Follow Through is Everything Care Transitions: Length of Stay and Readmission Management Leslie Foti, RN BSN ACM.

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  • Slide 1
  • Follow Through is Everything Care Transitions: Length of Stay and Readmission Management Leslie Foti, RN BSN ACM
  • Slide 2
  • Presenter Disclosures Leslie Foti, RN BSN ACM No relationships to disclose.
  • Slide 3
  • Why Do Care Transitions, Length of Stay (LOS), and Readmission Matter? Setting the Table
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  • New Payment Structure: Incentivizing Value and Quality Its Here! Hospital Value-Based Purchasing Pay-for-Performance Readmission Penalties Increased Scrutiny of Utilization
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  • Why Does Length of Stay (LOS) and Readmission Matter? Financial Sustainability Appropriate Stewardship of Resources The Right Thing to Do for the Patient!
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  • What are Care Transitions? Transition of Care The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another (CMS, 2010) Goal the shortest, safest, most efficient hospital stay with discharge to a level of care that has the needed resources and knowledge to manage the patients care outside of the hospital setting
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  • Who Owns Care Transitions? a)Case Management b)The Health Care Team c)The Patient and Family d)All of the Above
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  • What is the Target?
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  • Transition Needs of the Stroke Population Stroke - a leading cause of serious long-term disability
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  • To Coordinate in an Average of 2-6 days! Ancillary Services Therapy Dietician Pharmacy Case Management Teaching Core Measures for Stroke New Diagnoses New Medications New Diet New Equipment
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  • To Coordinate in an Average of 2-6 days! Screen and Assess for : Depression Caregiver Burden Respite care Support groups Discharge needs Support Level of care Resources Financial Barriers
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  • Integrate & Deliver Services in Alignment with LOS Goals Communication, Coordination, Collaboration
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  • Managing LOS Ensure everyone knows the goal! Create systems that ensure all patient needs are addressed without over utilization Know the players on your team & ensure they know what position theyre playing! Establish a consistent communication plan
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  • Managing LOS Basic Nursing Care advancing diet, activity, weaning medications and O2, and Teaching! Special vigilance with longer ICU, intermediate stays Dysphasia PEG or not to PEG? Adequate intake on modified diets Look at your weekends is it a black hole?
  • Slide 15
  • Managing LOS Newer Anticoagulants Financial Barriers Delirium, Dementia, & Restraints Managing Patient and Family Expectations
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  • Reducing Readmission Starts with Discharge Preparation 30% of acute stroke patients experience a hospital readmission within 90 days of discharge (Roger, et al., 2011)
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  • Discharge Where the Ideal Meets Reality Home discharge we must prepare the patient and family to self-manage their care Willingness & Readiness Teaching is Vital! Access to Care Do they have a PCP? Can they afford their medications? What to do with the VA?!? Home Health vs. Outpatient therapy
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  • Readmission Reduction Strategies for the Home Discharge Structured Teaching Teach Back Discharge Instructions Should include EVERYTHING they need to know! What to know about risk factors, lab targets, medications, signs and symptoms Who to contact with phone numbers Follow-up appointments made prior to discharge Post Discharge call backs within 24 hours Respite and Support Resources
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  • Discharge Where the Ideal Meets Reality Facility Discharge LTACH, Acute Rehab, SNF, Custodial Care - which level? What Impacts the Determination Acuity Payer Support system Increased scrutiny of acute rehab Observation status Patient ability to participate in therapy
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  • Readmission Reduction Strategies for the Facility Discharge Choose the RIGHT level of care Handoff to post hospital care providers Discuss custodial care early if it is anticipated Family conferences and palliative care
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  • Other Strategies Consider: Partner with post hospital care providers and support them with stroke specific education Telephonic support for 30 days post discharge Reassess for Cognitive Decline, Depression, Caregiver Burnout with every follow up
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  • Thank you!
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  • References & Links Centers for Medicare and Medicaid (CMS), (2011). Eligible professional meaningful use menu set measures measure 8 of 10, stage 1, transition of care summary. E.H.R Incentive Programs. Retrieved from Guidance/Legislation/EHRIncentivePrograms/downloads/8TransitionofCareSummary.pdf Guidance/Legislation/EHRIncentivePrograms/downloads/8TransitionofCareSummary.pdf CMS, (2013). Hospital value-based purchasing program. Department of Health and Human Services Centers for Medicare & Medicaid Services. Retrieved from MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf CMS, (2013). FY 2014 final rule tables. Retrieved from Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html CMS, (2015, January 26 th ). Fact sheets: better care. smarter spending. healthier people: paying providers for value, not volume. Retrieved from Coleman, E.A., Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), p. 556-7. Olson, D.M., Prvu Bettger, J., Alexander, K.P., Kendrick, A.S., Irvine, J.R., Wing, L., Graffagnino, C., (2011). Transition of care for acute stroke and myocardial infarction patients: from hospitalization to rehabilitation, recovery, and secondary prevention. Agency for Healthcare Research and Quality, Publication No. 11(12)-E011. Mozaffarian D, Benjamin EJ, Go AS, et al., (2015) Heart disease and stroke statistics2015 update: a report from the American Heart Association. Circulation,e29-322 Naylor, M.D., Aiken, L.H., Kurtzman, E.T., et al., (2011) The importance of transitional care in achieving health reform. Health Affairs (Millwood)30 (4), p. 46-54. Poston, K. M., Dumas, B. P., & Edlund, B. J., (2013). Outcomes of a quality improvement project implementing stroke discharge advocacy to reduce 30-day readmission rates. Journal of Nursing Care Quality, 29 (3), p. 237-44. Roger, V.L, Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., Carnethon, M.R., Wylie-Rosett, J., (2011).Executive summary: heart disease and stroke statistics2011 update: a report from the American Heart Association. Circulation 123 (4):459-463. Links: Joint Commission Core Measures: Joint Commission Comprehensive Stroke Center requirements:


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