emergency department/hospital inpatient initiative
DESCRIPTION
For more information on the Group Health reducing readmissions and innovations like this, please go to www.ghinnovates.org.TRANSCRIPT
1 | Group Health Solutions for Transforming Care
Kate Brostoff, MD, medical director, APPLE (Acute, Post-acute, Pharmacy, Laboratory, Emergency) Patient Resources & Options, Group Health Physicians
Brenda Bruns, MD, executive medical director, Health Plan Services, Group Health Physicians
Barbara Trehearne, PhD, RN, vice president of Clinical Excellence, Quality, and Nursing Practice, Group Health
Barbie Wood, RN, MBA, director, Care Management Services, Group Health
Emergency Department and Hospital Inpatient Initiative
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OBJECTIVES
• Improve health care quality for our patients by streamlining care transitions
• Reduce avoidable costs during care transitions
• Reduce preventable hospital admissions, readmissions, and ER visits
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GOALS
• Improve the patient experience
• Ensure the best possible outcomes
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PATIENT EXPERIENCEPATIENT EXPERIENCE
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STRATEGIES
• Pre-admission assessment for alternative placement/services
• Personalized transition management for admitted patients
• Coordinated transitions with skilled nursing facilities and home health agencies
• Engaging patients with their end-of-life choices
EPRO
Transition Mgmt
SNF Discharge
Palliative Care
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PATIENT EXPERIENCEPRE-ADMISSION ASSESSMENT | Emergency Patient Resources and Options (EPRO)
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PROVIDING ALTERNATIVES TO ED AND HOSPITAL ADMISSION | 24/7 Telephonic Physician + Care Mgt RN Team
• Urgent Care access expanded
• Same day or urgent primary care and specialty appointing
• Next morning guaranteed home health RN visit
• Direct Skilled Nursing Facility placement
• Options to avoid “social admits”
• Telemetry Observation in UC or Extended Observation Service care
• 24/7 Benefit assessment and explanation
EPRO: 2011 Expansion
1/1/2011: Primary Care Pilot using EPRO for all hospitalizations
EPRO
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PATIENT EXPERIENCEPLACEMENT
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PATIENT EXPERIENCEADMISSION
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PATIENT EXPERIENCETHE METHOD | The Four Pillars
Teach
Medication
Self-
management
Teach a
patient about
their condition
and use of
a personal
health record
Provide
knowledge
of warning
symptoms
and how to
respond
Have a
patient set
up follow-up
care with
their doctor
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Patient Sorting Criteria Red Pathway – Needs Palliative Care CMLN/MSW • Would benefit from a Palliative Care Plan • Score 4 or more on Palliative Care Screening tool • “Would you be surprised if this person died in the next
year – Answer, “no” • Patient/Family expressing openness to talk abo ut
palliative care/end of life issues. Yellow Pathway – Discharged Home CMLN unplanned admissions, CMLN/DCP planned admissions if needed for leveling. • Is a Readmit • Plans are complex or have a need for continuity of care • Has a primary diagnosis of a Chr onic Disease • Significant medications changes made during LOS • Significant concerns with self -medication management Green Pathway – Transferring to another facility DCP/CMLN Discharge Planning Meets SNF/Rehab criteria Transfer to LTAC for continued weaning , wound care, etc. Blue Pathway – Meet & Greet Care Partner No significant discharge needs Discharge planning prior to hospitalization Less than or equal to 2 day LOS Not in isolation Not short stay/ambulatory surgeries
DAILY HUDDLE AND PATIENT IDENTIFICATION
Using new standard scripting and processes, staff manage patient care tightly and collaboratively via a daily huddle:
• UPON ADMISSION, sort patients into 4 pathways
• EACH SUBSEQUENT DAY, review patient progress and daily plan, discharge planning, and expected next steps.
• FOCUS ON AVOIDABLE DAYS, review whether admission / day was avoidable, LOS against expected target, and if a re-admit, what they could have improved to avoid the re-admit.
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TRANSITION MANAGEMENT | How do we do it?
WITHIN THE HOSPITAL• Huddle
• Transition Coaching (4 pillars)
• 48-Hour Post-Discharge Phone Call
• Readmit and Long Length of Stay Reviews
• Avoidable Days / Admissions Capture
Transition Mgmt
SNF Discharge
WITHIN THE SNF• Timely SNF Placement
• SNF MD Rounding within 48 Hours
• ARNP Rounding within 72 Hours
• POLST / DPOA Confirmation or Completion
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HOSPITALIST / CARE MANAGEMENT PARTNERSHIP | Collaborative Standard Work
• Participate in daily huddle
• Transition management dictation
• Palliative care review, discussion, and dictation
Upon patient admission• Participate in daily huddle
• Transition coaching using 4 pillars
• Schedule 7-day and 14-day follow-up visits with primary provider
• Readmit and long length of stay reviews
• Avoidable days/admissions capture
Upon patient discharge• 48-hour post-discharge phone
call
HOSPITALISTS CARE MANAGERS
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HOSPITAL BASED MD TRAINING
•Communication skills focused on setting Goals for Care, End of Life planning
•Decision support tools for identifying patients in need of those conversations
•Lean principles including Standard Work
•Daily Management system
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Would you be surprised if this patient died within the next 2 years?
PALLIATIVE CARE SUPPORT
PPS = 10% = 3 pts Totally bed bound ; no activity, total care ;
no oral intake; drowsy/ coma
PPS = 20% = 3 pts Totally bed bound; no activity, total care,
minimal oral intake; drowsy/confused
PPS = 30% = 3 pts Totally bed bound; no activity, total care,
reduced oral intake; drowsy/confused
PPS = 40% = 2 pts Mainly in bed; limited activity, assistance required; normal/reduced oral intake; full
consciousness to confused
PPS = 50% = 2 pts Mainly sit/lie; una ble to work; considerable
assistance; normal/reduced oral intake/ full consciousness to confused
PPS = 60% = 1 pt
Reduced activity; unable housework; occasional assistance; normal intake; full
consciousness to confused
Disease ProcessFunctional Status Level of Intervention+ =
Source: Pyramid tool adapted from Victoria Hospice Palliative Performance Scale; Disease Process Assessment adapted from a variety of hospital-based palliative care service tools.
Basic Disease Process (2 pts each) Cancer (metastic/recurrent), ad vanced COPD, stroke w/ decreased Function by at least 50%, end stage renal disease, adv. cardiac disease (CHF, severe CA D, etc), other life -limiting illness
Concomitant Disease Process (1 pt each) Cancer (metastic/recurrent), ad vanced COPD, stroke w/ decreased Function by at least 50%, end stage renal disease, adv. cardiac disease (CHF, severe CAD, etc), other life -limi ting illness
Other Criteria (1 pt each) Not a candidate for curative therapy Has life -limiting illness & declined life prolonging therapy Unacceptable pain or symptoms > 24 hours Has inadequate care system Readmit < or = 7 days Readmit < or = 30 days Frequent visits to ED Prolonged LOS w/o evidence of progress Prolonged stay in ICU w/o evidence of progress Is in an ICU setting with poor/futile prognosis Score = 2:No intervention/Score = 3: Observation Score = 4 or more:Palliative Care discussion
Score = 2 ptsNo intervention
Score = 3 ptsObservation
Score = 4+ ptsPalliative Care Discussion
Palliative Care
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PATIENT EXPERIENCEPOST-DISCHARGE
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CONNECTING BACK WITH OUR MEDICAL HOME
Key leadership within our Medical Home and Specialty divisions helped guide how patients would be reconnected back to their primary provider.
Key Points include:
• All patients called within 7 days following discharge from the hospital by a clinical pharmacist to reconcile medication
• All patients receive 14-day face to face visit with Physician post-discharge
• Initiate palliative care conversations as appropriate/when needed
• Specialists integrate transition management into hospital care of patients (in progress to be completed by end 2009), and incorporate palliative care planning into regular workload (expected 2010)
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Patient
Satisfaction:
SEPT 2010
DEC 2009
91st percentile
74th percentile
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OBJECTIVES• Reduce inpatient costs and readmit rates by providing consistent and reliable post-acute care transitions
• Optimize post-acute care processes
• Reduce unnecessary Emergency Department (ED) utilization and costs
$51 million total savings for 2010
METRICS• Readmit rate
• IP admit rates
• Hospital length of stay (LOS)
• SNF admits/1,000
• SNF LOS
• ED visits/1,000
GOALS AND MEASUREMENT
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$51mHOSPITAL
COST SAVINGS
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RESULTS
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Medicare patient readmission:
NATIONALLY:
19.6%
WASHINGTON:
16.4%
GROUP HEALTH:
15%
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OVERALL IMPROVEMENT
Medicare inpatient admits by 6.3%
Medicare inpatient days by 3.3%
Non-Medicare inpatient admits by 7%
Non-Medicare inpatient days by 10%
SNF Medicare admits
SNF Medicare inpatient days by 5%
ER visits by 5%