Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association’s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement work, particularly in the area of readmissions. She is also the clinical manager of the Tennessee Center for Patient Safety’s PSO (patient safety organization). Rhonda has worked in the field of hospital quality management since 2006 and has a clinical background in trauma, critical care, oncology, and organ donation. rdickman@tha.com 615-401-7404
THA Webinar Series Exclusive program for clinical leaders in hospitals that are part of the Tennessee Hospital Association Hospital Engagement Network (HEN) Focused on supporting clinical leaders who supervise front-line staff 18 webinars in total 1.5 contact hours for each webinar Transitioned to new webinar platform
Objectives Participants will be able to: 1. Describe the benefits of involving patients and families as partners 2. Recognize the valuable role of family caregivers in high quality care transitions 3. Share tips on getting patients and family members involved and removing barriers to effective partnerships 4. Use a self-assessment tool on readiness for patient engagement
Kathy Duncan, RN Kathy D. Duncan, RN, Director, Institute for Healthcare Improvement (IHI), oversees multiple areas of content, directs multiple virtual multiple learning webinar series. Currently she serves as Faculty for the AHA/HRET Hospital Engagement Network (HEN) 2.0 Improvement Leadership Fellowship Ms. Duncan also directed content development and spread expertise for IHI’s Project JOINTS, an initiative funded by the Federal Government to study adoption of evidenced-based practices. In 10 US States, Project JOINTS spread three evidence-based pre-and perioperative practices to reduce the risk of surgical site infections in patients undergoing total hip or knee replacement. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She has also served as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care, Orthopedics and Neuro for a large community hospital.
Peg Bradke, RN, MA Peg M. Bradke, RN, MA , has held various administrative positions in her 25-year career in heart care services. Currently she is Vice President of Post-Acute Care at St. Luke's Hospital in Cedar Rapids, Iowa, where she oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also serves as faculty for the Institute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (STate Action on Avoidable Rehospitalizations) initiative.
Gail A. Nielson, BSHCA, RT(R), FAHRA Fellow and Faculty of the Institute for Healthcare Improvement (IHI). Nielsen is the former system-wide Director of Learning and Innovation for UnityPoint Health (formerly Iowa Health System). Her current work as faculty for IHI includes reducing avoidable readmissions and improving transitions in care, leading 2-day Reducing Readmissions seminars, improving the quality of care in nursing facilities, and other assignments. Nielsen’s ten years of experience in improving care transitions and reducing avoidable readmissions began during her 1-year IHI Fellowship. Her most recent experience includes system- wide work in Iowa; four years in the STAAR initiative across three states: Massachusetts, Michigan, and Washington; and support to Hospital Engagement Networks in multiple states. Additional past areas of expertise and work with IHI includes six years on the Patient Safety faculty; four years on the faculty for Transforming Care at the Bedside; engagement and patient-centered care; reducing falls and related injuries; spread and scale-up of innovations; and ACOs-Post Acute Care.
Amy 7 Assignment for April 13 Thorne Become more aware of the services provided in your area: Reach out to one Community Agency to discuss ways to meet the unique needs of our patients to provide for safe transition between sites of care. – Share your findings Be prepared to share your findings or what surprised you: – Medication Management program in your community – Advanced Care Planning – Care Transition Cindy Jeter – Other
https://www.gnrc.org/agencies-programs/aaad
https://www.tn.gov/aging
https://www.tn.gov/aging/article/aaad-map1
http://www.cdc.gov/aging/pdf/acp-resources-public.pdf
http://www.jointcommission.org/toc.aspx
http://www.ashp.org/DocLibrary/Policy/Tran sitions-of-Care/ASHP-APhA-Report.pdf
14 Improve Transition From Hospital to Skilled Nursing Facility April 13 Call Number 7
Session April 13 SNF Partners
Definition of a “Skilled Nursing Facility” Umbrella term “Skilled Nursing Facility” refers to the following: • Nursing Home • Skilled Nursing Care Center • Long-term Care • Rehabilitation to Home • Post-acute Care/Sub-acute Care • Assisted Living
Discussion in Your Cross-Continuum Team Describe how a patient and family would ideally experience care as they transition into a SNF setting (i.e., what they might want and need). Identify three things that you will need to do in order to deliver that ideal care for your patients and families.
SNF Functions as Key Transitions Out of the Acute Care Episode Results of hospital care are dependent on the post-acute care Appropriate follow-up care post-SNF matters equally – SNF discharges to Home Health National SNF Readmission Rate Average = 22% Quality, staff skill mix, and available technology differs significantly by site One-third of beneficiaries admitted to SNFs experience a care-related adverse event
Timely Consults INTERACT Implementation Guide 2013 . Available at www.interact2.net.
Background: Many are Avoidable Subjects: The population of interest is a cohort of long-stay NH residents. Data are from the Nursing Home Stay file, a sample of residents in 10% of certified NHs in the United States (2006–2008). Results: Three-fifths of hospitalizations were potentially avoidable, and the majority was for infections, injuries, and congestive heart failure.
We are in this Together The Bottom Line “ Collaboration among hospitals and community-based providers is essential for improving transitions between care settings and keeping discharged patients out of the hospital. Fostering partnerships among providers, payers, and health plans can help identify causes of avoidable rehospitalizations and align programs and resources to address them ”
Process Changes to Achieve an Ideal Transition from Hospital (or SNF) to Home Skilled Nursing Care Centers Hospital Primary & Specialty Care Home (Patient & Family Caregivers) Home Health Care
40% of Medicare Discharges Admit to PAC • Hospital ≤ Continuing Care Hospital (2%) ≤ 17% HIGH Inpatient Rehabilitation (30%) ≤ 12% Severity of Skilled Nursing Facility (43%) Illness Palliative ≤ 22% Care Home Health (37%) LOW ≤ 28% Outpatient Therapies (9%) ≤ 20% Source: RTI/Cain Brothers Analysis, Integrating Acute and Post-Acute Care” 2012
Current State Post-Acute Care Nationally 40% of the Medicare patients utilize PAC services Medicare per capita spending on post-acute services is growing at 5% a year PAC shows the greatest variation in spending compared to acute and ambulatory
Looming Threats for Post-Acute Care SNF – Oct. 2018: 2% payment withhold to fund incentive pool to reward SNF based on preventable readmissions – Lower readmissions rates can recoup the 2%+ Due diligence in obtaining publicly available information to make decisions. – Only 2% of consumers use STAR ratings to make decision. Connectivity and engagement strategies.
Working in Cross-Continuum Teams By understanding mutual interdependencies of the patient’s journey across the care continuum, the team can co-design processes to improve transitions in care. Collectively, team members should explore the ideal flow of information and patient/family experiences for the individual patient and their family. 29
Resources Successful CCT Use to Identify Ways to Reduce Harm During Care Transitions INTERACT - Interventions to Reduce Acute Care Transfers IHI How to Guide Advancing Excellence (AE) – Volunteer Quality Campaign based on measurement of meaningful goals National Partnership to Improve Dementia Care Quality Assurance and Performance Improvement (QAPI) National Nursing Home Quality Care Collaborative
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