Presentation ID: CD2

March 13, 2014

Disclosure Slide 

Today’s presenters do not have any relevant financial interests presenting a conflict of interest to disclose.  Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation.  The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.  

AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non-ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives.      

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At the conclusion of the presentation participants will be able to:Identify the roles of nurse leaders and

physicians in redesigning the future care delivery system across the continuum of care.

Describe an innovative clinical process entitled Structured Interdisciplinary Bedside Rounds used to achieve desired value-based metrics.

Delineate the role of the Clinical Nurse Leader as a change agent in redesigning care delivery systems.

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A Model Designed to Improve Patient and Hospital Outcomes

Program and Implementation GuideWellstar Kennestone Regional Medical Hospital

Laura Caramanica, RN PhD CENP FACHE, FAANVP & Chief Nursing OfficerSonia Camphor, MDMedical Director of Accountable Care UnitsCarole Harman, BSN, MSA. RNExecutive Director of Nursing, Acute Care Service Line

Accountable Care is….Having a reimbursement system that

emphasizes primary care, wellness and population health management

Taking fiscal and clinical accountability for the population

Actively engaging patients to take more responsibility for their health

Building hospital-physician relationships and partnering in a deeper way with patients, populations and payors

Improving the health of our communities and decreasing health care costs by proactively managing chronic care and patients’ health needs6

Current State of Healthcare System Delivery Care delivered in unorganized silos

No orchestrated care pathways

Network may not be high value-driven

No integrated comprehensive health information

Providers’ goals & outcomes not aligned

Payors not partnered with aligned & incented providers

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FEE FOR SERVICE TO INTEGRATED CARE, NEW PAYMENT MODELS AND RISK

Population management•Population analytics•Care management•Financial modeling and management•Legal•Physician integration

High-value episodes•DRG and episode targeting•Care models and gainsharing•Data analytics•Cost management

High-performing hospitals and physician networks•Best outcomes in quality, safety•Waste elimination•Most efficient supply chain•Satisfied patients

Bundled payment

Shared savings

Value-based purchasing:HACs, quality, efficiency, cuts

Capitation

Readmissions/HAC Penalties

Source: Center for Accountable Care Intelligence, “Growth and Dispersion of Accountable Care Organizations: June 2012 Update (06/2012)

– 310 ACOs in 45 states and the District of Columbia– First ACOs (10 organizations) part of the PGP Demonstration project beginning in 2006

– 32 CMMI “Pioneer” participants, program began January 2012– Roughly 30% physician organization led

– Medicare Shared Savings Program– 04/01 – 27 ACOs selected to participate.

– Majority of organizations physician organization led– 07/01 – 89 ACOs selected to participate in this second cohort

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CMS Shared Savings ProgramFocus on the Triple Aim =

Better health, Better Quality, Lower Costs

Current FFS payments to providers continue

CMS establishes an ACO benchmark for “bending the cost curve”

Must achieve a “Minimum Savings Rate” (MSR) + performance on 33 Quality metrics

50/50 cost savings sharing between CMS and ACO

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Why Are We Doing This?ACO Future State

Create seamless coordinated world class carePut beneficiary and family at the centerProactively manage beneficiary care Attend carefully to care transitionsManage resources carefully and respectfullyRemember patients over time and placeEvaluate data to improve care and patient outcomesInnovate around better health, better care and lower

costsInvest in team-based care

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Background How do you optimize clinical outcomes for

patients nurses and physiciansProperly Designed Hospital Units (ACU)Institute Medicines STEEEP Dimensions of Care Safe, Timely, Effective, Efficient, Equitable and

Patient CenteredTeam Based Setting

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Story of Harm

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Mrs. BB is 80yo lady: Admitted in January by urologist for nephrectomy stayed in

Hospital 5 days (acute renal failure, hyperglycemia) went home with Cr=1.9/Hct=26 all previous medications continued (patient’s Nephrologist/Cardiologist/PCP not aware of surgery)

10 days after discharge Mrs. BB came to see Nephrologist complaining of weakness, somnolence, “just not feeling well” hypoglycemic, Cr=2.9, Hct-22 admitted by Nephrologist most medications discontinued

Hospital Stay – one week Seen by:

three different nephrology MDs and one AP three different cardiologists two different pulmonologists two different GI MDs Urologist

On their way home (Friday @7pm) patient’s daughter called family member-MD asking what to do with her blood sugars/diabetes medications (prior to discharge BG=200) and stating patient c/o urinary urgency.

OpportunitiesNo Lead Physician

Patient/Nurse do not know who is in chargeRN discussing POC with 30+ providers

Patients regularly discharged after 4pmRN needing to paging multiple physicians leads to

delayed dischargePatient satisfaction with discharge process very

low (HCAHPS)Patients’ understanding of the “next steps” very

low

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SolutionsEstablish Accountable Care Unit (ACU) with

following attributes:Unit-based Hospitalist-led teamsStructured Interdisciplinary Bedside

Rounds (SIBR) – MD, RN, CNL, Care Coordinator, Pharm. D, (PT. Dietary)

Redesigned MD-RN collaborative partnership

Unit level performance data (HCAHPS, LOS, discharges before 2pm, readmission rate, cost-per-case)

The structured ACU&SIBR were introduced by Dr. Jason Stein (Emory University) and adapted for this presentation

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Definition:A geographic inpatient area consistently responsible for clinical and cost outcomes it produces

The structured ACU&SIBR were introduced by Dr. Jason Stein (Emory University) and adapted for this presentation

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Building hospital-physician relationships and partnering in a deeper way with patients, populations and payors

Design Features of Team-Based ModelPatient-Centered Team-Based Work Flow

SIBR Roll CallPatient/FamilyHospitalistNurseClinical Nurse LeaderCare CoordinationClinical Pharmacist

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Transition CoachCharge NurseAs Staffing/Pt needs

allow: Physical Therapy Respiratory

Therapist

SIBR Ground RulesAll patients 5 days/weekAll SIBR team members must be

presentStart and finish on time Rounds end only after patient’s plan-

for-the-day has been verbalized and patient/family had an opportunity to ask questions

The structured ACU&SIBR were introduced by Dr. Jason Stein (Emory University) and adapted for this

presentation18

The Structured Dialogue of SIBREmphasis on Role Clarity

Introduce All Team MembersUpdate Status: (45 sec)

Overnight events & Review patients goal of the day (On in room white board) Vital Signs & Pain ControlFluid and Food Intake Urine and Bowel OutputMental Status and ADLsPhysical Findings/Pathophysiology

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Report “abnormals”

The Structured Dialogue of SIBREmphasis on Role Clarity

Checklist for Quality and Safety (15 sec)Foley CatheterCentral or Pic LineVTE Prophylaxis Pressure Ulcers/StagePlan of the Day and Assign Responsibilities

Discharge Planning Checklist (30 sec)Discharge Needs Discharge day and realistic timeFollow up Appointment

Patient Education (30 sec)20

Clinical Nurse Leader (CNL) Masters Prepared RN (University of

West Georgia) CNL functions as clinical leader for

RNSs, Clinical Care Partner, &ancillary staff

Comprehensive knowledge about each patient in their unit

Provides continuity of care for patient in the hospital to offset fragmentation

Acts in the role of ‘traffic control’ in coordinating rollout of the plan for care

Acts as the primary liaison for physicians, other disciplines, and families

Monitors competency and provides mentorship to team members

and students21

MDsRNs, CCP’s, and Students

CNL

FamiliesOther Disciplines

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ACU and the CNL

• Leads interdisciplinary team, fosters collaborative in SIBR Rounds

• Addresses gaps in care with Physicians and Nurses• Develops complex plan of care• Mentor for nursing staff• Translates & integrates evidence into practice• Emphasizes systems to accomplish health promotion,

risk reduction, & preventing readmission• Facilitates quality & LEAN process improvements at the

bedside• Conducts comprehensive unit-level assessment to

establish plan for improvement in efficiency, effectiveness & outcomes

• Mentor Staff

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Average Length of Stay ALOS 6S /7W ALOS 6N /7N ALOS 7W TOTAL LOS

BEFORE JAN 2013

AFTER JAN 2013

BEFORE JAN 2013

AFTER JAN 2013

BEFORE JAN 2013

AFTER JAN 2013

BEFORE JAN 2013

AFTER JAN 2013

4.00 3.89 4.21 4.01-

3.81 5.01 4.89

Δ2.39%

% DISCHARGES PRIOR TO 2 PM

BEFORE JAN 20

AFTER JAN 20

24.20% 43.44%

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*Implemented ACU Jan 20, 2013

Accountable Care Unit Outcomes

ACU 2PM Discharge Comparison

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Accountable Care Unit Outcomes

2 PM Discharge Compliance

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Accountable Care Unit Outcomes

Cost per Case SavingsBefore January 20th 2013 After January 20th 2013

$8,134 $7,954

•364 patients/month X 8months X $180 = $524,160 (Annualized $786,240)

•HM at KRMC annual census 8,000 = potential savings ~$1,440,000/year

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Accountable Care Unit Outcomes

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ACU HCAHPS Outcomes

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Lessons LearnedPositive impact on Nursing staff

Potential for system-wide large-scale impact

Transformation is a process - not an eventUnderstanding the stages of change and

common pitfalls increases chances of successful transformation

Transformation requires investment of human and financial capital

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Greets Patients /Introduces Team

Overnight EventsVital Signs and Pain

I & OADLs

Addresses Medication Questions

Addresses Discharge Plan

Supports Clinical Aspects of Care

Quality Safety

Checklist

Active Problem listTest results

Consult FindingsFamily Inputs

Foley Catheter

Central Line

DVT-Prophylaxis

SCD

Pressure Ulcers

Glycemic Control

Hospitalist synthesizes all information inputs from SIBR team and summarizes the patients care plan

for the day, updates anticipated discharge date and time. Answers patient questions.

Med Red Side Effects & Complication

New or Discontinued Medication

Follow Up Appts.

Addresses Issues that Measure or Affect

Clinical Quality

Answers Questions as to

Processes

Discharge Assessment

Family Support Issues

Addressed

Home Health Requirements

Discharge Medications

Unit Charge NurseRemains Outside the Patient

Room during SIBR. Holds Primary RN Phone,

Coordinates Additional resources such as PT/OT, Acts

as Timekeeper.

STOP3

Minutes

SIBR Process Map for Accountable Care Unit (ACU)

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A Model Designed to Improve Patient and Hospital Outcomes

Program and Implementation Guide

Contact us at:carole.harman@wellstar.org

Carole Harman, BSN, MSA. RNExecutive Director of Nursing, Acute Care Service LineWellstar Kennestone Regional Medical HospitalMarietta, GA