheministry.

Meetings:TheinitialmeetingoccurredinSeptember2010.SubsequentmeetingsofthefulltableorPanelsub-groupsoccurmonthlyforasix-monthduration.TheroleandfutureofthePanelwillbeassessedintheSpring.

40

Appendix 3. Safe Discharge Practices Checklist

Guidelines to the Field for use of Checklist and other practical toolsThePaneldevelopedpracticaltools(page42)thatappearintheformofa(i)checklistand(ii)relevantmeasuresandevaluations.Ifdevelopedinfuture,aproposalfor(iii)aninventoryofleadingclinical/administrativepracticeswouldcompletethesetofthreeinter-linkedresources.ThePanelofferedthefollowingadviceforusingthetoolsinthefield:

i.TheSafe Discharge Practices for Hospital Patients Checklist (Checklist)isanindexofstepsthatcanbefollowedwhenprovidingcaretopatientswithunplannedhospitaladmissions.HealthcareorganizationscandelegateresponsibilityoftheChecklisttoahealthcareprofessional(e.g.,MostResponsiblePhysician,NursePractitioner,DischargePlanner,etc.)whowillensuretheChecklistiscompleted,butthestepsthemselvesarecarriedoutbyanumberofhealthcareprofessionals,includingprimarycarephysicians,nurses,pharmacists,CCACandwardclerks.TheChecklistillustratesafive-dayhospitaladmissionasarepresentationofahospitalstay,acknowledgingthatnotallhospitaladmissionsarefivedays.

TousetheChecklist,healthcareprovidersmustcompletetheServiceProvisionattheidentifiedtime.IftheServiceProvisionishighlighted,healthcareproviderscanlearnmoreabouttheServiceProvisionbyfollowingthelink.IftheServiceProvisionhasan[M&E]symbol,ChecklistuserscanfollowthelinktolearnaboutarecommendedMeasure and Target.Infuture,iftheServiceProvisioncorrespondstoaninitiativedescribedintheproposedHospitalAvoidancePracticesInventory(HAPI),thehealthcareproviderwouldbeabletofollowtheHAPIlinktolearnaboutapeer’sexperiencewithasimilarinitiativesomewhereinOntario.

ii.Measures and Evaluations:forhealthcareorganizationstoeffectivelyevaluatetheireffortstoreduceavoidablehospitalizations,thefollowingcanbeconsidered:

• hospitalandCCACshouldtrackreadmissionriskscoresandtargetresourcestopatientsathighriskforacutereadmission(e.g.,LACEscore10+)

• serviceprovisionssuggestedintheSafe Discharge Practices for Hospital Patients Checklistshouldbeimplementedandtrackedforeachpatient,particularlythoseathighriskforreadmission

• performancemeasuresshouldbeusedtotrackandimproveperformancefortheseoutcomes–targetsare100percentforallmeasures

• Ongoingreportsshouldincludenotonlyperformancemeasuresbutalsoincludeananalysisoftheobservedrelationshipbetweenprocessperformancemeasuresandthereadmissionoutcomemeasure

iii.TheHospital Avoidance Practices Inventory(HAPI)wouldbeasearchableelectronicdatabaseofpracticesthattargetsreducingreadmissionsandavoidinghospitalizationsinOntario.HAPIwouldpromotesafe,effective,patient-centredhealthcaretransitionsandwouldbedisseminatedthroughoutthehealthsector,engaginghealthcarepractitioners,healthsystemleadershipandqualityimprovementorganizationstoparticipate,develop,andimplementprovincialinitiativesdesignedtoguideimprovements.Healthsystemproviderscouldreviewpracticesthathadbeenimplementedinotherorganizationstofindopportunitiesforimpactwithintheirownsetting.

Panel Recommendations for Implementation and Spread of Checklist/Practical Tools i.TheeffectiveimplementationanddisseminationoftheSafe Discharge Practices for Hospital

Patients Checklistwillrequiretheexecutionofthefollowing:

• shareChecklistforreviewandconstructivefeedbackfromotherstakeholders(e.g.,OMAandOHA)• carefulfieldtestingandevaluationinbothacademicandcommunitysettingstofinalize:

41

– Checklistcontent(i.e.,servicesprovisions,languageandtimeframe)– Checklistformat,easeofuseandfunctionality

• onceavailable,includeariskassessmenttoolproventopredictrehospitalization(e.g.,LACEIndex)

• agreementfromthefieldandstakeholdersonhealthcareactor,orteam,responsibleforensuringeachstepiscarriedout.

• establishexplicitlinksbetweentheChecklistandHAPI,avoidablehospitalizationworkoftheHealthQualityOntario,MostResponsiblePhysiciantraining,MOHLTC,andothers

• developstrategyforcommunicationandengagement

• integrateChecklistintocurrenthospitalITinfrastructure

ii.TosuccessfullyimplementMeasures and Evaluationstogaugethesuccessofinterventionsaimedatreducingavoidablehospitalization,thefollowingstepsmustfirstbeconsidered:

• timelyperformancemeasuresshouldbereportedonapublicwebsite• riskscreeningshouldbeimplementedandtrackingautomatedinelectronicpatientinformation

systemsinacutehospitals• CCACreferralprocessesshouldbestreamlined(anyadmissionfromcommunityshouldbe

consideredforhomecarereferralpriortoLTCapplicationorreferraljusttoCCACandletCCACdeterminecapacitytodischargetocommunity)

• patientself-careknowledgesurvey(e.g.,usingHealthOutcomesforBetterInformationandCareinitiative(HOBIC)therapeuticself-caremeasure)shouldbecompletedpriortodischargetoidentifypatientknowledgegaps

• collaborationbetweenacuteandCCACisessential,effectivehospitaldischargeplanningprocessesareessential

• engagementwithcommunitypharmacyisanimportantresourcetoachievetargetoutcomes• ongoingevaluationofinterventionsusingcomparablemeasuresisimportanttoenable

(comparative)effectiveness• apositionpapershouldbecommissionedtoidentifylocalopinionandevidentiarybasisforclinical

governanceandaccountability,includingsharedaccountabilityandintegratedaccountabilityforavoidablehospitalizations

• informationshouldbewellpublicized/communicatedtostakeholdersregardingfinancialincentivestoseepatientsafteracutedischarge(physicianandpharmacy)

iii.DevelopingtheHospital Avoidance Practices Inventorywebsiteandfosteringacommunityofuserswillrequirecarefulstagingofmultipleinterdependentsteps.TheAdvisoryPanelrecommendsthefollowing

sequence:

• establishexplicitlinksbetweenHAPIandcomplementaryavoidablehospitalizationprogrammingofHealthQualityOntario,MOHLTC,andothers

• recruitlaunchpartnersandfinalizeanagreedstrategyforcommunicationandengagement• confirmreviewprocessfornewsubmissionsandrecruitexpertreviewers• preparedevelopmentsitefortesting,includingallseedcontent,hyperlinksandfunctionality• submitterspreviewtheirrespective“seed”initiativesonthedevelopmentsite,includinglinksto

Registryandrelatedcontentonexternalsites(checklists,publishedliterature,etc.)• introducetargetedcommunicationsandappropriaterewardstosolicitnewinitiativesforHAPI,

especiallywheregapsexist(long-termcaresector,NobleFailures,initiativesthatmeetthestandardfor“EvidenceBased,”etc.)

42

Safe Discharge Practices for Hospital Patients ChecklistDay

1Day

2Day

3Day

4 D/C D/C+1

D/C+2

D/C+3

D/C+4

D/C+5

D/C+6

D/C+7

D/C+8

D/C+9

D/C+10

Admit

1 Hospital

a Assesspatienttoseeiftheystillrequirehospitalization[M&E] ü ü ü ü

2 PrimaryCare

a Identify&/orconfirmpatienthasanactiveprimarycarephysician(PCP)–alertcareteamifnoPCPand/orcontactHealthCareConnecttobeginPCPsearch[M&E]

ü

b ContactPCPandnotifythemofpatient’sadmission,diagnosisandpredicteddischargedate ü

c Bookpost-dischargeprimarycarefollow-upappointmentwithin7-14daysofdischarge[M&E]]:•Patientmayneedtobeseensoonerbasedonrisk

ofreadmission(LACE)•NotifyPCPpendingdiagnosisdate•PCPcanusesupplementalbillingcodee080if

seeingpatientfollowingahospitaldischarge

ü

3 MedicationSafety

a Developbestpossiblemedicationhistory(BPMH)andreconcilethistoadmission’smedicationorders[M&E]

ü

b Teachpatienthowtoproperlyusedischargemedicationsandhowtheserelatetomedicationstheywereonpriortoadmission

ü ü ü ü ü

c Reconciledischargemedicationorder/prescriptionwithBPMHandmedicationsprescribedwhileinhospital[M&E]

ü

4 Follow-up

a Performpost-dischargefollow-upphonecalltopatient.Duringcall,ask:•Haspatientreceivedtheirnewmeds(ifany)?•Haspatientreceivedhomecare?•Remindpatientofupcomingappointments•Ifnecessary,schedulepatientandcaregiverto

comebacktofacilityforeducationandtraining

ü

b Ifnecessary,arrangeout-patientinvestigations(lab,radiology,etc.) ü

c Ifnecessary,bookspecialtyclinicfollow-upappointment ü

5 CCAC

a CCACsharesinformation,whereavailable,aboutpatient’sexistingcommunityservices ü ü ü ü

b EngageCCAC(e.g.,bulletrounds)[M&E] ü ü ü ü ü

c Ifnecessary,schedulepost-dischargecare ü ü ü ü ü

6 Communication

a Providepatient,communitypharmacy,PCP,andformalcaregiver(family,LTCH,CCAC)withcopyofDischargeSummaryPlan/Note,MedicationReconciliationFormandcontactinformationofattendinghospitalphysicianandinpatientunit[M&E]

ü

7 PatientEducation

a PatientperformsTeachBack(seePatientTeachingfortips)toclinicalteam ü ü ü ü ü

b Explaintopatienthownewmedicationsrelatetodiagnosis ü

üü

d Thoroughlyexplaindischargesummarytopatient(useTeachBackifneeded) ü

e Explainpotentialsymptoms,whattoexpectwhileathomeandunderwhatcircumstancespatientshouldvisitED

ü

Ser

vice

pro

visi

ons

(ifn

eede

d)

43

Primary Care

Identifying if a Patient has a Primary Care PhysicianThebelowProcessMap,providedbyProvidenceHealthcare,canbeeasilyappliedtoanyhealthcarefacilitytodetermineifapatienthasaprimarycarephysicianfordischargefollow-up.

Determining Providence Patients have a Family Doctor for Discharge Follow-up

ProvidedbyProvidenceHealthcare

Health Care Connect HealthCareConnectisaprovincialprogramthathelpsOntarianswhoarewithoutafamilyhealthcareprovidertofindone.Peoplewithoutafamilyhealthcareproviderarereferredtoafamilydoctororanursepractitionerwhoisacceptingnewpatientsintheircommunity.Patientsmayconsiderregisteringif:

• theyareactivelylookingforaregularproviderforongoingfamilyhealthcareneeds;• theyhaveavalidOHIPcard(orareeligibleforhealthcoverageinOntario);and• theyarenotcurrentlyenrolledwithafamilyhealthcareprovideraccordingtoMinistryofHealthand

Long-TermCarerecords(i.e.,havenotsignedaministryenrolmentandconsentform).

Frequently Asked QuestionsVisitHealthCareConnect:http://www.health.gov.on.ca/en/ms/healthcareconnect/public/

PFC ensures AC teams educated re including GP

information in all applications

Highlight on Preadmission

summary if GP needed

Patient arrives in Admitting

ADT verifies if patient has a family doctor

ADT issues standard e-mail

to unit SW to advise of no

family doctor

Patient discharged Chart Delivered

Discharge Summary completed

SW determines who could best assist

patient/family

Assisted by SWs to obtain family doctor (See B)

SW assists patient further or notifies team of

no GP

Patient finds GP?

SW/CSC notify ADT

Assisted by CSC in admitting to obtain family

docotr (See A)

Patient has GP

Patient has GP but no contact

>1 year

Patient has no GP

Contacts GP office to

confirm patient on roster

ADT enters contact info into

MediTech

ADT updates MT GP

dictionary

ADT prints admission

summary sheet

Summary sheet to

patient HR on unit

Discharge Summary to GP with note to

follow- up with patient if not already seen

PF

CIn

fo p

rint

s on

adm

issi

on s

heet

for

pati

ent H

R

CSC

coor

dina

tor

Uni

t Soc

ial

Wor

ker

HIM

Yes

Yes

No

No

44

Primary Care Physician Fee CodeNew Fee Codes

AnewfeecodeforaprimarycarevisitafterhospitaldischargewasintroducedtotheScheduleofBenefitsforPhysiciansServicesonOctober1,2006.Paediatriciansmayclaimthisfeecodeforpatientswhentheyarethepatient’sprimarycarephysician.

E080:Firstvisitbyprimarycarephysicianafterhospitaldischargepremium,add$25.00

ForPaymentrulesandmoreinformation,visit:http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4439.pdf

LACE Index: Readmission Prediction ToolTheLACEIndexisaneasy-to-usetoolthatpredictstheriskofdeathorunplannedreadmissionofcognitivelyintactmedicalorsurgicalpatientsafterdischargefromthehospitaltothecommunity.Keyfactorsassociatedwiththeseeventsarelengthofstay(L),acuityofadmission(A),patientcomorbidity(C)andnumberofvisitstotheemergencyroom(E).

Ondayofdischarge,ChargeNurse(orTeamLead)takes3-5minutestoreviewpatient’scharttocompleteLACEIndexScoreCard.Dependingonthepatient’sLACEscore,post-acutesupportisarrangedaccordingly.

LACE Scoring Guide LACE Index Score Card

LACEScoreExpected

Probability,%Attribute Value Point Score

0 2.0 Lengthofstayindays <1 0

1 2.5 1 1

2 3.0 2 2

3 3.5 3 3

4 4.3 4-6 4

5 5.1 7-13 5

6 6.1 ≥14 7

7 7.3 AcuteAdmission Yes 3

8 8.7 Comorbidity(Charlson0 0

9 10.3 comorbidityindexscore)

10 12.2 1 1

11 14.4 2 2

12 17.0 3 3

13 19.8 ≥4 5

14 23.0 EDvisitsinlast6months 0 0

15 26.6 1 1

16 30.4 2 2

17 34.6 3 3

18 39.1 ≥4 4

19 43.7 Total

45

Medication Safety

Best Possible Medication History (BPMH)BPMH:Amedicationhistoryobtainedbyapharmacistortheirdesignatewhichincludesathoroughhistoryofallregularmedicationuse(prescribedandnon-prescribed),usingsomeorallofthefollowingsourcesofinformation:patientorcaregiverinterview;inspectionofvitalsandothermedicationcontainers;reviewofapersonalmedicationlist;and/orfollow-upwithacommunitypharmacyorreviewofacurrentmedicationlistprintedbythecommunitypharmacy.

Best Possible Medication Discharge Plan (BPMDP):Accountsforthemedicationsthatthepatientwastakingpriortoadmission(BPMH),theprevious24-hourmedicationadministrationrecordMAR,andanynewmedicationsplannedtostartupondischarge.TheBPMDPshouldbecommunicatedtothepatient,communityphysician,communitypharmacyandalternativecarefacilityorservice.

UsingtheBPMHandthelast24-hourMARasreferences,createtheBPMDPbyevaluatingandaccountingfor:

• newmedicationsstartedinhospital• discontinuedmedications(fromBPMH)andadjustedmedications(fromBPMH)• unchangedmedicationsthataretobecontinued(fromBPMH)• medicationsheldinhospitalandnewmedicationsstartedupondischarge• non-formulary/formularyadjustmentsmadeinhospital• additionalcommentsasappropriate(e.g.,statusofmedicationstobetakenatpatient’sdiscretion)

DescriptionprovidedbytheInstituteforHealthcareImprovementandtheSafer Healthcare Now!Campaign

Medication Reconciliation Theultimategoalofmedicationreconciliationistopreventadversedrugeventsatallinterfacesofcare,forallpatients.Theaimistoeliminateundocumentedintentionaldiscrepanciesandunintentionaldiscrepanciesbyreconcilingallmedications,atallinterfacesofcare.

Medication Reconciliationisaformalprocessof:

1. Obtainingacompleteandaccuratelistofeachpatient’scurrenthomemedications–includingname,dosage,frequencyandroute;

2. Usingthatlistwhenwritingadmission,transferand/ordischargemedicationorders,and3. Comparingthelistagainstthepatient’sadmission,transfer,and/ordischargeorders,identifyingand

bringinganydiscrepanciestotheattentionoftheprescriberand,ifappropriate,makingchangestotheorders.Anyresultingchangesinordersaredocumented.

Medicationerrorsthatcanbepreventedbyreconcilingmedicationsmayincludebutnotbelimitedto,inadvertentomissionofneededhomemedications,failuretorestarthomemedicationsfollowingtransferanddischarge,duplicatetherapyatdischarge(theresultofbrand/genericcombinationsorformularysubstitutions),anderrorsassociatedwithordershavingincorrectdosesordosageforms.

DescriptionprovidedbytheInstituteforHealthcareImprovementandtheSafer Healthcare Now!Campaign.

46

Follow-up

Follow-up Phone Call Moderate-risk and high-risk patients:Priortodischarge,schedulefollow-upphonecallwithin7daysofpatient’shospitaldischarge:

• callcanbeconductedbyvariouscareproviders,suchasnursewhocaredforthepatient,physician,staffatacallcentre,casemanager,etc.

• duringthecalls,verify(usingTeachBack)that:– Thepatientrecallswhy,when,andhowtorecognizeworseningsymptomsandwhenandwhomto

callforhelp;– Thepatientwillkeepthephysicianappointment;and– Thepatientunderstandshowandwhentotakemedicationsandothercriticalelementsofself-care.

Ifnecessary,scheduleanofficevisitwithin3to5daysafterdischarge;verifywiththepatientandfamilythattransportationisarrangedfortheappointment.

DescriptionprovidedbyInstituteforHealthcareImprovement:NielsenGA,RutherfordP,TaylorJ. How-to Guide: Creating an Ideal Transition Home. Cambridge,MA:InstituteforHealthcareImprovement;2009.Availableathttp://www.ihi.org

Communication

Medication Reconciliation FormHospitaldischargeisacriticalinterfaceofcarewherepatientsareatahighriskofmedicationdiscrepanciesastheytransitionoutofthehospital.Thegoalofdischargemedicationreconciliationistoreconcilethemedicationsthepatientistakingpriortoadmissionandthoseinitiatedinhospital,withthemedicationstheyshouldbetakingpost-dischargetoensureallchangesareintentionalandthatdiscrepanciesareresolvedpriortodischarge.Thisshouldresultinavoidanceoftherapeuticduplications,omissions,unnecessarymedicationsandconfusion.

Dischargemedicationreconciliationclarifiesthemedicationsthepatientshouldbetakingpost-dischargebyreviewing:

• Medicationsthepatientwastakingpriortoadmission(BPMH)• Previous24-hourMAR(MedicationAdministrationRecord)• Newmedicationsplannedtostartupondischarge

Adischargemedicationreconciliationformmaybedevelopedsimilartotheadmissionmedicationreconciliationform.Theresultofdischargereconciliationshouldbeclearandcomprehensiveinformationforthepatientandothercare.

DescriptionprovidedbytheInstituteforHealthcareImprovementandtheSafer Healthcare Now!Campaign.

47

Patient Education

Teach BackTeachBackinvolvesaskingthepatientorfamilycaregivertorecallandrestate(intheirownwords)whattheythoughttheyheardduringeducationorotherinstructions.Askingpatientstorecallandrestatewhattheyhavebeentoldisanimportantpatientsafetypractice.TouseTeachBack:

• explainneededinformationtothepatientorfamilycaregiverandthenaskinanon-shamingwayfortheindividualtoexplaininhisorherownwordswhatwasunderstood

• ifagapinunderstandingisidentified,offeradditionalteachingorexplanation• assessthepatient’sabilityandconfidencetoperformintendedself-care,includinguseofmedications;

diet;symptomawarenessandmanagement;abilitytofillprescriptions;andreasonstocallthephysician(e.g.,pain,weightgain,difficultybreathing)

• usemultipleopportunitieswhilethepatientisinthehospitalforreviewofimportantinformationtoincreasepatientandfamilyrecallandconfidence

• checkforunderstandingusingTeachBackaftereachsegmentorportionoftheinformation.Forexample,conductTeachBackaftertellingthepatienthowtotakehis/her“waterpill”andagainafterexplainingthereasonstocallthedoctor.

DescriptionprovidedbyInstituteforHealthcareImprovement:NielsenGA,RutherfordP,TaylorJ.How-to Guide: Creating an Ideal Transition Home.Cambridge,MA:InstituteforHealthcareImprovement;2009.Availableathttp://www.ihi.org

Patient TeachingFacilitatepatientteachingusingthefollowingguidelines:• useplainlanguage,breakingcontentintosmaller,easy-to-learnparts.

– PlainLanguageAssociationInternational:www.plainlanguagenetwork.org– ClearLanguageGroup:www.clearlanguagegroup.com

• slowdownwhenspeakingtothepatientandfamily,andbreakmessagesintoshortstatements.Useeasy-to-learnsegmentsofcriticalinformationtohelppatientsandfamilycaregiversmasterthelearningmoreeasily.

• ifwrittenmaterialsareused,highlightorcirclekeyinformation.• “AskMe3”isanotherusefulpatientcommunicationandeducationtoolthathelpsstafftoteachpatients:

1. whatthemainproblemis2. whatthepatientshoulddoforthatproblem3. whytheactionisimportant.

AskMe3alsoencouragespatientstoadvocatetogetthisinformationabouttheircare.

DescriptionprovidedbyInstituteforHealthcare:NielsenGA,RutherfordP,TaylorJ.How-to Guide: Creating an Ideal Transition Home.Cambridge,MA:InstituteforHealthcareImprovement;2009.Availableathttp://www.ihi.org

48

Appendix 4. Measures and Evaluation

Measures included in recommendations:

Hospital1a. Lengthofstayinacutecare.Thisisrecommendedasabalancingmonitoringmeasuretoensurethat

staysarenotabbreviatedorelongatedandtoenableassessmentofrelationshipbetweenLOSandreadmissions.ThereisnoperformancetargetassociatedwithLOS[Acute]

Primary Care2a. HealthCareConnectlinkageforunattachedpatients.Itisrecommendedthatallpatientswhoreport

nothavingaPCPareenrolledinhealthcareconnect[Acute]

2b. Primarycarevisitwithin7daysforhigh-riskpatients[Acute,PCP];primarycarevisitwithin14daysforlow-riskpatients[Acute,PCP]

Medication Safety3a. Fullmedicationreconciliationcompletedpriortodischargefromacute[Acute]3c. MedicationReconciliation(PharmacyMedsCheck)billingwithin14days[Pharmacy]

CCAC5b. TimefromreferraltoCCACtoacutedischarge.ItisrecommendedthatallCCACreferralsoccurat

least48hourspriortodischargeforallhigh-risk*patients[Acute];

TimefromreferraltoCCACassessmentwithRAI-ContactAssessmentforpatientsreferredtohomecare(onlyforhomedischarges).ItisrecommendedthatRAI-CAassessmentsbecompletedwithin24hoursafterreferralforallhigh-riskpatients[CCAC]

TimefromdischargetofirstCCACnursingvisitforhigh-riskpatients[CCAC].ItisrecommendedthatCCACensureanursingvisitinhomewithin3daysofacutedischarge(preferablyearlier)forallhigh-riskpatients.Thisnursingvisitshouldincludeareviewofpatientmedicationstoidentifypotentialrisks.

Communication6a. DischargeSummaryProvidedtoPatient,includingfulllistofmedicationsandfollow-upappointments

[Acute]

6b. DischargeSummaryProvidedtoPhysician,includingfulllistofmedicationsandfollow-upappointments[Acute]

6c. DischargeMedicationListProvidedtoPharmacy,includingfulllistofmedicationsandfollow-upappointments[Acute]

6d. Patientprovidedinformationonwhotocontactanduseofmedications(communicationofdischargeplantopatient)[Acute]2

2IncludedinexistingNRCPickerPatientsSatisfactionTool–Appendix1.

49

Evaluation Recommendations1. Trackingofinterventioncomponentsshouldataminimumincludefactorsassociatedwitheachof

theperformancemeasures.Aqualityimprovementplantemplatethatincludedtheseelementswouldfacilitatethisdatacapture.

2. Performancereportsincludeananalysisoftheobservedrelationshipbetweenprocessperformancemeasuresandthereadmissionoutcomemeasure.

3. Feedbackofstatusorongoingoperationalreportsshouldbeprovidedtoallrelevantstakeholders(LHIN,CCAC,hospital,pharmacy,andphysician).

Performance Measures for Acute Patients Discharged to Community

Link to Pharmacy •MedsCheckwithin14daysforalldischarges

Link to primary care•Healthcareconnectforunattachedpatients†

•PCPvisitwithin7dayspost-dischargeforhigh-riskpatients*

•PCPvisitwithin14daysforlow-riskpatients*

All acute patients•LACEscreenforhighrisk(10+)•LengthofStay

Link to CCAC•ReferraldatetoCCACforhigh-riskpatients*†

•CCACassessmentdateforhigh-riskpatients*†

•CCACvisitwithin3daysforhigh-riskpatients*

During Hospital Stay After Hospital Discharge

*LACEscreennotmeasuredbutusedincalculationofsubsequentrisk-stratifiedmeasures†Indicatesserviceprovisionmeasuresfrombestpracticeguidanceworkinggroup

50

Appendix 5. ReferencesAgencyforHealthcareResearchandQuality.(AHRQ).(2008a).Peeradvisorycoachingcombinedwithnurseoutreachimprovesadherencetomedicalrecommendationsamongelderlycardiacpatientswholivealonefollowingdischarge.AgencyforHealthcareResearchandQuality.AccessedMarch21,2010fromhttp://www.innovations.ahrq.gov/content.aspx?id=1823.

(2008b).Post-dischargecaremanagementintegratesmedicalandpsychosocialcareoflow-incomeelderlypatients.AgencyforHealthcareResearchandQuality.AccessedMarch21,2010fromhttp://www.innovations.ahrq.gov/content.aspx?id=1746.

(2008b).Hospital-basedasthmaeducatorstrainpatients,providers,andcommunitymembersonoptimalcare,leadingtofeweradmissions,emergencydepartmentvisits,andmissedworkdays.AgencyforHealthcareResearchandQuality.AccessedMarch21,2010fromhttp://www.innovations.ahrq.gov/content.aspx?id=2476.

BoutwellA,GriffithF,HwuS,ShannonD.(2009).Effectiveinterventionstoreducerehospitalizations:Acompendiumof15promisinginterventions.Institute for Healthcare Improvement,Cambridge,MA.

ColemanEA,ParryC,ChalmersS.(2006).Thecaretransitionsinterventions:Resultsofarandomizedcontrolledtrial.Arch Intern Med;166:1822-1828.

Goldfield,N.(2011).Howimportantisittoidentifyavoidablehospitalreadmissionswithcertainty?CMAJ,19;183(7):E368-9.Epub2011Mar28.

Ham,C.,Imison,C.,Jennings,M.(Ed).(2010).Avoidinghospitaladmissions.Lessonsfromevidenceandexperience.The King’s Fund 2010.

KesselsRP.(2003).Patients’memoryformedicalinformation.J R Soc Med.May2003;96(5):219-22.

MedicarePaymentAdvisoryCommission.(2007).ReporttotheCongress:PromotingGreaterEfficiencyinMedicare.MedPAC,Washington,DC.

NaylorMD,BrootenDA,CampbellRJ,etal.(1999)Comprehensivedischargeplanningandhomefollow-upofhospitalizedelders.JAMA1999;281:613-20.

NaylorMD,BrootenDA,CampbellRJ,MaislinG,McCauleyKM,SchwartzJS.(2004).Transitionalcareofolderadultshospitalizationswithheartfailure:Arandomizedcontrolledtrial.Journal of the American

Geriatric Society;52:675-684.

NielsenGA,RutherfordP,TaylorJ.How-to Guide: Creating an Ideal Transition Home.Cambridge,MA:InstituteforHealthcareImprovement;2009.Availableathttp://www.ihi.org.

Purdy,S.(2010).Avoidinghospitaladmissions:Whatdoestheresearchevidencesay?TheKing’s Fund.

ISBN:9781857176070

Walraven,C.,Bennett,C.,Jennings,A.,Austin,P.C.,Forster,A.J.(2011).Proportionofhospitalreadmissionsdeemedavoidable:Asystematicreview.CMAJ,183(7):E391-402.Epub2011Mar28.

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