powerpoint presentation - whcawical.org · •bnp - b-type natriuretic peptide significant lab...

3/24/2017

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©Pathway Health 2013

Disease State Management –

Redesigning and Aligning Your Clinical Department

Sue LaGrange, RN, BSN, NHA,

CDONA, FACDONA, CIMT

Director of Education

Pathway Health


• Understand how to set up a system to assist licensed professionals to improve competencies around specific disease states.

• Develop disease state assessment expectations.

• Identify key expectations for disease state management across a provider continuum.

Objectives

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The Whole New World for PAC


Times…. are Changing!

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Dr. Joseph Ouslander

INTERACT™ QIP

Re-Hospitalization

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Value Based Purchasing

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Sh

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Percentage of Short-Stay Residents who were Re-hospitalized after a

Nursing Home Admission

Percentage of Short-Stay Residents who have had an Outpatient Emergency

Department Visit

Percentage of Short-Stay Residents who were Successfully Discharged to

the Community

Quality Measures


• For the three claims-based measures, facilities are divided into five groups based on the national distribution of the measure.

– The top-performing 10 percent of facilities receive 100 points;

– The poorest performing 20 percent of facilities receive 20 points;

– The middle 70 percent of facilities are divided into three equally sized groups (each including approximately 23.3 percent of nursing homes) and receive 40, 60 or 80 points.

Nursing Home Care QMs Rating

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SNFRM estimates risk-standardized rate of all-cause, unplanned hospital readmissions of Medicare SNF beneficiaries within 30 days of discharge from their prior proximal acute hospitalization

• Hospital readmissions are identified through Medicare claims

• Readmissions within 30-day window are counted regardless of whether the beneficiary is readmitted directly from SNF or had been discharged from SNF

• Risk-adjusted based on patient demographics, principal diagnosis in prior hospitalization, comorbidities, and other health status variables that affect probability of readmission

• Excludes planned readmissions since these are not indicative of poor quality

• The FY2019 SNFRM will be in use for the first year of the program

Previously Finalized Measure:SNF 30-Day All Cause Readmission Measure

(SNFRM)Adopts the SNFRM methodology and assesses the risk-standardized rate of unplanned, potentially preventable readmissions (PPRs) for Medicare fee-for-service (FFS) Skilled Nursing Facility (SNF) patients within 30 days of discharge from a prior proximal hospitalization.

• The 30-day risk window for the SNFPPR measure includes PPRs before a beneficiary

is discharged from a SNF (Within-PAC Stay) and PPRs after a beneficiary is

discharged from a SNF. The Within-PAC Stay list of potentially preventable conditions

is applied before SNF discharge, and the Post-Discharge list is applied for the

remainder of the 30 days after SNF discharge, if any.

• Risk-adjusted based on patient demographics, principal diagnosis in prior

hospitalization, comorbidities, and other health status variables that affect probability

of readmission

• Excludes planned readmissions because these are not indicative of poor quality

• Pursuant to statute, we will propose to replace the SNFRM with the SNFPPR in future

rulemaking

Proposed Measure:SNF 30-Day Potentially Preventable Readmission

Measure (SNFPPR)


www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/Value-

Based-Programs/Other-VBPs/Final-Measure-

Specification.pdf

(732 pages)

SNF Potentially Preventable Readmission


Medicare Payment Features:

• Performance standards must include both achievement and improvement

• SNF Performance Scores must be ranked from low to high

• 2% of SNFs’ Medicare payments will be withheld to fund incentive payments

• Incentive payments must total 50-70% of amount withheld

• No exclusions in statute for SNFs based on volume

Protecting Access to Medicare Act of 2014

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/Final-Measure-Specification.pdf

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• Increased discharge planning responsibilities

• Baseline care plan required within 48 hours of admission

• Trauma informed care

• Sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services .. As determined by resident assessments and individual plans of care

• Competency and skill set verification of nurses

Transmittal: 168 Dated March 8, 2017:

CMS State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities: https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/2017Downloads/R168SOMA.pdf

NEW State Operations Manual


Nursing Home Quality of Care Collaborative Change Package

• Lead with a sense of purpose

• Recruit and retain quality staff

• Connect with residents in the celebration of life

• Nourish team work and communication

• Be a continuous learning environment

• Provide exceptional and compassionate clinical care that treats the whole person

• Construct solid business practices that support your mission statement

Success Depends on Quality

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https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/nnhqcc-package.pdf


Strategies for Success

Assess Readiness

Capabilities and

Competencies

Partner and Collaboration

Technology©Pathway Health 2013

Assess Readiness

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• Measuring Readiness

– Systemic analysis of organization

– Ability to take on transformational process or change

• QI Readiness

Clinical Readiness

17http://www.hrsa.gov/quality/toolbox/508pdfs/readinessassessment.pdf


Clinical Readiness

Assess Clinical Readiness

– Your Role

– Industry initiatives

– Market initiatives and expectations

– Quality Outcomes

• Payer and External Expectations

• Consequences

– Internal competency process

– Right People and Right Roles

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https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R168SOMA.pdf

https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/nnhqcc-package.pdf

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Capabilities and Competencies

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• Are we confident in our preadmission process?

• Is our admission assessment and management process solid?

• Do our nurses have excellent head-to-toe assessment skills?

• Do our nurses understand disease processes?

• Do our nurses understand pharmacology related to disease processes and management?

• What is our process for comprehensive discharge care planning upon admission?

• What systems do we have in place to ensure good assessment, communication and follow through for early identification of changes in condition?

A Few Questions…….

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• Assess current status

• Determine targeted population

• Develop capabilities list

• Utilize best practice standard tools for listing, communication strategy

• Medical Director, physicians, and extenders – input and agreement

• Internal and External Communication

• Monitor via QAPI

Clinical Capabilities


Clinical Competence

• Assess Clinical Competencies

– Process competencies; e.g., admission, discharge

– Technology competencies; e.g., equipment, EHR

– Disease state competencies

• Right Individual in the Right Role

• Engage Vendors

– Lab , Radiology, Tele-health, Diagnostic, Pharmacy


• Admission Assessment (Baseline):

• Vitals, Weight, Height

• Allergies

• Diagnoses

• Body Audit/Skin Condition

• Neurological Evaluation

• Cardiovascular/Respiratory

• Musculoskeletal

• Gastrointestinal/Genitourinary

• Oral/Dental

• Communication, Vision, Hearing

• Sleep Patterns/Pain

• Fall Risk, Devices

• Mood/Behavior

Capabilities & Competencies


• Medical Record

– H&P

– Diagnosis List

– Physician Orders

– Lab or Diagnostic Testing

– Consultation Reports

– Medication and Treatment List

– Therapy Notes

– Wound Care Notes (if applicable)

– Dietary Reports

– Discharge Summary


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• Care Assessment and Management Skills

– Pain interview, assessment, and management needs

– S/S or identified infection

– B&B information (LBM, voiding status, etc.)

– Vitals (Normal? Unstable?)

– Weight and weight history

– Special procedures (IV’s, TPN, resp. care, etc.)

– Abnormal (or pending)labs

– Mood and Behavior concerns

– Fall risk

– Device use

– Psychotropic drug use

– **Medication Reconciliation



• Care Planning

– Initial

• Safety, Skin, ADLs, Reason for skilled stay, Discharge status

– Comprehensive

• Chronic Disease Management, CAAs

– Acute

• Infections, Falls, Injuries, etc.


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• Strategies for Competency:

– Education

– Post-Test

– Competency Skills Checklist:

• Heart Sounds

• Lung Sounds

• Vital Signs

– Temperature

– Pulse

– Respirations

– Blood Pressure

– Oxygen Saturation



Clinical Capacity

• Assess Clinical Capacity

– Safely manage acute conditions

– Disease state programs

– Episodic Management

– Rapid turnaround for admissions

– All hours

• Engage Medical Director and Physicians

– Specialists

– Extenders

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Clinical Capacity

• Partnership and Collaboration

– Acute care – clinical strategies

– Diagnostics

– Telemedicine

– Performance Reviews

• Determine benchmarks

– Internal

– External entities


Partner and Collaboration

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• Clinical integration readiness assessment

– Are you ready to plug into acute care/physician networks and payer payment models?

– Have you met with partner leaders to review clinical paths, expectations, performance metrics and monitoring processes?

– Are you the provider of choice in marketplace?

– Do you have development, training, tracking of clinical standards and benchmarks in place?

– Do you have a data management strategy and operational processes for monitoring performance?

– Is entire organization prepped and versed on QAPI?

Clinical Integration and Partners


• Transition/Discharge Planning and Admission Process

• Comprehensive Communication

• Coordination of Care

• Resident/Family Teaching with evidence of understanding

• Medication Education and Reconciliation

• Shared Accountability

• Resource-AMDA Clinical Practice Guideline: Transitions of Care in the Long-Term Care Continuum https://www.amda.com/members/flashpapers/papers/TOC/

Care Transition Process

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Technology

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Technology

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• Electronic Health Records – Next Step

• Data Analytics/Predictive Analytics

• Diagnostics and Clinical Integration

• Tele Health/Tele Medicine – At the Bedside

• Store and forward

• Remote monitoring

• Interactive services

• Teleconsultation

• Emergency Care

• Specialists


Technology

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• Patient Portals – SNF, HHA and ALF

• Wearables – Fitbit technology, vitals

• Interoperability

• IoT – devices (LG, HP and others)

– “Internet of Things” or “smart devices”

• Public Data - Data Transparency

https://www.amda.com/members/flashpapers/papers/TOC/

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Disease State Management:

CHF, Pneumonia, MI37


New York Heart Association Functional Classification

• Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.

• Class II: slight, mild limitation of activity; the individual is comfortable at rest or with mild exertion.

• Class III: marked limitation of any activity; the Individual is comfortable only at rest.

• Class IV: any physical activity brings on discomfort and symptoms occur at rest.

CHF Classification

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http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WMiMIm_ysnQ


American College of Cardiology/American Heart Association

• Stage A: Individuals at high risk for developing HF in the future but no functional or structural heart disorder.

• Stage B: a structural heart disorder but no symptoms or mild symptoms at any stage.

• Stage C: previous or current symptoms of heart failure (moderately severe cardiovascular disease) in the context of an underlying structural heart problem, but managed with medical treatment. Limitation in activity.

• Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care—severe limitations

• http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WMiMIm_ysnQ

CHF Classification

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Educating Nurses on Heart Failure

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Left-Sided Failure


Right-Sided Failure

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Nursing Assessment


Nursing Assessment

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• BUN / Creatinine

• Hgb / Hct

• Glucose

• Chloride

• Potassium

Significant Lab Values with CHF


• Sodium

• BNP - B-type Natriuretic Peptide

Significant Lab Values with CHF

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• Head to toe assessment

• Vital Signs

• Blood Glucose

• Dietary assessment and weights

• Medication discussion

Nursing Interventions for CHF


• Assess fluid intake

• Refer to Dietician if necessary

• Notify physician of findings

• Implement new orders (draw labs, order x-rays, adjust medications)

• Educate resident on symptoms

Nursing Interventions for CHF cont.

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• Vital signs

• Daily weight monitoring

• Edema

• Dietary instructions

• Respiratory symptoms

• Energy

Resident/Caregiver Education: CHF


• Exercise and any limitations/restrictions

• Oxygen

• Environmental factors

• Medication management

Resident/Caregiver Education: CHF

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Educating Nurses on Pneumonia

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Pneumonia

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• Nursing Interventions will focus on:

– Symptoms

– Medication management

– Oxygen use / management

– Lifestyle modifications

Pneumonia


• Commonly classified by where or how acquired

• Can also be classified by area of lung affected

• Pneumonia may be classified by the causative organism

Pneumonia Classification

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Potential for Sepsis

• Sepsis refers to the systemic inflammatory response to infection (sepsis). It may present with symptoms such as fever, hypotension, reduced urine output, or acute change in mental status.

• Fever above 100° F or temperature below 96.8°F, Heart rate higher than 90 beats/minute, Respiratory rate greater than or equal to 25 breaths/minute.

Pneumonia Can Lead to Sepsis


• Labored breathing or SOB

• New or worsening cough

• A change in mental status

• Sputum

• S/S of hypoxia:

Assessment/Symptoms-Pneumonia: Pneumonia

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• May have c/o muscle pain

• Appetite may decrease

• Significant weight gain or loss

• Respiratory Assessment reveals:

– Rales , rhonchi, rubs, wheeze or stridor present upon inspiration or expiration with auscultation.

Assessment/Symptoms-Pneumonia


• Complete a full head to toe assessment

• Complete vital signs & notify MD

Nursing Interventions: Pneumonia

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• Monitor oxygen use - ensure proper liter flow

• Complete a cardiac assessment

• Assess for s/s dehydration

• Review the resident’s medications, including inhalers & nebulizers for accuracy

• Notify the physician with full assessment and any abnormal findings from the nursing assessment.

Nursing Interventions

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Educating Nurses on Acute MI

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Management of Post-Acute MI


• Cardiac Status Evaluation

• Pain Management

Nursing Assessment/Symptoms

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• Head to toe assessment

• Vital signs

• Notify physician for changes

• Question the resident about any new symptoms identified



• Evaluate signs & symptoms of chest pain including

– Onset

– Duration

– Location

– Quality

• Evaluate medication use


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• Question resident about feelings of depression / anxiety

• Notify the physician of any findings which may indicate worsening or uncontrolled cardiac symptoms or infection

• Implement physician’s orders

• Educate resident/resident representative on reportable symptoms



• Vital signs

• Weight monitoring

• Edema

• Dietary

• Exercise regimen or cardiac rehab program

• Respiratory symptoms

• Energy conservation

• Oxygen administration and safety as indicated

Resident/Caregiver Education

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• Medication management




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• Additional Symptoms for Women


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©Pathway Health 2013 70

Final Thoughts


1. Prepare a “Needs Assessment” of our Clinical Team!

a. Communication System for Changes of Condition

b. Assessment Skills of the Nurses

c. Knowledge of Disease States

d. Pharmacology knowledge for nurses

e. Comprehensive, person-centered care planning

f. Communication

g. Documentation

Preparation


2. Engage Key Players:

a. Medical Director

b. Practitioners

c. Acute Care Partners

d. Pharmacy Consultant

e. Lab/Radiology

f. Home Care, Assisted Living, Hospice entities

Action

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3. Develop Your System

a. Policies and Procedures

b. EHR/Forms Management

c. Assessment Process

d. Care Plan Process (Including

Discharge Care Planning)

c. Communication Process

d. Staff Education

e. Practitioner Education

f. Resident/Family Education

g. Evaluation and Follow-up

Action


Communication System for Acute Changes in Condition:

• INTERACT™ 4.0 Quality Improvement Program

What System are YOU using?

Evidence Based Systems

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http://interact.fau.edu/


Action Plan

AREA OF CONCERN RECOMMENDATIONS GOAL DATE RESPONSIBLE PERSON

Lung Assessment not completed with resident s/s “productive cough”(Pneumonia dx)

1. Nurse re-educated in assessment process with return demonstration of lung assessment.

2. Nurse re-education in documentation requirements.

3. Follow up review of assessment and documentation each shift

5/1/17

5/1/17

Beginning 5/15/17

DON or Nurse Manager




QAPI Action Plan

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• CMS:

– https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-21-2.html

– https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html

References and Resources


• CMS Innovation Center:

– https://innovation.cms.gov/

• Protecting Access to Medicare Act of 2014:

– https://www.congress.gov/113/plaws/publ93/PLAW-113publ93.pdf


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http://interact.fau.edu/

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-21-2.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html

https://innovation.cms.gov/

https://www.congress.gov/113/plaws/publ93/PLAW-113publ93.pdf

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• AMDA: The Society For Post-Acute and Long-Term Care Medicine. Transitions of Care-Clinical Practice Guideline:

– http://www.paltc.org/product-store/transitions-care-cpg

• National Quality Strategy:

– http://www.ahrq.gov/workingforquality/



• http://www.mayoclinic.com/health/heart-failure/DS00061http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp

• my.clevelandclinic.org/heart/services/tests/labtests/bnp.aspx


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• www.ncbi.nlm.nih.gov

• www.lung.org/lung-disease/pneumonia

• www.clevelandclinicmeded.com/.../diseasemanagement

• Stone, Nimalie D., et al, Infection Control and Hospital Epidemiology, “Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeerCriteria”, Vol. 33, No. 10 (October 2012), pp. 965-977



• www.nurse-ocha.com/2007/06/nursing-care-plan-for-mci

• www.escardio.org/guidelines.../guidelines-universal-MI-slides.pdf

• http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WMiMIm_ysnQ


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Disease State Management –

Redesigning and Aligning Your Clinical Department

Sue LaGrange, RN, BSN, NHA,

CDONA, FACDONA, CIMT

Director of Education

Pathway Health

http://www.paltc.org/product-store/transitions-care-cpg

http://www.ahrq.gov/workingforquality/

http://www.mayoclinic.com/health/heart-failure/DS00061

http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp

http://www.ncbi.nlm.nih.gov/

http://www.lung.org/lung-disease/pneumonia

http://www.clevelandclinicmeded.com/.../diseasemanagement

http://www.escardio.org/guidelines.../guidelines-universal-MI-slides.pdf


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