reducing hospital readmissions: home care as the solution · 2014-06-13 · integrated care...
TRANSCRIPT
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Reducing Hospital Readmissions: Home Care as the Solution
Kathy Duckett RN, BSN Sutter Center for Integrated Care [email protected] www.suttercenterforintegratedcare.org
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Review the 3 principles of Integrated Care Management (ICM)
Define key ICM Transitions of Care practices in the hospital and home
Discuss home care’s unique value as a transitions of care partner
Learning Objectives
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Facts About Who We Serve
Sutter Care at Home
28 Locations • 11 Home Health • 7 Hospices • 2 Infusion • 2 HME • 1 Private Duty &
Geriatric Care Management
1,800 Employees 770 Volunteers 18,000 Average Daily Census
Sutter Health: Transitions of Care, PCMH, Case Management 5900 Providers outside of SCAH/SH 48 States 3 Countries: US, Canada & Singapore
Sutter Center for Integrated Care
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Integrated Care Management (ICM): Where it Started
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Journey Towards Excellence In Homecare:
Improving Outcomes
of Care
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The Right Thing to Do: IOM Quality Chasm Report
• Current healthcare systems cannot do the job
• Trying harder will not work
• Changing care systems will work
• Make the right thing to do the easy thing to do
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The Right Thing to Do: IOM Quality Chasm Report
ALL health care providers should pursue six major aims: 1) Safe 2) Effective 3) Patient Centered 4) Timely 5) Efficient 6) Equitable
“ A New Health System for the 21st Century” (IOM, 2001)
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“Providing care that is respectful of and responsive to individual patient preferences, needs, & values & ensuring patient values guide all clinical decisions.”
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Integrated Care Management (ICM) Model What is It?
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• A care delivery model • Based on Wagner’s Care
Model (aka Chronic Care Model)
• Integrated Health Literate Care
• All patients across continuum • Defines key best practices
& competencies for all providers across settings
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Integrated Care Management (ICM): A Care Delivery Model for Improved Outcomes
Person Centered - Care with dignity and respect
- Goals drive care - Patient as partner
Evidence-Based - Clinical best practices - Patient Engagement: Self-management
support Health literate care
Coordinated Care - Seamless transitions across providers, settings, and time
- Meaningful and timely information exchange
Improved outcomes leading to better health, better care and lower cost
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Patient Goals BEFORE: Patient will…
Wellness At Risk Chronic Conditions
Complex Conditions
Advanced Illness
• Receive flu and pneumonia vaccine according to guideline level care.
• Remain free of signs and symptoms of infection at surgical site.
• Reach control of diabetes with BS levels of 100 – 130 and daily control of diabetes as evidenced by HgA1C of less than 7.
• Be able to walk 100 feet unassisted. • Be at acceptable pain level while remaining as alert as
possible.
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ICM Person-Centered: Patients Goals Drive Care
Wellness At Risk Chronic Conditions
Complex Conditions
Advanced Illness
• Return to weekly bridge game without undo fatigue. • Remain in home without going to ER or Hospital in order
to participate in all of grandchildren’s school and ballet activities.
• Be able to safely drive again. • Walk on my own to the activity center without assistance. • Able to join ROMEO (Retired Old Men Eating Out) group
for lunch once a week.
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Stoplight: Supports Patient & Family Engagement • First person
• Patient daily assessment drives navigation
• Font, layout, graphics consistent with health literacy and plain language principles
• Supports patient and caregiver engagement
• Supports teach back with content ready for “chunk and check”
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ICM Evidence-Based: Patient Engagement
Where we tend to focus: • Adherence to
clinical guidelines • Patient education • Directing
Where new focus is needed: • Clear communication • Comfortable with
questions • Choices provided, not
just advice • Confidence building
focus
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Health Literate Stoplight Tools In Action
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http://bcove.me/ckmub1o1
One Patient’s view on the Stoplight tool
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Care Transitions Definition
“Care transitions refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.”
Eric A. Coleman, MD, MPH
Care Transitions ProgramSM
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ICM: Coordinated Across Providers, Settings, & Time
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Hospital Home
Transitions Can Be Tricky
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Stats and Facts – Medicare pts
• 1 in 5 patients discharged from hospital readmitted within 30 days
• Readmissions often a sign of inadequate discharge planning, poor care coordination between hospital and community clinicians, and the lack of effective longitudinal community-based care.
• The additional hospital stays imply that many patients are getting sicker, not better, after their initial discharge.
• Other patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care.
• These readmissions lead to more tests and treatments, more time away from home and family, and higher health care costs. After Hospitalization:
A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries September 28, 2011
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WHAT
Literature Review of Care Transitions Best Practices Across Providers & Settings
Hospital Programs Ambulatory Care Programs
Home/Community Programs Accrediting Organization Programs
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1. Patient/family action/ engagement
2. Early identification for “at risk” patients
3. Transitions planning 4. Medication management 5. Multidisciplinary
collaboration 6. Transfer of information 7. Leadership support
Source: Hot Topics in Healthcare, Issue # 2, Transitions of Care: The need for
collaboration across the healthcare continuum. The Joint Commission, February, 2013
ICM TOC Aligns with The Joint Commission 7 Foundations For Safe Transitions
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• Comprehensive assessments including risk assessments
• Focus on medication reconciliation, signs & symptoms, MD Follow - up appointments
• Case management & care coordination • ICM Training: Skills for effective health coaching in
self management support & evidence-based guideline care
Home Care's Unique Role in Transitions
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• Expand the role of home health professionals • Provide transition of care services in the hospital
and home settings • Restructure in-home care processes to optimally
support transitioning patients • Provide systematic approach for care of home
health high-risk patients discharged from the hospital
ICM Transition of Care Objectives
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ICM Transitions of Care (TOC) Compared to Other TOC Models
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INTERVENTION
Coleman CTI
Naylor TCM
Project BOOST
Re-engineered Dis-Charge RED
ICM
Risk Assessment √ √ √ √ √ Medication Reconciliation √ √ √ √ “Red Flags” & Follow-up √ √ √ √ √ 24/7 on call response √ √ Hospital Visit √ √ √ √ √ Physician F/U √ √ √ √ Home Visit post discharge √ √ √ √ Remote Monitoring √ √ √ Active engagement of pts √ √ √ √ √ PHR (Patient Health Record)
√ √ √ √
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ICM Unique TOC Interventions
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INTERVENTION Coleman CTI
Naylor TCM
Project BOOST
Re-engineered Dis- charge RED
ICM
Health Literacy Screen √ √ Depression Screen √ √ Personal concerns/goals √ √ Med Management √ √ Pt friendly med list √ √ √ √ Health Literate stoplights √ Case conf High Risk pts √ Family Caregiver Assessment
√ √
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• Care transition support begins in the hospital and continues in the home by same healthcare sector – home health
The fewer the transitions the less the risk • No – one size fits all • Patients have fewer layers of care providers • Clinicians are trained to identify patients’ common
barriers for self-care • Clinicians provide care based on patient goals and
aspirations
How Is This Model Different?
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ICM Transitions of Care: Hospital & HH Partnership In Hospital Process
Multidisciplinary Rounds
•Attendees: MDs, Case Management, Nursing, Social Work, Pharmacists
• Risk Assessment
Transitions Care Planned by Team
•Appropriate for Homecare
•MD writes order
Hospital Secures Pt Choice
•Hospital Case Manager meets with patient and secures Pt Choice
•Notify SCAH if selected to provide Home Care services
HCC Accesses Patient Data
• Chart Review • Reviews with RN
Case Manager • Initiates Referral
Intake (RI)Note
HCC Initial Bedside Visit
• Explains program and inquires about patient’s concerns
HCC Second Bedside Visit
•Continues assessment and stoplight teaching
•Builds rapport •Updates RI note
Admission
HCC notifies branch of discharge
Discharge • Pt Assessments: Risk for readmission
• Begins Stoplight teaching
Family/caregiver conference may be held to determine appropriate level of care: HH, AIM, Hospice
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Risk Stratification: Institute for Health Improvement
High-Risk Pts Moderate Risk Pts
a. Patient has been admitted two or more times in the past year
b. Patient failed teach back, or the patient or family caregiver has a low degree of confidence to carry out self-care at home
a. Patient has been admitted once in the past year b. Patient or family caregiver has moderate degree of confidence to carry out self-care at home
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Person-Centered Starting in Hospital
“I have four areas we need to focus on to help prepare you and your family for discharge, but before we start on my list can you tell me what you are the most concerned about when you leave here and go home?”
Then transitions of care focus areas ….
1. Medication Management Post-Discharge 2. Early Follow-up 3. Symptom Management 4. Personal Health record
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Provider specific instruction determined here: • Call your nurse • Call your doctor • Call HH/hospice • Call Case Manager
Patient Facing Tools: Consistency Across Providers & Settings
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14 Topics available: 1. Heart failure 2. COPD 3. Diabetes 4. Depression 5. Pneumonia 6. Falls 7. Wounds 8. Pain 9. Constipation 10. Nausea 11. Anxiety 12. Stroke 13. Shortness of breath 14.High risk medication stoplights
(Coumadin, Lovenox & anticoagulants, Plavix & antiplatelets, Tamoxifen, Methotrexate)
Coming soon: • Skin care • Aspiration • Insulin/oral hypoglycemics • Weight gain/edema
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ICM Transitions of Care: Home Health “Touch-Points”
Pre-discharge
•Home Care Coordinator in-hospital pt visit
•Pt Assessments: Risk for readmission
•Pt Concerns & Stoplight teaching
Home visits
•1st visit w/in 24 hrs of dc
•2nd visit w/in 72hrs by same clinician
•3rd visit same week •Focus on med rec, signs & symptoms, MD f/u, personal health record
Remote monitoring
• Remote monitoring to detect signs of exacerbation
3 home visits
• Focus on patient engagement, med management , barriers and confidence-building
Remote monitoring
• Remote monitoring with focus on health coaching
Additional interventions
•Case conference •Pt –friendly med list •Medication Management •SBAR communication
Week 1
Week 2
Home visits continue based on need
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Health Coach in the Home: Medication Management
• Emphasis on med reconciliation and adherence • Med – “brown bag” – bring all meds out • Include all meds taken before hospitalization • Ask: - What concerns do you have about your medications? - Do you take any herbs and over the counter meds? - Teach back: Show me which meds you take when… • NOTE: Ongoing Reconciliation: Any new or changed meds
since my last visit?
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Medication and Route Dose Frequency Reason Instructions
Client Friendly Medicine List
Font size increased
to 14 pt
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SBAR Application
• Transitions of Care Notes
• EMR Documentation
• New or change order requests of MD
• Personal Health Record
• Case Conferences/ Huddles
• Eliciting information from
patients/families/caregivers
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MY Personal Health Record (PHR)
• Record belongs to patient and they are asked to be responsible for maintaining it
• Helps them take a more
active role in care and empowers them
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SBAR for Patients in PHR
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Technology in Transitions Theory-Based Telehealth
• Utilized for early identification of exacerbation
• Demonstrate cause and
effect relationships • Coaching for symptom
reporting • Postive reinforcement/
confidence building
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ICM Transitions Of Care: Provider, Payor, Healthcare System
-40% -47% -38%
-100%
-80%
-60%
-40%
-20%
0%
20%
40%
Decrease in 30-Day Readmission Rates After Implementing ICM Transitions Of Care
Sutter-SantaRosa
White CountyMed Ctr (AR)
First Health(NC)
Our care transitions partnership with Sutter Santa Rosa resulted in a 40% decrease in 30-day rehospitalization rates from Q2-2012 to Q3-2013.
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ICM Transitions Of Care: Outcome Measure from Patients’ Perspective
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Mar2012
Apr2012
May2012
Jun2012
Jul2012
Aug2012
Sep2012
Oct2012
Nov2012
Dec2012
Jan2013
Feb2013
Mar2013
Apr2013
May2013
Jun2013
Jul2013
Aug2013
Santa Rosa HH 89.5% 75.0% 87.5% 84.6% 89.3% 94.4% 88.5% 68.4% 85.0% 81.0% 89.5% 76.9% 78.9% 95.2% 84.6% 91.7% 88.9% 100.0%All SCAH HH 81.7% 86.5% 81.3% 82.8% 85.6% 82.1% 84.7% 83.0% 86.8% 83.2% 83.2% 80.3% 85.0% 84.8% 78.9% 83.5% 87.7% 84.9%
n=19
n=200 n=24
n=13
n=28
n=18
n=26
n=188
n=20
n=21
n=19
n=200
n = 21
n=13
n = 12
n = 9
n = 11
n=229
n=20
n=252 n=157
n=188 n=184
n=196
n=19
n=212 n=226
n=179 n=188
n=19
n=211
n=204
n = 154 n = 126
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
90.0%
95.0%
100.0%
Perc
enta
ge o
f "al
way
s" re
spon
ses
Did your clinician listen carefully to you?
n=182
n=26
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ICM: Tools, Practices, and Competencies Across the Health Care System
Disease/ Population
Management Case
Managers
Patient-Centered Medical Home
Practices
Hospital Staff: Coordinators Transitions
Coach
Home & Community
Services Providers
• Person-Centered – Patient as partner – Dignity and respect – Goals drive care
• Evidence-Based – Patient engagement – Clinical best practices – Self-management
support – Behavior change
• Coordinated Care – Meaningful and timely
information exchange – Across settings,
providers and time
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ICM Transitions of Care: Hospital staff perspective
I just wanted to take the opportunity to let you know how much we appreciate the Sutter Home Health hospital liaisons. We have had several cases lately that required an enormous amount of post discharge follow up and their follow through has been amazing. Just wanted you to know! Thank you!
Susan Case Management Sutter Medical Center, Santa Rosa
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What patients should expect from their health care team:
Cooperation: “Those who provide care will
cooperate and coordinate their work fully with
each other and with you. The walls between
professionals and institutions will crumble, so
that what you experience becomes seamless.
You will never feel lost.”
Crossing the Quality Chasm: A new Health System for the 2st Century, (IOM, 2001)
10 rules to redesign and improve care
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