Health Optimization Program for Elders (HOPE)Transitional Care from Duke University Hospital to Skilled Nursing Facilities

HeidiK.White,MD,MHS,MedTammieShepherd,MHA,BSN,RN,ACMWilliamEnglish,MBA,MSHA

BACKGROUNDHealth Optimization Program for Elders (HOPE)

What is HOPE?Transitional care model designed to prevent avoidable

readmissions and other adverse outcomes during and after transition from the acute inpatient care setting to the post-acute

care setting for adult patients age 55 and older at Duke University Hospital

Acute HOPE SNF

SYSTEM LEVEL

PATIENT LEVEL

Why HOPE?

Too many patients, families, and providers experience a disconnect between hospital

care and skilled nursing facility care.

HospitalSkilled Nursing Facility ?

Why Now?

Hospital Readmission Penalties

Bundled Payments

Movement toward Capitated Systems w/ Shared Risk• Medicare Shared Savings Plan (MSSP)• Duke Connected Care• Duke Well

Framework

• Optimize function

• Reduce risk of delirium & falls

• Enhance GeroD/c readiness

Acute Care(Pre-discharge)

• Medication review• Provider-to-

Provider communication

• Goals of care

Transitional Care(Bridging Transition) • Sub-acute care

for at-risk elders• Early recognition

of geriatric syndromes

SNF Care(Post-discharge)

Occurswithinaprocessimprovementframeworkthatsystematicallyevaluatespreventablehospitalizations

Organizational Structure

Timeline

2013

• Pilot Program/ Phase I Initiated

• Workgroup• DUHS Quarterly

SNF Conference

2014

• First Formal Data Analysis to Show Efficacy

2015

• Jun: Dedicated Administration & Data Engineering Support

• Jul: Acquisition of APP FTE to Staff Clinical Program

• Oct: Joined MSCC CSU at DUH

2016

• Feb: Hired NP

• Apr: Referral Source Changes

• May: NP Leads Clinical Program

• Nov: Second Formal Data Analysis to Show Efficacy

Key Partnerships

HOPEDuke Geriatrics Division

DUH Hospital Medicine

Local Skilled Nursing Facilities

DukeSchoolofNursing(SON)

Case Management

Duke Well

Duke SON & HOPE

• Student Collaborators– Patient Education Materials

• Nurses Improving Care for Healthsystem Elders (NICHE)– Interagency Education

Case Management & HOPE

Original Referral Source

Case managers requested HOPE referrals from hospitalists

Discharge Documentation

Used feedback from HOPE Workgroup to work with

EHR technicians to optimize discharge documents

First Efforts at Risk

Stratification

METHODS & RESULTSHealth Optimization Program for Elders (HOPE)

Methods

Phase I:September 2013 – September 2014

Phase II:May 2016 – November 2016

• Staffing: – Geriatrics Consult Physicians & Fellows

• Patient Population:– General Medicine– Ages 65+

• Patient Identification: – Case-management driven

• HOPE Consultation:– Chart review– Med review– Patient exam– Patient/family discussion re: diagnosis, prognosis and rehab potential, and goals of

care– Recommendations for optimization of rehab– Identification of issues– Verbal handoff to SNF team

Results

Phase I:September 2013 – September 2014

Phase II:May 2016 – November 2016

General Medicine HOPE

n= 1,315 n = 59

Readmission Rate

10-day % 19.1% 18.6%

30-day % 9.5% 6.8%

LOS

Mean 9.9 11

Methods

• Staffing: – HOPE Nurse Practitioner

• Patient Population:– General Medicine– Ages 55+

• Patient Identification: – General Medicine medical leadership / hospitalists– Case Management– SNF Partners

• HOPE Consultation:– Chart review– Med review– Patient exam– Determination of need for additional service (e.g. Geriatrics Specialist Care, Palliative Care etc.)– Patient/family discussion re: diagnosis, prognosis and rehab potential, and goals of care– Recommendations for optimization of rehab– Identification of issues– Verbal handoff to SNF team– Post-discharge follow-up within 72 hours (via phone or in-facility)– Hand-off to other Duke services (e.g. Duke Well)

Phase I:September 2013 – September 2014

Phase II:May 2016 – November 2016

Results

General Medicine HOPE

n= 540 n = 118Readmission Rate

7-day % 4.9% 2.2%14-day % 8.4% 6.5%30 day % 15.4% 10.1%90-day % 27.8% 25.9%

LOSMean 9.4 12.4

CMIMean 1.85 2.04

Phase I:September 2013 – September 2014

Phase II:May 2016 – November 2016

0%

2%

4%

6%

8%

10%

12%

14%

0

5

10

15

20

25

30

35

May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

HOPEConsultVolume&Readmissions

Volume 7-dayReadmit 14-dayReadmit

CONCLUSIONS & NEXT STEPSHealth Optimization Program for Elders (HOPE)

Conclusions

• Proven potential to avoid discharge failures

• Post-discharge follow-up critical in correcting missteps and building relationships with SNF medical providers/nursing staff

• HOPE is a part of a broader transitional care plan

Next Steps

• Data Refinement

• Risk Stratification

• Assessment of protocolized hand-offs to appropriate services post-discharge