objectives - lake superior qin...2018/09/11 · 48 how colonial acres will measure improvement •...

September 11, 2018

Learning Session Six Webinar #4

Nursing Home Strategies to Reduce Avoidable Hospitalizations, Part 2

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Objectives

• Describe strategies nursing homes are using to prevent hospital admissions

• Describe measures nursing homes are using to identify if strategies resulted in improvement

National Nursing Home Quality Care Collaborative CHANGE PACKAGE

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Strategy 6Provide exceptional compassionate clinical care that treats the whole person

Change Concept 6.c Transition with care (between shifts, departments, and all care settings)

https://www.lsqin.org/wp-content/uploads/2015/03/C2_Change_Package_20170425_508.pdf

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Luther Haven

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Speakers

• Diane Landmark, RN

• PIPP Coordinator

• Luther Haven, Montevideo, MN

• [email protected]

• Cindy Stinson RN

• DON

• Luther Haven, Montevideo, MN


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Luther Haven

• Located in west central Minnesota

• Church-sponsored; not-for-profit

• Purpose: Serve the elderly and disabled and promote their physical, social, emotional, and spiritual needs in a Christian atmosphere

• Bed capacity is 90, average census is 80

• 24 hour staff: RN, LPN, TMA, CNA

• Activities staff 7 days a week and evenings

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Luther Haven

• Contract for SLP, PT & OT therapies

• A clinic NP rounds 2x/week to assist with resident needs and non emergency orders

• Chippewa County Montevideo Hospital (CCMH) Lab comes to facility 2x/week for lab work

• CCMH Physicians round monthly in facility

• Physically connected to CCMH hospital - no 911 or ambulance services needed for our ED transfers

• .

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Performance-Based Incentive Payment Program (PIPP) Project

PIPP: Reducing re-hospitalizations, developing an effective discharge planning process and follow-up post discharge

• MN PIPP supports provider-initiated projects aimed at improving the quality and efficiency of nursing home care

• Provider-initiated projects that are tied to state nursing home performance measures are selected through a competitive process and funded for up to 5% of the weighted average operating payment rate

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Reducing Re-Hospitalizations

• Were aware of our use of the ED and knew this was a measure that was going to be identified and used in all facilities

• Residents were being seen in the ED by a provider that wasn’t familiar with them

• Had a significant number of ED visits and hospitalization especially after hours identified via:

― Minnesota Quality Indicators

― Discharge and hospital leave reports

― Achieve Matrix admission

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What Are You Trying to Accomplish?

• Decrease ED visits and re-hospitalizations by 10% over 2 years

• Improve quality of life/care by reducing re-hospitalizations

• Develop effective discharge planning processes for residents who are discharged to the community

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How Will You Know That Change Is an Improvement?

PIPP Outcome Measure One

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PIPP Outcome Measure Two

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Measures:

• Minnesota Quality Indicators

• CMS Casper/Quality Measures

• Achieve Matrix Software

• Admission, Discharge and Hospital Leave Reports

• Review of each ED visit and hospitalization including the residents’ progress notes to determine trends

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Changes Made That Resulted in Improvement

• Education and communication with the medical director, clinic staff, ED staff, hospital staff, our staff, residents, and their family members.

• Met with staff from all areas, identified problems, developed a plan, and initiated it.

• Identified the need for ongoing constant communication

• Continue to meet at least quarterly to review and revise the plan as needed.

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January 1, 2017 through December 31, 2018 Activities:• Education to staff and families on project and goals

• Regular communication to all involved regarding goals and progress

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January 1, 2017 through December 31, 2018 Activities

• Auditing and monitoring of these strategies:• Patient/caregiver introduced to the educational process upon

admission.

• Educational sessions for a successful discharge identified by the IDT and the patient/caregiver.

• Patient/caregiver participate in educational sessions.

• Patient/caregiver learning is validated.

• Weekly calls are made to all residents discharged to the community to follow up on their status and any needs/education they may need

• Determination of successful or failed transition is made.

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January 1, 2017 through December 31, 2018 Activities:

• Auditing and monitoring of these strategies:• Identify residents who discharge quickly and successfully and compare

their recovery to those that have similar circumstances but a longer stay.

• Continual research and literature review to assist with all programs and interventions

• Meet with outside agencies to share progress on project goals and identify barriers and necessary changes

• Collect, organize, and analyze data collected on all goals (ongoing throughout the project).

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January 1, 2017 through December 31, 2018 Activities:

• Auditing and monitoring of these strategies:• Compliance audits on all programs and document action taken

throughout the project.

• Ongoing education to staff and residents re: Lean Process, reducing re-admissions to hospital and discharge planning goals and protocol

• Refine Care Coordination for residents upon admission and discharge to identify resident needs for a successful and efficient discharge to home and transition to independence

• Provide outcomes to staff, residents, partners and providers

• Make appropriate changes to ensure sustainability of program

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Progress-to-Date

• 7/1/2017 - 12/31/2017: 19 discharges to the community with 1 hospital readmission within 30 days; we were unable to track any ED visits.

• 1/1/2018 – 7/31/2018 : 32 discharges to the community with 1 ED visit and 5 re-admitted within 30 days.

• Positive communication from staff

• Constant communication and ongoing education is necessary to be successful

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Progress-to-Date

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Progress-to-Date

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Progress-to-Date

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Resources That Have Contributed to Our Success

• Reports from Matrix, our Electronic Medical Record, QI/QM, and Casper reports.

• Manual review of hospitalizations and ED visits.

• 4 RN Managers attended Pathways Interact Training.

• All facility staff attended Lean training to improve our discharge planning process.

• Partner buy-in:

• Hospital HIS staff alert PIPP Program Manager of any ER visits or hospitalizations occurring with our community discharges

• Clinic, Hospital, and ER Managers

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Dove Healthcare

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Speaker

Kris Modl

• ACBSW Director of Social Services / Admissions

• 715-895-9032


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Dove Healthcare

• Dove Healthcare includes six skilled nursing and rehab facilities and five assisted living residences within a 60-mile radius of Eau Claire, WI

• Core services include rehabilitation, post-acute care, ventilator / tracheostomy care, skilled nursing, long-term and end-of-life care, assisted living, and memory care.

• Workforce of 1000+ employees serves an average of 425 residents and patients daily

• Owns and operates Transitions Rehabilitation which employs over 90 physical, occupational, and speech therapists

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Chippewa Valley Continuum of Care Coalition

• Formed in 2010 as a result of strategic planning

• Initially comprised of two hospitals, five Skilled Nursing Facilities (SNF), and a Family Care organization

• Focus was to improve the continuum of care process as patients transitioned from the acute care setting to an SNF in a timely manner

• The Coalition has grown to include 4 hospitals, hospice, and home care agencies, Community Based Residential Facilities, and multiple SNFs

• Open to any organization or individual interested in fostering the vision by actively engaging in the work and planning of the Coalition

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Our Purpose

• To focus on improving care transitions

• To encourage person-centered and person-directed models of care

• To reduce the number of re-hospitalizations and patient care transitions

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Our Commitment

As members we join in a commitment to:

• Share best practices and knowledge with each other

• Mentor our partners and providers

• Share data and support analyses related to care transitions

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Improvement Goals

• Minimize transitions between entities and ensure timely and consistent transitions (reduce re-hospitalizations)

• Improve the well-being of the community through collaborative processes that promoted optimal care and services

• Ensure resident needs could be met including behavioral needs

• Share data across providers

• Improve transportation

• Develop tools and resources

• Education

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Identified Gaps

Some of our initial work identified gaps that have an impact in transitioning patients.

Examples include:

• SNFs with various capabilities

• Regulatory differences between acute care setting and SNF setting

• Placement challenges related to behavioral issues

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Identified Gaps

• Inconsistent / incomplete information from the acute care setting

• Lack of education / lack of earlier education regarding advance care planning

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• Transitions (re-hospitalizations) will be reduced

• Appropriate patient placements

• More timely discharges

• Collaboration amongst providers

• Improved transportation

• Improved overall collaboration / communication

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• Transfer Communication Tool – EMR / paper

• Standardized acute care referral summary

• Standardized acute care discharge information

• Standardized Physicians Plan of Care (PPOC)

• Accompaniment to appointments, tests, etc.

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• Timelier receipt of DC summaries

• Facility capabilities

• RN to RN Handoff / Handover

• Formation of subcommittees – Education, Transitions, and Transportation

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Sub-Committee Focus

Provider and Community Education• Identify knowledge gaps regarding care

transitions

• Identify opportunities to improve communication, knowledge and quality of care with transitions

• Provide education to healthcare providers and community regarding health care resources and support along the continuum of care

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Sub-Committee Focus

Transitions of Care• Monitors transitions from both the acute

setting and SNF setting

• Improve the continuum of care process as patients transition

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Sub-Committee Focus

Transportation

• Centralized compilation of transportation resources to allow for multi-organizational access

• Collaboration with local and state levels to ensure services are available no matter the need or payer source

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Next Steps

• Implement multi-directional flow of information

• Educate receivers of this information – what to do with it

• Educate medical providers using health care resource utilization data

• Sponsor a community event to focus on advance care planning and facilitation of setting goals

• Ongoing collaboration with MetaStar – focus on reducing all cause admission / readmission rates

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Resources/Tools

• Add as needed to share

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Colonial Acres Health Care Center at Covenant Village

of Golden Valley

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Speaker

Christine DeLander - MS, RN

• Director of Nursing

• Colonial Acres of Golden Valley at Covenant Village of Golden Valley. A Covenant Retirement Community.

• Direct line: 763.732.1412

• Email address: [email protected]

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Colonial Acres HCC at Covenant Village of Golden Valley

• Located in Golden Valley, MN• Part of a Continuing Care Retirement Community

(CCRC) of Covenant Retirement Communities (14 communities across 8 states)

• Not-for-profit, faith-based community as a part of the Evangelical Covenant Church

• Colonial Acres is the Skilled Nursing Facility campus:― 88 bed capacity: 38 Medicare Certified, 50 Private

Pay― Rehabilitation, LTC, and Memory Care services

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Reducing Avoidable Hospitalizations at Colonial Acres

• Covenant Retirement Community’s goal: reduce the readmission rate to hospitals to 10% by the end of 2018

• Current rate (Nursing Home Compare Q4 2016 to Q3 2017) is 29.4%

• Other reasons why this project is important to us:

• Improve health care outcomes for our population

• Decrease/avoid financial penalties associated with readmissions within 30 days.

• Be a responsible partner to our hospital systems

• Improve systems that help increase staff confidence, efficiency, morale, and effectiveness

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How Colonial Acres Will Measure Improvement

• A reduction in the Hospital Readmission QM to gain 20 or more points.

• Better and longer transition of our residents in the community through increase in QM – successful community DC (Short Stay) – our goal is 65%. We are currently at 58.3%.

• Internal measure - Reduction in avoidable readmissions through Interact QI tool (will impact QMs when out)

• Increased employee satisfaction regarding nursing system

• Increased employee recognition through Inspire to Serve

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Changes Made That Will Result in Improvement

• Re-Introduced INTERACT to the facility after strategically coming up with a flow chart on how a change in condition will be orchestrated.

• Utilization of INTERACT tools – embedded in our EMR

• Worked with Lake Superior QIN to come up with a plan

• Re-educated all facility staff on the new plan/process

• Completing a root cause analysis/RCA on all hospital transfers by using the INTERACT QI tool and reviewing at IDT meetings daily

• Re-education/resource planned review review is ongoing and based on identified RCA/trend review/advice by QAPI committee monthly

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Change of Condition Process Map

https://www.lsqin.org/wp-content/uploads/2018/09/Change-of-Condition-Comm-Process-Eval-Tool.docx

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Progress-to-Date at Colonial Acres

Data from May-August 2018 shows:

• 12 readmissions to hospital after entry to facility from highest ranking falls then CHF – identified through Interact QI RCA tool

• Current rate is 29.4% (CMS claims data that generates our QM) So far, from 5/1/18 to present, internal data shows our number to be –17%.

• Internal goal is to reduce to 10%

• Areas of focus to reduce hospitalization rates include falls and CHF

• Working on building orders sets for CHF into the EMR for all new admits with CHF

• Implementation of FSI to ensure RCA matches fall – prevents recurrent falls and staff/resident/family education on fall prevention

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Progress-to-Date at Colonial Acres

• Looking at partnerships with home care agencies with readmission rates of 15% or below to increase LOS in the community

• Held nursing meetings in August and INTERACT re-discussed. Staff report feeling better about what they are doing.

• Formal surveys to occur in September 2018 to gauge feelings about progress

• Nursing staff recognition by HCP from Allina, NMMC and Methodist hospital – comments “your nurses know what they are doing”

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Resources/Tools

INTERACT® Version 4.0 Tools:

http://www.pathway-interact.com/interact-tools/interact-tools-library/interact-version-4-0-tools-for-nursing-homes/

Data.Medicare.gov:

https://data.medicare.gov/Nursing-Home-Compare/Star-Ratings/ax9d-vq6k/data

Questions via phone or chat….

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Next Steps: Participate in These Webinars:

• Watch this pre-recorded 24-minute webinar: • Reducing Hospital Admissions to Improve Resident Outcomes,

Quality, and Financial Incentives

• https://youtu.be/PcMcyoYpWD8

• Watch these recorded webinars:• Using QAPI to Reduce Readmissions:

https://youtu.be/7irxuOWtZec

• Nursing Home Strategies to Reduce Avoidable Hospitalizations, Part 2:

• (YouTube link will be available shortly)

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Next Steps: Participate in These Webinars:

Register for the last webinar in this series:

• September 20, 2018: Nursing Home Strategies to Reduce Avoidable Hospitalizations, Part 3

More information, including registration link: https://www.lsqin.org/initiatives/nursing-home-quality/ls6/

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Lake Superior QIN

Michigan: Holly Standhardt • 248-912-6709 • [email protected]

Minnesota: Kristi Wergin • 952-853-8561 • [email protected]

Wisconsin: Toni Kettner • 608-441-8290 • [email protected]

This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-18-159 090618

objectives - lake superior qin...2018/09/11 · 48 how colonial acres will measure improvement •...

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