Hunt Regional Telehealth Project: Remote patient monitoring of CHF patients Intensive outpatient case management Patient education focusing on self- management Reconciling the treatment plan with the American Heart Association Heart Failure guidelines Category 3 Outcome Measure: Reducing CHF 30-day readmissions
Patient takes vital 1. signs and answers daily health questions at home. Information is 2. transmitted via land or cell line to Phillips data server and formatted into electronic medical record Information is reviewed 3. by telehealth nurse via internet Telehealth nurse calls 4. or makes home visit to assist patient
Patients receive in home education on heart failure self-management techniques including: The heart failure disease process Signs and symptoms of exacerbation and corrective actions When and where to seek help Lifestyle modifications including diet, exercise and smoking cessation Diet and fluid restriction, weight monitoring Heart failure medications- action, side effects and adverse reactions Advance care planning
• Implement Care Transitions Project • Implement Readmission Risk • Reduce All Cause 30 day Assessment in Meditech for all Readmission Rates admissions • Review evidence based • Implement Project RED best practices to reduce components to patients at a high risk of readmission readmissions • Provide patients with chronic • Develop Care Transitions diseases disease specific project incorporating Plan Do education and self- evidence based management tools interventions • Arrange 1st follow-up PCP or • Engage Stakeholders specialty care appointment and transportation prior to hospital discharge • Ensure patient has the resources to obtain medication or provide it prior to discharge • Provide telephonic follow-up Act Study • Determine All Cause 30 day readmission baseline rates • Complete readmission root • Monitor All Cause 30 cause analysis on readmitted Day Readmission failure patients Rates • Study root cause analysis and • Refine Care aggregate causes Transitions interventions from Root Cause Analysis
Don’t reinvent the wheel, there are many • care transition models that provide a good starting framework. Network and build relationships with • healthcare providers outside of the hospital, they have tremendous resources to offer our patients. Ensure patients leave with an a follow-up • appointment prior to discharge. Follow-up phone calls are critical to ensure • patient needs are met. Give patients a hospital direct contact • person. In addition to medical components, social • support and resources are extremely important factors in readmissions.
Emergency Department’s have evolved into the safety net healthcare provider for the nations Medicaid, uninsured and people with limited access to healthcare providers. Over the previous decade: The US population grew by 12% Hospital visits increased 13% ED visits increased by 26% 425 ED’s closed Hospitals had a net loss of 198,000 hospital beds Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point. Available at: http://www.nap.edu/catalog/11621.html
Medicaid beneficiaries access the ED more than any other payor group: Medicaid 81 visits/100 enrollees Uninsured 40 visits/100 patients Private insurance 20 visits/100 enrollees Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point. Available at: http://www.nap.edu/catalog/11621.html
EMTALA ~ ED’s can not restrict access based on inability to pay Decreasing numbers of primary care providers accepting Medicaid Limited access to specialty care Patient culture
ED Navigation Project Objective: provide navigation services to high risk/high need patients to support timely, coordinated care in the most appropriate setting. Related Category 3 outcome measure: Reduce ED visits for ambulatory sensitive conditions. Model: based on the Institute for Healthcare Improvement Care Coordination Model
Future ure State ate: The Objec jective Curren ent State ate: The Gap HRMC Actions: ns: The Bridge Implementation of the ED Navigation Program Decreased d ED utiliza zati tion on for non- High volume of urgent and acute Implementation of ED Medical Screening emerge gent t care primary care provided in the ED Implementation of Primary Care DSRIP project Prima mary care capacity ty for the Lack of primary care capacity for Partnership with Greenville Community Health Service uninsured d and Medic dicaid d popu pulati tion on the uninsured and Medicaid Agency to provide primary and urgent visits population Agreement with The Connection to provide healthcare Public transpo porta tati tion on for health thcare Limited public transportation related transportation to ED Navigation patients needs ds Medication Assistance Policy developed Resources for under derserved d patients ts to Patients unable to obtain post Resources, funds to provide emergency post discharge receive post t discharge ge medic dicati tion ons discharge medication medication for free to ED Navigation Patients Procedure developed outlining ongoing medication assistance from Medicaid, Prescription Drug Assistance Programs, FISH Ministries, Prescription Drug program (grant) at Hunt Regional Home Care Implement ED Navigation Program which will provide Discharge ge follow ow-up Limited follow-up after ED telephonic follow-up to ED Navigation patients and home discharge visits to the highest volume ED super-users Patient disease self-management education incorporating Improv proved d health th liter teracy y and the Poor Health Literacy the “teach - back” method patients ts under dersta tandin ding g their Patient education packets developed diagn gnos osis, aftercare and self- manage gement t plan Limited knowledge of Community Developed Community Resource Guide Hunt t County ty Commu munity y Resource Resources Guide de that outlines available ble resou ources
We must find methods to incentivize patients to seek care from their PCP versus the ED to reduce ED utilization. It will take time and perseverance to change patient behavior from seeking primary/urgent care in the ED to primary care. In addition to establishing care with a PCP, it is equally important to address transportation, ability to obtain discharge medication, lifestyle modification and self-management strategies; Mental illness, depression and drug abuse are significant factors in the ED super-user population.
Reducing Congestive Heart Failure Readmission by improving care transition process 127278302.2.17 – Apply systematic Approach to Improve Quality /Efficiency for CHF patients QI Learning Collaborative – RHP1 Meeting June - 02, 2014
Traditional Model Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement
Fix 1 : Improved Patient Education Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement
Fix 2 : Improved Care in Hospital Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement
Fix 3 : Adequate post discharge support Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement
Fix 4 : Reduce ER Visits Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement
Goal : Reducing Readmissions Adapted from Pittsburgh regional health Initiative and network for regional healthcare improvement
PSC & CHW – Roles & Responsibilities 1. Patient Services Coordinator (PSC) • Assesses barriers to patient’s access to care – Including the need for CHW intervention 2. Community Health Worker (CHW) • Health coach – Reinforcement of provider/nursing education • Peer-to-peer support • Social support • So much more… Burgess, Grayson – PSC & CHW roles and responsibilities
PSC/CHW Referral Process
Staffing Plan of PSC & CHW’s with respect to reducing CHF readmissions
CHW & PSC Clinic integration benefits • Better Care Coordination – Med reconciliation, follow up appointments with PCP • Patient Education – Why/how to take medications, discharge education • Better Self Management Support – Coaching, financial and transportation assistance • Proactive interventions – Home visits, phone calls , continuous monitoring
Thank You For More information on Patient Service coordinators and Community Health workers Contact Grayson Burgess grayson.burgess@uthct.edu 903-877-8960 Carlton Allen carlton.allen@uthct.edu 903-877-8939
Heart Failure Risk Stratification Scoring Tool Adrian Nedelcut Good Shepherd Medical Center
GSMC CHF Readmission Team MallikChowdary Yenigella Dr. Emmanuel Elueze Adrian Nedelcut Dr. Hafiz Fakih Dr. Rumit Thakkar Lydia Dejong Rhonda Tramel Marylu Kilpatrick Susan Cooper Brandon Amyx Missy McKee Marcia Oxsheer Joey Sutton
Problem Statement Lack of a region-personalized risk stratification scoring tool that would accurately show the correlation between the patient's risk factors and their probability of readmission. Readmission rates for GSMC CHF patients show an ascending trend from 18.65% in 2012 to 25.63% in 2013. Our CHF cases have been shown to constitute approximately 50% of the total readmissions. The national average for CHF readmissions is 23%. CMS reimbursement linked to the Readmission Reduction program constitutes of 2% of all CMS payments for FY 2015.
Goal The purpose of this study was to develop a convenient and inexpensive method for identifying an individual's risk for hospital readmission for CHF using the information derived exclusively from the data sources available at the time of patient arrival. The goal is reduce the current CHF readmission rate by half if these patients are monitored appropriately and are provided continuum-of-care solutions for their disease management.
Data Analysis A total of 1024 admissions for CHF were recorded within the last 6 quarters which included 235 readmissions. Of these 235 readmissions, 43 individual patients accounted for approximatively 50% of all CHF readmissions (N=110) which is approximatively 5% of the entire CHF patients population (N=955). Following the 80/20 rule we decided to focus on this subgroup and analyze the common factors that contributed to these patients' readmissions.
Process • We did not have a risk stratification scoring tool that would accurately show the correlation between the patient's risk factors and their probability of readmission. • The tools present in literature did not provide a reproducible model for our patient population. • Multivariate analysis of subgroup of patients that readmitted more than twice within 30 days post discharge.
Risk Stratification Tool old score new score old score new score Demographics Past medical history Hx of Readmission 30days 1 45 Lack of social/family support 0 0 HF,COPD, DM or CRF 2 0 Has social/family support 0 -14 Hx LOS > 7 days 1 0 Age > 70 0.5 -14 Literacy and patient engagement Lack of financial support 0.5 9 Race w 0 11 Literacy low 0 37 Race b 0 -10 Literacy medium 0 0 Literacy high 0 0 Race a 0 18 Patient engagement low Pathology Patient engagement medium CHF 2 20 Patient engagement high EF 0-15 0 50 EF 16-35 0 6 EF 35-50 0 15 Results EF 51+ 0 29 ELOS > 5 days 1 -13 CORRELATION 0.807419 COPD/Pneumonia 2 24 AMI 1 15 High risk meds - Insulin, Warfarin 1 20 More than 10 meds 1 -36
Risk Stratification Tool Polynomial distribution 10 y = 0.0002x 2 - 0.0287x + 2.8805 9 R² = 0.8814 8 7 Readmissions 6 5 readmissions Poly. (readmissions) 4 3 2 1 0 0 50 100 150 200 250 Score
Scoring • 40-85 – 75% chance of readmitting twice • 86-115 – 83% chance of readmitting three times • 115-150- 100% chance of readmitting four times or more (over 150 points)
QUESTIONS…????
T HANK Y OU
To reduce readmission rates of Heart Failure patients by 40% by the end of 2014 by improving compliance with preventive measures.
Average HF Readmission Rates: October 2011 - September 2012 = 20.22% October 2012 – September 2013 = 14.80%
To achieve a HF Readmission Rate of 13.6% or less by the end of the first quarter of 2014 and to maintain that reduction for all of the calendar year.
A comprehensive analysis of the baseline data for readmission causation revealed the most common factors to be: • Non-Compliance to medication therapy, weight monitoring, and diet • Failure to follow up with physician
Implemented a Transitional Care Program to include: 1.) Case Management scheduling patient follow up visits with the physician 2.) Transitional Care Nurse visiting the patient at home 3, 10 and 20 days after discharge for compliance monitoring and reinforcement education.
Summary Data 46 HF patients discharged 1Qtr 2014 Of those, 27 qualified for referral to TCN 6 out of 27 refused services 10 of 27 were not referred 11 of 27 were seen by TCN.
Data Analysis
Compliance barriers identified immediately post-implementation, but improved with nursing education/scripting: January – 33% improved compliance February – 50% improved compliance March – 90% improved compliance
HF Readmission team now focusing on: • Improving referral process • Decreasing patient refusals • Continued work to further improve compliance as readmission rates are still above goal.
RHP 1 Regional Learning Collaborative QI Initiative to Reduce CHF Readmissions
Current Condition • Increased CHF readmission rate compared to previous year. • July 13 – November 13 had an average of 21% readmission (all payors)
Counter Measures • Reduce readmits with increased education from Registered Dieticians prior to discharge • Focus will be on diets and fluid restrictions that will lead to better overall health outcomes
Plan • Met with contracted dieticians to highlight why this is a need for our facility and what other efforts would lead to better outcomes • Set to begin tracking RD education December 13
Early Results Discharge education by RD’s on HF Readmission Rate HF patients: • Dec 13 – 41% • Dec 13 – 10.6% • Jan 14 – 55.6% • Jan 14 – 13.8% • Feb 14 – 78% • Feb 14 – 12.2% • Mar 14 – 78.3% • Mar 14 – 13.9%
Questions
MEDICAID WAIVER PROJECTS IMPLEMENT/EXPAND CARE TRANSITIONS PROGRAM June 2, 2014 Project 0941008002.2.3 Presenter: Mary Elizabeth Jackson
Overview Trinity Mother Frances 474 bed acute care facility 350 physicians and mid-levels 39 specialties in 36 locations throughout east Texas Primary referral site – Largest number of patients seen in ER in Smith County Need Conducted a needs assessment and established ties with community-based organizations to create support for post-discharge
Goals Project Goal • Improve coordination of care from inpatient to outpatient, post-acute and home care settings • Prevent increased health care costs and hospital readmissions Regional Goals Support hospitals’ collaborative efforts to improve access • • Move toward triple aim • Satisfaction - Improve patient experience of care • Quality - Improving the health of populations Cost – Reduction of per capita costs of care •
CARE TRANSITION CHALLENGES: • New concept, so there is little experience with care teams outside of the acute care setting • Senior population often lacks support group in primary and secondary area • Inability to make immediate medical decision Easy Access • Hired a CHF Nurse Navigator, Susie Howell • Timely, protocol driven scheduling of testing and procedures • Timely diagnosis • Multidisciplinary care team with standardized care
Care Transition Team CEO MFH & LPOHH: John McGreevy Chief of Cardiology: Dr. Flagg Sanford Clinical Coordinator for Cardiology Observation Unit: David McCaskill, ANP Dept. of Emergency Medicine: Dr. Luis Haro Administrative Director Patient Progression: Robyn Silber, RN Clinical Director of Care Management: Holly Morawski, RN Chief of Primary Care Services: Dr. Roger Fowler
CARE TRANSITION PROJECT Overview • New project so there are no protocols • Develop /establish evidence-based protocols using American Heart Association 2009 guidelines for diagnosis & management for heart failure • Implement standardized care transition policies and procedures • Conduct an assessment with community-based organizations to create a support network for targeted patients post discharge • High risk patients have a more stringent follow-up procedure
Guidelines for contact Overview Hospitalization • Contact patient and family and complete assessment • Review discharge planning documents • Determine need for home visit • After Hospitalization • Phone call or MyChart within 2 business days • Verify transitional appointment has been made • If visit is >14 days, call patient back to verify assessment • Repeat calls every 7 – 14 days until endpoint •
Guidelines for Contact If Patient Readmitted • Visit patient in hospital during business hours to • assess reason for readmit If unable to see patient, do phone interview after • discharge and restart entire protocol Discharge • If patient has not been readmitted by 45 days post- • discharge then dismiss from service by phone call
Project Summation Challenges and Lessons Learned • Difficult to get timely outpatient appointment until new clinic opened • Developing multi-disciplinary teams is challenging • Importance of communication • Between providers and departments in caring for patients • Budgets and staffing to cover additional volumes Questions and Answers
MEDICAID WAIVER PROJECTS Expand Specialty Services Pulmonology and Cardiology Pulmonary Lung Nodule Clinic Heart Valve Clinic June 2, 2014 Project 094108002.1.2 Presenter: Andrea Anderson
Overview Trinity Mother Frances • 474 bed acute care facility • 350 physicians and mid-levels • 39 specialties in 36 locations throughout east Texas • Primary referral site Need - Gap Analysis for Specialists • Inpatient and outpatient care • Willing to travel to regional clinics • Focus on Pulmonary and Cardiology Clinics
Goals Project Goal • Increase the capacity for specialty services • Adding providers to accommodate demand Regional Goals Support hospitals’ collaborative efforts to improve • access • Move toward triple aim • Satisfaction - Improve patient experience of care • Quality - Improving the health of populations Cost – Reduction of per capita costs of care •
Pulmonary Lung Nodule Clinic Outpatient Pulmonary Clinic opened March 2013 Goals of Lung Nodule Clinic • Easy Access • Clinical Coordinator to facilitate • Timely, protocol driven scheduling of testing and procedures • Timely diagnosis • Multidisciplinary care team with standardized care Team • Pulmonologist(s) • Cardiothoracic Surgeon • Nurse Practitioner • Nurse Navigator/Program Coordinator • Clinical Support Staff
Pulmonary Lung Nodule Clinic Overview • Early identification of lung cancer • Defined protocols to refer lung nodules above a certain size • Distinct pathways for care based on nodule size • Patients identified through imaging, CTs, and by PCPs in the region educated by the Pulmonologist or Navigator • High risk patients have a more stringent follow-up procedure Guidelines consider cancer’s high/low risk factors • • Multispecialty visits • Testing ordered prior to visits based on protocols • Prior review of each case determines need for surgical consult • Case review by Navigator and physicians
Heart Valve Clinic Opened June 2013 Overview • Echo alert protocols were developed for use by Imaging • Patients having 1 of 3 criteria for potential heart valve problems, are referred to the clinic • Nurse Navigator • Data mining for patients fitting criteria or risk factors • Communication with Cardiologist, Cardiothoracic Surgeon & PCP • Ensured appropriate diagnostic testing is completed • Guides patient through the process • Multidisciplinary care team with standardized care • Tests are reviewed by physicians prior to visits • Collaborative decision to treat medically or surgically • If surgery is required, the patient is scheduled prior to leaving the clinic
Project Summation Challenges and Lessons Learned • Provider recruitment for inpatient, outpatient, travel • The correct mix of providers on multi-disciplinary teams • Importance of communication • Between providers and departments in caring for patients • Budgets and staffing to cover additional volumes Questions and Answers
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