Re-Admission Intervention Strategies

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HOSPITAL RE-ADMISSION INTERVENTION INTERVENTION

STRATEGIESPresented By

Robin Seidman, RN, MSN, MBA, LNCC, HCS-DNatalie Kenney RN, Care Transitions Nurse Specialist

National Association of Homecare & HospiceANNUAL MEETINGNovember 1, 2013

INTRODUCTION

It’s no secret…everyone wants to lower hospitalization rateshospitalization ratesSteps of Implementing a RE-ADMISSION INTERVENTION STRATEGY COUNCILTool for data collection & analysis

Creating a DASHBOARDCreating a DASHBOARD

Identify Interventions & Strategies to help reduce re-hospitalizations

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Re-Admission Intervention Strategies

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What does RISC mean?Re-admission Strategy Intervention CouncilWHENo Instituted December, 2011

WHYo Responding to increase in

acute care hospitalizationsWHOo Clinical Managers, Nursing, Rehab,

Transitions in Care, Palliative Care3

RISC ImplementationInvite Council MembersSet Meeting Scheduleo Weekly – decrease to monthly

Meeting Agendao Compile reasons for Re-Admissions

• Need to TREND & ANALYZE

o Create Trigger Lists (i.e. case conference, palliative consultconsult

o Create written processes• Case Conferences• Managing the non-compliant patient• Front loading visits for STAAR & high-risk patients• PCP Appointment follow up 4

Re-Admission Intervention Strategies

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RISC GoalsMust have GOALS to be SUCCESSFUL:

Use data collection and analysis to identify any trendUse trends to develop programs & resourcesIncrease awareness of patients that return to hospitalU C C fUse Case Conferences,POC modification & otherstrategies / interventions tokeep patients at home US Women’s

Soccer WINS 3rd

GOLD Medal5

IDENTIFY TRENDS

In order to identify trends, RISC developed an automated data collection tool using Microsoft Excel. The data is collected for every patient transfer to the hospital. The data collected includes:o Patient Information (ID #, Name)o Start of Care Date for Home Health Serviceso Transfer Date to Hospitalo Reason for Hospitalizationo Reason for Hospitalizationo Risk Factors that could impact transfers (i.e. lives

alone, complex medication regime)o Patient’s Case Manager (RN or PT)o Physician

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Re-Admission Intervention Strategies

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RISC Data Collection RISC Data Collection Tool (Excel)

o Information from All-Calls We are trying to set

o Fields of Entry:• ID# & Name• SOC & Transfer Date• REASON for Hospitalization• RISK Factors

AVOIDABLE or Not

We are trying to set Natalie up for RISC data collection…...which line is for OASIS???

• AVOIDABLE or Not• Case Manager• MD• Comments

Sort data for analysis & trending7

User Friendly Data Entry Tool

EASY To UsePull-Down Menus

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Re-Admission Intervention Strategies

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User Friendly Data Entry Tool

Select ALL RISKs that Apply

Pull-Down

Enter Case Manager, MD & applicable comments

Pull-Down Menu to select AVOIDABLE or Not

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Sample of Tool

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Re-Admission Intervention Strategies

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RISC Analysis - Dashboard

Primary REASONfor

HOSPITALIZATION(OASIS M2310)

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RISC Analysis - DashboardRISK

CategoriesDetermined by RISC y

yAVOIDABLE or Not Avoidable

& by DIAGNOSIS 12

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&&

Re-Admission Intervention Strategies

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What is the PIRT Alert

WHAT type of PatientWHAT type of PatientPPatient at IIncreased RRisk for TTransferWHAT type of Patient WHAT type of Patient TransferTransfero The PIRT alert identifies a patient

that has been transferred to the hospital more than once in a 60-day HH Episode.

“Frequent Flyers”

WHO is ResponsibleWHO is Responsibleo Clinical Managers, Case Managers,

all others disciplines involved in the case.

• Senior Management included on Alerts15

PIRT Alert Process

Case conference will review why patient went to the hospitalpatient went to the hospitalReview current Plan of Care (POC) and all related clinical documentationModify POC to reduce patient’s risk of re-hospitalization.pAction plan initiated before resumption of home care serviceso i.e. management of non-compliant patients

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Re-Admission Intervention Strategies

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SAMPLE PIRT ALERT

Typical PIRT Alert sent via email communication:o PIRT Alert for SECOND Transfer in

episode starting 5-02-13• 7-11-13 Dehydration , Adult FTT• 8-17-13 Fall with Left Clavicle FX.f

Thanks,RISC

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SAMPLE PIRT ALERT & AVOIDABLE HOSPITALIZATIONPIRT Alert for SECOND Transfer in Episode. SOC 7-26-13

o 7-29-13 N/V D, Hypokalemia

o 8-10-13 N/V, Metastatic Prostate CA.

o Case Conference thoughts:

• Why so much Nausea, Abd Ct 10 days ago, no Obstruction.

• Is He currently getting Chemo/Radiation?

• Reglan will enhance Motility,? Diarrhea.

D h d thi l f N ??Z f• Does he need something else for Nausea, ??Zofran.

• The Morphine IR is for Break through pain, How often does he use this , and should the Fentanyl patch dose be changed?

• Palliative Care consult?

Thanks, RISC18

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Case Conference ProcessCreated Case Conference Guidelines specific for PIRT Alert & Avoidable re-hospitalizationo Objective

• To manage the needs of high-risk patients as effectively as possible until discharge back into the community

o Trigger List• High-risk patients (i.e. STAAR, SHP, OASIS M1032)

o Format of Case Conference• Identify Facilitator (i.e. Clinical or Rehab Manager)• Invite appropriate clinicians• Face to face or Conference Call (Agency # set up)• Attend meeting with documentation needed (i.e. laptops)

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Case Conference AGENDA

REVIEW & DISCUSS:REVIEW & DISCUSS:Plan of Care Medication ListTreatmentsClinical Notes→ Visit notes prior to transfer→ Transfer note→ Transfer note

Visit FrequencyScheduling & Continuity of caregiversSupport services

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Expected OutcomesModify Plan of Care as neededReview FALL RISKFALL RISK► TUG > 30 seconds► OASIS ADLs – difficulty out of chair, commode► Benefit from a PT/OT EVAL??► LIFELINE Program

Case Conference should occur as soon after Transfer as possibleTransfer as possible.o Average LOS in hospital = 2.8 days

Document Case Conference in the Clinical Notes in Allscripts.

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STRATEGIES - ResourcesPatient & Family Guide Tri-Folds

CHFCOPDWound ManagementCatheter ManagementBladder HealthDehydration PreventionDehydration PreventionMIPneumoniaConstipation

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STRATEGIES - Programs

ProgramsAdvanced Heart Failure ManagementAdvanced Heart Failure Management

Advanced COPD Management

Wound Care Essentials

LIFELINE

SBARSituation Background Assessment Recommendation

CALL US FIRST STICKER INITIATIVE

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Heart Failure & COPD Management Programs

Identified at Intakeo “STAAR” on documentationo STAAR on documentation

Patient Schedulingo Front-loading (5W1, 3W1, 1-2W7)

o Medication Intensive Visit (within 10 days)o Case Manager continuityg y

Program Booklet as Teaching GuideCollect, analyze & report program data to Quality & Safety Council

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Wound Management Program

Collaborative wound educationo Nursing and Therapyo Nursing and Therapy

PowerPoint presentationEssentials of Wound Management in the HomeCare Setting Bookleto Wound Chart Illustrations foro Wound Chart Illustrations for

Identificationo OASIS Documentation Tip Sheet

1.5 CEUs

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Strategy - EDUCATION

o Specialized educationRISC THINK–TANK

o Specialized education program to introduce RISC initiative to all staff

o Provide staff with tools & strategies to reduce avoidable re-hospitalizationsre hospitalizations

o PowerPoint presentationPrinted resourceActual Case Conference Examples (3 patients)Informal open discussion to engage staff in sharing of new ideas and/or strategies 26

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Post-Hospital Discharge

ALL hospital discharges should be ASKED:“Have you made an appointment with yourHave you made an appointment with your PCP now that you are out of the Hospital?”

What are YOUR goals now that you are home and out of the hospital?

Current data tells us that patients who see their PCP within 7-10 days of hospital D/C y phave a 30% reduction in under 30-day Re-hospitalization Rate

ALWAYS ask if MD appointment was made

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OnOn--Call StrategiesCall StrategiesBefore calling the patient back:oGet a quick view picture of the patientoGet a quick view picture of the patientoReview:

Medication List– Note symptom relief meds & high alert meds

(i.e. Digoxin, Insulin)DiagnosesProblem List

- Read last few Clinical Visit NotesBefore sending to ED….Think VISIT or follow-up PHONE call…Last straw - ED

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Strategies - ResourcesIn-House RESOURCESRESOURCES:

Your PeersClinical MangersSocial WorkersTransitions in Care Program

Palliative CareHospicePain Management

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PROVEN SUCCESS

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AWARD RECOGNITIONRISC was awarded the QUALITY PILLAR OF EXCELLENCE in 2012o Pillar Awards are recognition based

on demonstrated commitment to excellence by

• Achieving a measurable improvement in one or more of the six pillars

– People, Service, Quality, Growth, Finance, Community

o Going above & beyond expectations of all patients, family members, physicians, co-workers and members of the community

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THANK THANK YOU!YOU!YOU!YOU!

QUESTIONS ?QUESTIONS ?IDEAS ?IDEAS ?IDEAS ?IDEAS ?COMMENTS ?COMMENTS ?