Lee Memorial Health System Our Journey Through Transitions of Care

Joan Carroll RN, BA, CDMS, CCM Director Care Transitions

Lee Memorial Health System

Lee Memorial Health System

1,423 Acute Care Operational Beds Not For Profit Public Hospital System with 10

Member Elected Board of Directors 10,000 Employees, 4,300 Volunteers & 1,200

Staff Physicians, 85 Employed Physicians 6 Hospitals, Sub Acute, Physician Group,

Convenient Cares, Home Health, Skilled Nursing Facility, Rehabilitation, Regional Cancer Center, LPG united Way House

81,531 Admissions Annually

Care Transition Coaching CT is a 4 week program to help patients transition

from hospital to home, while learning how to manage their chronic condition

The LMHS model for Care Transition Coaching is a combination of the Coleman Model, Project RED, BOOST

5 basic areas of our coaching program include Patient self management assessment

Medication ManagementPersonal Health RecordDiagnosis / Red Flags / Actions Communicating with health care

professionals

Discoveries Didn’t know their diagnosis Had no idea what it was No understanding of acute or chronic Believed the hospital cured them Recovery is a rest period No knowledge of their role No knowledge of red flags Reverted to meds they already paid for No medication management system Couldn’t remember 3 of their meds and their

purpose or side effects

Patient had prescription meds that were not on the discharge instructions

Patient had no prescriptions for new meds on the discharge instructions

Patient had no idea of their limitations DME had not been delivered BIPAP not delivered / patient in trouble Patient extremely SOB 1days post discharge/ ankles

still showing extreme edema / Poor discharge Home not safe Patient depressed or lonely

Discoveries

Discoveries Couldn’t find their discharge instructions Didn’t remember anyone going over them Had not filled their new prescriptions Taking OTC meds unapproved Believed the salt shaker (which they didn’t use)

was the only source of sodium Had not scheduled their PCP appointment Drank 10-15 glasses of water a day (per Dr. Oz) Used their inhalers incorrectly Couldn’t read and/ or follow direction Were unstable on their feet

Had 50 feet of Oxygen tubing Nebulizer was filthy Alcoholics? No money for meds or groceries No transportation to the doctor No caregiver assistance Couldn’t get an appointment for 1 month Caregiver was worse than the patient Depression Electricity had been turned off No food

Even More discoveries

AHA!Could these possibly be the

root causes for re-admissions?

Where do we begin?

Next step/ collect data

Patient Activation Assessment

Discharge Evaluation

Medication Discrepancies

Readmissions

Patient Activation Assessment showed patients prior to discharge– Scores 1-3/10

Discharge Evaluations March 2011 -60%

Med Discrepancies – 92% in January of 2011

Results

Hospitalists and SpecialistsCase management

VP of NursingDischarge Nurses

Staff NursesNursing Education

PharmacistsRespiratory Therapists

Physical TherapistsNutritionists

What Next? Communicate and Collaborate

Discharge order sets for CHF and COPD/ simplified / disease specific

CHF Unit opened and certification completed Physicians include specific discharge orders for

screening for balance/ medication review Improved cognitive assessment Palliative Care Training Increased Home Health Referrals Teach Back education Standardized Handouts Caregivers are identified in the EMR

What did we do in Acute Care?

LMHS System Initiatives

Acute Care• System Wide Risk Stratification Tool• Tracking Readmission reasons• Care Transitions • Care Management Website – Community

Resources• Teach Back and F/U appointment• Pharmacy Collaboration on Medication

Discrepancies• CHF Unit / Cardiac Decision Unit for Obs

patients• Readmission work groups- Pulmonary & CHF

System Accomplishments CHF Unit opened / Certification completed/

readmissions reduced at HP Pharmacy providing Medication prior to discharge EPIC update of Discharge orders improved Rounding initiated at ¾ facilities COPD Management Program GC Reduce LOS/ Readmissions Committee CCH Readmissions Committee Home Health protocols for diuresis in home

completed Home Health Telehealth using 400 units in the

community Home Health frontloading Nutrition Assessment with Food Bank Vouchers

• SNF Administrator and DON• Case Management & Medical Social

Workers• Hospitalist• ED Physician• SNF Medical Directors• ED Nurses• Care Transitions Director• Infection Control• Educator• Palliative Care

Home Health Agencies/ CoalitionWork Group

Home Health Care CCCaaauuussseee aaannnddd EEEffffffeeecccttt DDDiiiaaagggrrraaammm (((fffiiissshhhbbbooonnneee)))

Home Health Care CCCaaauuussseee aaannnddd EEEffffffeeecccttt DDDiiiaaagggrrraaammm (((fffiiissshhhbbbooonnneee)))

Date 1/23/2013

Pt/family lack understanding of HHC Hospitalist will not sign HHC order Pt needs higher level of care then HHC Delay in order Hospitalist does not communicate with PCP Caregiver fatigue Delay in face to face Pt has increased co-pay for HMO Lack of orders related to condition-wound care Caregiver does not have skills to care Incorrect or no diagnosis-especially with for the patient with depression No copy of discharge order

Lack of discharge summary PCP does not know that HHC ordered Lack of discharge date in information HHC referral sent to multiple agencies Patient is not informed that a JJC has Lack of balance of payers to HHC been ordered Incorrect patient demographics on referral Special needs not identified

Lack of supplies for Pertinent social issues not communicated Pt is not educated on HH level of care

Referral delay or delay in order

Readmission Rate High

Patient Physician

Hospital Communication

Lack of supplies, wound care, ostomy

SNF Coalition and workgroup/ Quarterly meetings

• Review Lee County readmission data• Discuss 2 facilities Readmissions initiatives• Create Readmission Task Force• Developed a tool to collect transfer data for SNF

on CHF, COPD and MI• Root Cause Analysis completed• Action Plan completed• Completed INTERACT Training• Training 13 facilities

Readmission Root Cause Analysis

Causes ofReadmission

Patient

Orders

Communication Family

Unrealistic familyexpectations

Advance directiveissues

RN to RNcommunication

Medicationcommunication

Lack ofcommunicationto ED from SNF

Lack of standing orders

from SNF

Physicians

Lack of SNF Attendingseeing patient promptly

More complex

Medically unstable,Impacts therapy

Fear of liability

Lack of patient education

Lack of family education

Inappropriateadmission

Unrealistic patientexpectations

Lack ofknowledge

Information

UnknownPrognosis

Lack of medicalrecord access

Inappropriateadmission

Coordinated Care

Lack of care path

Patient not seen atbedside by familiar

caregivers

Assessing rehabservices potential

MedicationReconciliation

Medication

Insufficientancillary service

coverage

Medication orders not received timely

Discharge planninginfo not accurate/comprehensive

Small Tests of Change

• Discharge Summary faxed to SNF 24- 48 hr• Updating the automated referral near discharge • INTERACT II utilized at a few SNFs• Include Transition of Care with all new physician

Orientation • Nurse to Nurse Hand off communication• Epic transfer information printed and sent to SNFs• Standardized PT / OT post acute recommendations • Pharmacy completes Medication Reconciliation all

SNF transfers

Oct-0

9

Dec-0

9

Feb-1

0

Apr-10

Jun-1

0

Aug-10

Oct-1

0

Dec-1

0

Feb-1

1

Apr-11

Jun-1

1

Aug-11

Oct-1

1

Dec-1

1

Feb-1

2

Apr-12

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

LMHS - SNF - 30 DAY READMISSION RATE FY2010 - FY2012 (THROUGH MAY)

System Wide High Risk Assessment

• Age 70 or greater• Chronic Conditions (CHF, AMI, Pneumonia, Diabetes,

etc.)• Polypharmacy• Takes Anticoagulants, ASA, Plavix, Insulin, Digoxin• Previous Admissions within last 3, 6 or 12 months• Living Situation• Health Literacy & Language• Cognitive Impairment• Patient Self-Health Rating• Fall Risk• Palliative Care• Psych/Social- Depression

Chronic Disease Self-Management Program• An evidence-based health promotion program for persons

with chronic diseases• Teaches participants self-management techniques• Brings community agencies together to tackle chronic

illness in a unified manner; thus, maximizing utilization of resources and minimizing overlap of initiatives

• Train-the-trainer format to improve self-management and build self-confidence

• Generic enough to cover a variety of different conditions

CDMP Program Overview

Six weekly 2.5 hour sessionsEach class is led by two trained lay leadersFocusing on:

- Nutrition and exercise- Using community resources- Learning about medication use- Relaxation techniques- Solving health-related problems

Care Transitions Update

The Personal Health Record and handouts are available in SpanishExpansion to all the hospitals (7 coaches, 2 RT, 1 MSW)HPC+RC / PT CT CoachProvided Teach back education for several HHA / acute care unitsCHF handouts available in SpanishSee patients twice, at discharge and 15 daysMay add Grand AidesDeveloping a Caregiver Assessment toolNutritional assessment program with supplementation

Discharge education begins on admission Providers are alert to all the possible care

needs after discharge Compassionate teach back is provided by

all disciplines Literacy and health literacy are assessed

and education is provided at the patient‘s level of understanding

Appropriate caregivers are included in the discharge education

What is a successful transition?

Care Transitions coaches follow the patient for 30 days

Patients are referred to appropriate agencies for additional services

The patient has transportation to the PCPs office within 8 days of discharge

The patient has food and has obtained his medications

The patient has knowledge of his medications and self management details

The Patient’s primary caregiver knows about the hospitalization

What is a successful transition?

Thank you for your attention. Transition home safely!

Finally DONE!!