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[Compatibility Mode]5/6/2013
1
David Weinstein, Executive VP and COO Mary Frances Thaler, Vice President of
Administration Dr. Zachary J. Palace, Medical Director
May 22, 2013
Presentation Objectives Review :
Best practices The role of clinical interventions and technology The importance of collaborations
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5/6/2013
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Reason for D/C 7/1/09 6/30/10 7/1/10 6/30/11 7/1/11 6/30/12 Percentage
Year 1 to Year 3
Anemia 36 23 20 44%
CHF 10 9 4 60%
Elec. Imbalance 6 2 1 83%
Resp. Infection 112 70 62 45%
Sepsis 40 32 49 23%
UTI 13 1 3 77%
Overall Hospitalization totals for tracked
categories 217 137 139 36%
5/6/2013
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Presentation Outline
I. Description of the CMS Nursing Home Value Based Purchasing Demonstration Project (NHVBP) II. Review of communication tools and clinical assessment utilized to reduce avoidable hospitalizations III. Review of technological interventions used to promptly identify changes in resident conditions IV. Description of an Institutional Special Needs Program V. Description of Care Transition Efforts
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5/6/2013
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Nursing Home Value Based Purchasing Demonstration Project (NHVBP)
Background: NHVBP is a Centers for Medicare and Medicaid Services (CMS) Pay for Performance Initiative Goal: to improve the quality of care furnished to all Medicare beneficiaries in nursing homes
7
Nursing Home Value Based Purchasing Demonstration Project (NHVBP)
CMS selected three states to host the demonstration: Arizona, New York, Wisconsin As of June 30, 2010 there were 78 participating nursing homes in New York, 61 in Wisconsin and 38 in Arizona Comparison group nursing homes were selected either through random assignment or matching The Hebrew Home at Riverdale was selected as a participating nursing home for the duration of the demonstration project – July 1, 2009 to June 30, 2012
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Overview of NHVBP Design Objective: To improve the quality of care furnished to all Medicare beneficiaries residing in nursing homes
Approach: Assess nursing home performance based on selected measures of quality Make annual payment awards (if savings are achieved) to those nursing homes that achieve the best performance or the most improvement based on the performance measures
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NHVBP Performance Payments
In each State, a payment pool will be determined each year The payment pool will be based on the estimated Medicare savings achieved by the participants Higher quality of care is expected to result in fewer avoidable hospitalizations If no savings are achieved, then no payment pool
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NHVBP Performance Measures Each year of the demonstration, CMS will calculate an overall quality score by summing the scores in four domains NHVBP Demonstration Project included four domains/performance measures:
Nurse staffing Outcomes from State survey inspections Outcomes on selected MDSbased quality measures Rates of potentially avoidable hospitalizations
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12
20 pts.
Potentially avoidable hospitalizations
NHVBP Performance Measure Staffing (30 Pts.)
RN/DNS hours per resident day Total licensed nursing hours (RN/DNS/LPN) per resident day Certified Nurse Aide (CNA) hours per resident day Nursing staff (RN, LPN, CNA) turnover rate Agency staff count 80% of staff level measure Case Mix adjusted Quarterly Payroll data will be source for staffing levels and turnover measures
13
NHVBP Performance Measure State Survey Inspections
(20 pts.) Deficiencies are assigned values based on scope and severity Return visit to correct deficiencies will be considered Facilities cited for substandard care will be ineligible for an incentive payment FTags only, no life safety
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(from MDS) (20 Pts.)
Chronic Care (LT Stay) Points reduced for percentage of residents:
whose need for help with ADL has increased whose ability to move in & around their room became worse who are considered high risk residents with pressure ulcers who have had a catheter left in their bladder who were physically restrained
15
NHVBP Performance Measure Quality Measures (from MDS) (20 Pts.)
PostAcute Care (shortterm) Points gained for percentage of residents:
with improving ADL’s. who improve status on midloss ADL functioning. with failure to improve bladder incontinence.
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NHVBP Performance Measure Potentially Avoidable Hospitalizations
(30 Pts.) “Avoidable” is defined as hospitalizations with any of these diagnoses:
• Heart Failure • Respiratory Infection • Electrolyte Imbalance • Sepsis • Urinary Tract Infection • Anemia (Long Term Residents Only)
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NHVBP Implementation Strategies Protocols Developed for Reducing Unnecessary Hospitalizations:
All RN’s IV certified Increased inhouse Lab hours to 6 days per week and oncall for 7th day Established outpatient transfusion capabilities without hospitalization Purchased EKG machine for stat EKGs onsite Implemented Care Paths for the identified diagnoses
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5/6/2013
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Creation of NHVBP Committee comprised of: Executive VicePresident / Chief Operating Officer Associate Administrator Medical Director Director of Nursing Services Director of Clinical Documentation and Reimbursement Infection Control Nurse
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Concurrent Evaluation Strategies
NHVBP Committee objectives: To track all hospitalizations for all diagnostic categories To review biweekly data to identify patterns of incidence of hospitalizations by diagnostic categories To complete indepth medical and nursing audit for a sample of all residents hospitalized To review audit results for identification of patterns/trends
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Concurrent Evaluation Strategies NHVBP Committee objectives continued:
To complete an indepth audit of a selected sample for comparison to the defined clinical care path To review audit findings discussed at biweekly committee meetings with the clinical team To revise clinical pathways based on audit results To further develop strategies to reduce hospitalizations
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• The Hebrew Home is committed to treating patients in place
• The Hebrew Home chose to participate with the Continuing Care Leadership Coalition (CCLC), an affiliate of the Greater New York Hospital Association (GNYHA), in implementation of the INTERACT II program
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The INTERACT II Program INTERACT: “Interventions to Reduce Acute Care Transfers”
Is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition Includes evidence and expertrecommended clinical practice tools, strategies to implement them, and related educational resources
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5/6/2013
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The INTERACT II Program Goal To improve care, not to prevent all hospital transfers Can help with more rapid transfer of residents who need hospital care Can help your facility safely reduce hospital transfers
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Early Warning Tool – Stop and Watch SBAR Quality Improvement Tool
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5/6/2013
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Improve management of acute changes in clinical status: Identification Assessment Treatment in the facility Documentation Communication
Internal With hospitals
Early Warning Tool Stop and Watch
Utilized by clinical and nonclinical staff who have direct resident contact Utilized when an important change in condition is noted when caring or interacting with the resident Presented to the charge nurse before the end of the shift Utilized by charge nurse in evaluation and treatment of the resident Results in earlier identification of subtle changes in resident condition
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5/6/2013
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EARLY WARNING TOOL “Stop and Watch” If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Name of resident: __________________________________________ Seems different than usual Talks or communicates less than usual Overall needs more help than usual Participated in activities less than usual
Ate less than usual (not because of dislike of food) No bowel movement in the last 48 hours Drank less than usual
Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual Staff: ____________________________ Reported to: _______________________________ Date: _____ / _____ / ________ Time: ____________________ 29
SBAR: Physician/NP/PA Communication
and Progress Note
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and Progress Note Before calling the MD/NP/PA the Nurse should:
Evaluate the resident – complete the SBAR form Check vital signs Review the medical chart – including recent labs Review an associated clinical care path if applicable Have relevant information available when reporting – including advanced directives, allergies, medication list, and the medical record
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SBAR
SBAR provides clear guidelines for communication around a resident’s change in condition SBAR utilization results in more efficient and effective transmission of important information SBAR form can also be used in place of a nursing progress note
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Purpose of this tool is to retrospectively review acute care (nonelective) transfers to an emergency department or for direct admission to the hospital Tool should be completed within 24 to 48 hours after a resident is transferred Utilization of this tool helps facility staff:
Understand the reasons for acute care transfers Identify possible opportunities to prevent avoidable transfers Identify common patterns among the acute care transfers
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The QI Review Tool 1. Background Information 2. Change in Condition 3. Evaluation and Management 4. Transfer Information 5. Opportunities for Improvement
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Quality Improvement Tool Retrospective review of quality improvement tool information is used to determine if the patient transfer might have been prevented Opportunities for improvement are discussed to determine if the team thinks the transfer might have been prevented:
The new sign, symptom or other change might have been detected earlier The condition might have been managed safely in the facility without transfer Advance directives and/or palliative or hospice care could have been discussed Other
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Summary of Interventions Utilized to Reduce Unnecessary Hospitalization
Stop and watch early warning tool utilized by care team members SBAR tool utilized by nursing staff in communicating with MD/NP/PA Quality improvement tool utilized for retrospective audit of staff performance, clinical team education, and identification of opportunities to prevent avoidable transfers
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Assessment Clinical assessment is about asking the right questions It is a datadriven process Improving the process will improve the outcomes
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CHF Interventions Ongoing continuing medical and nursing staff education utilizing evidencebased medicine guidelines as well as clinical care paths, including INTERACT, for each diagnostic category
Raised level of awareness of physicians to manage the patients inhouse
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CHF Interventions Baseline numbers low to start as medical staff vigilance was focused
INTERACT NY quality improvement review tool is used for the retrospective chart review comparing the care path with actual practice – Medical Director provides feedback to the Attending Physician regarding their decision to transfer
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49 • 60% Decrease in CHF Discharges
Electrolyte Imbalance Interventions Improved monitoring via increased availability of labs onsite and over the weekend Availability of STAT labs with results available within 30 to 45 minute timeframe Increased utilization of IV fluids Increased nursing vigilance for symptom management Utilization of care paths for medical and nursing staff education
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Anemia Challenges Most patients with chronic anemia and a low hemoglobin do not need to be admitted to hospital Many can be managed on site (eg. iron, erythropoetin) Some do need a blood transfusion Patients presenting to the emergency room for a blood transfusion are ADMITTED
53
Consequences of the Elderly Being Admitted to the Hospital
Loss of physical function due to prolonged immobility Development of new decubitii Nosocomial infections (MRSA, VRE) Acute adjustment reaction
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Asking the Question… How can our facility send patients for a blood transfusion without them getting admitted?
Hematologists send their patients living in the community to the blood bank for transfusions.
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Anemia Interventions • Developed anemia care path for education and audit purposes
• Created outpatient transfusion protocol • Developed anemia / transfusion transfer tool which is completed by MD.
• Scheduled transfer to blood center the following day • Same day return to nursing facility
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Objective: To develop a favorable alternative to the unnecessary hospitalization of nursing home residents requiring blood transfusion Through clinical collaboration with a geriatrician liaison at a local hospital, the transfusion protocol transfer form was developed.
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Anemia Interventions The protocol was developed for the nursing home resident who is evaluated for anemia and a clinical decision is made for a blood transfusion without pursuing an extensive diagnostic workup and an inpatient admission.
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Anemia Interventions: Clinical Collaboration
Developed transfusion transfer form Transfusion transfer form is faxed to the hospital geriatrician Hospital geriatrician coordinates with the hospital blood center for an outpatient transfusion the following day Resident is transported to the hospital blood center for transfusion and returned to the nursing home later that same day, avoiding an inpatient hospital stay
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Exclusion Criteria Active bleeding Hemodynamic instability Family request for admission
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Transfusion Protocol
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Anemia Interventions From 7/1/09 through 7/31/11 there were 78 residents with hemoglobin values less than 8 mg/dl on evaluation 31 of these residents (40%) were successfully transfused through use of the outpatient transfusion protocol
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Reducing Hospitalizations: Technological Interventions
Nearly 20% of Medicare hospitalizations are followed by readmission within 30 days Early detection and timely intervention is a key element in preventing adverse events Provision of realtime alerts transmitted to the nurse control station and directly to caregivers using handheld devices enables timely intervention by the medical staff
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Technological Intervention: EarlySense
The system is a patient status monitoring solution for currently unmonitored units EarlySense measures changes in patients’ respiration rate, heart rate, patient movement and turn status EarlySense provides continuous, contactfree bedside monitoring with realtime alerts Builtin management tools include a wide range of patient status and alert reports
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mobile devices
Delayed activation feature
Wandering patients feature
Personalized Sensitivity level
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5 months with EarlySense
Sustained, more predictable results
Reduction in hospital acquired
Actual clinical data of 6 months: CHW site #2 2010
# of pressure ulcer events 75%
# of patient falls 62%
# of ICU transfers 63%
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Problem Assessment InterventionRecognition
Reducing Hospitalizations: Impact of an Institutional Special Needs Program
A Medicare Advantage health plan available to nursing home residents who meet certain eligibility requirements Residents receive an extra layer of care through the personal support of a Nurse Practitioner (NP) NP helps anticipate and identify health concerns early, before they become more serious
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Institutional Special Needs Program The Nurse Practitioner:
builds oneonone relationships with the resident and their family provides handson care and monitoring acts as a communication link to the doctor, nursing facility staff and family coordinates and integrates the different aspects of the resident’s care
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Institutional Special Needs Program NP provides the following services, under a physician’s direction:
Conducts physical examinations Manages chronic conditions Orders lab tests Writes prescriptions (in most states) Quickly determines need for preventive or diagnostic services Communicates with all parties to coordinate services Ensures that treatments are working well together
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Institutional Special Needs Program NP assists with analysis of resident transfers to hospital Transfers are investigated to determine:
Who transferred the resident What day/time the transfer occurred
Transfers are categorized as: Avoidable Unavoidable but potentially preventable transfer Appropriate hospital admission
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Institutional Special Needs Program Results of Analysis of Transfers from August 2011 to July 2012:
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13%
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Care Transition Efforts In 2010, The Hebrew Home worked with one of our hospital partners in the “Hand Off Communication Project” This project was a quality and patient safety collaborative with the Joint Commission and peer collaborators across the country The goal of the project was to improve care transitions by providing all critical information needed for medical management and discharge planning
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“Hand Off Communication Project” Project involved the use of a revised resident transfer form Transfer form was paper based Project initially focused on hospital and nursing facility staff completion of a survey at the time of specific patient transfer Provider input was utilized in identifying required transfer documents for both hospital and nursing facility Development of transfer documents for both hospital and nursing facility utilization was achieved
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“Hand Off Communication Project” Hospital and nursing facility providers were surveyed to determine if they:
Received the handoff communication in a timely manner Received all of the relevant medical and social information to provide safe/quality care for the patient Provided sufficient time for the handoff Experienced limited interruptions during the handoff Communicated directly with the sender regarding any questions and concerns for safe care of the patient
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ACUTE CARE TRANSFER DOCUMENT CHECKLIST These documents should ALWAYS accompany patient: • Resident Transfer Form • Face Sheet • Current Medication List or Current MAR • Advance Directives • Care limiting Orders • Out of hospital DNR • Bed hold policy Send these documents IF INDICATED: • SBAR/Nurse’s Progress Note • Most Recent History & Physical and any recent hospital discharge • summary • Recent MD/NP/PA Orders related to Acute Condition • Relevant Lab Results • Relevant XRays
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Care Transition Efforts Currently working with Continuum of Care Improvement Through Information New York, Inc. (CCITI NY) – a notforprofit corporation engaged in health information exchange CCITI NY:
received health information technology grants from NY State related to improving care transitions determined transfer form data elements by working with a team of clinicians from numerous institutions around the country
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Care Transition Efforts CCITI NY received additional NYSDOH grant funding to conduct a project to improve care transitions between acute and postacute settings The project is piloting the use of an interoperable electronic transfer form with Hebrew Home, New York Presbyterian Hospital and several other facilities Utilization of Regional Health Information Organizations (RHIO) facilitates information exchange between sites The system allows for clinical data from an EMR to be leveraged in the sending of the transfer form
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Care Transition Efforts
Currently, CCITI NY is modifying the transfer form to more closely resemble the INTERACT transfer form CCITI NY plans to offer a less complex web based version of the transfer form for organizations who are not part of a RHIO Beta testing of the electronic transfer form is in progress
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Care Transition Efforts The Hebrew Home at Riverdale utilizes an EMR Clinical providers initiate transfer of patient demographic information and clinical data from our EMR to the Healthix RHIO CCITI System transfers patient and clinical data from RHIO into the transfer form Demographic information and clinical data is prepopulated onto the CCITI NY transfer form from the RHIO
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Care Transition Efforts Provider logs into transfer form and completes additional information
Reason for transfer Updated problems, medications, allergies Most recent vital signs, pain Immunizations Functional status including advance directives Follow up interventions Additional comments
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Care Transition Efforts Clinical decision support is integrated into the computerized transfer form
Drug – drug interactions Drug – allergy interactions
Nursing facility provider selects the receiving hospital Hospital ED registration of SNF patient triggers alert within the ED EMR Alert directs hospital staff to log into the RHIO to access patient transfer form Patient specific information is available prior to patient arrival at ED
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Care Transition Efforts Use of the electronic transfer form is intended to:
Improve staff efficiency in completing transfer form Provide automated clinical decision support to clinicians managing medically complex patients Facilitate efficient and timely exchange of accurate information between care providers in advance of patient arrival Reduce the incidence and cost of avoidable readmissions to acute care facilities Improve quality of care
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Patient ready for discharge
Provider logs into EMR, reviews documentation and launches CC Transfer form
CCITI System transfers patient and clinical data from RHIO into the CC Transfer form
Hebrew Home to Hospital RHIO
Internet
Hospital Admits Patient and Receives Transfer Form
Provider logs into system and accesses transfer form
Patient arrives at Hospital
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Conclusion • Clinical staff communication tool utilization contributed to achieving a decrease in hospitalization rates
• Diagnostic care paths continue to be utilized and refined as needed
• The quality improvement tool provides timely and specific feedback to clinicians responsible for resident transfer
• An electronic transfer form is being developed to improve care transitions between providers
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Conclusion
Effective care transitions Enhanced care across settings Improved quality of care during transitions
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Conclusion
The Hebrew Home was recently selected to participate with the Greater New York Hospital Association/Continuing Care Leadership Coalition in the CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
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Strengthen nursing homehospital partnerships Provide for engagement of registered nurse care coordinators to implement INTERACT and other evidence based practices Provide the support of an electronic information and exchange system Assist with monitoring care coordination and the transfer process
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The INTERACT II Program Acknowledgement
The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Center for Medicare and Medicaid Services The current version of the INTERACT Program was designed by the INTERACT team, with input from many direct care providers and national experts in projects based at Florida Atlantic University and supported by the Commonwealth Fund. The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.
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Speaker Contact Information David Weinstein, EVP, COO Executive Vice Present, Chief Operating Officer [email protected]
Mary Frances Thaler, P.T., M.H.A. Vice President of Administration [email protected]
Zachary Palace, M.D., C.M.D. Medical Director [email protected]
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1
David Weinstein, Executive VP and COO Mary Frances Thaler, Vice President of
Administration Dr. Zachary J. Palace, Medical Director
May 22, 2013
Presentation Objectives Review :
Best practices The role of clinical interventions and technology The importance of collaborations
2
5/6/2013
2
3
4
Reason for D/C 7/1/09 6/30/10 7/1/10 6/30/11 7/1/11 6/30/12 Percentage
Year 1 to Year 3
Anemia 36 23 20 44%
CHF 10 9 4 60%
Elec. Imbalance 6 2 1 83%
Resp. Infection 112 70 62 45%
Sepsis 40 32 49 23%
UTI 13 1 3 77%
Overall Hospitalization totals for tracked
categories 217 137 139 36%
5/6/2013
3
Presentation Outline
I. Description of the CMS Nursing Home Value Based Purchasing Demonstration Project (NHVBP) II. Review of communication tools and clinical assessment utilized to reduce avoidable hospitalizations III. Review of technological interventions used to promptly identify changes in resident conditions IV. Description of an Institutional Special Needs Program V. Description of Care Transition Efforts
5
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5/6/2013
4
Nursing Home Value Based Purchasing Demonstration Project (NHVBP)
Background: NHVBP is a Centers for Medicare and Medicaid Services (CMS) Pay for Performance Initiative Goal: to improve the quality of care furnished to all Medicare beneficiaries in nursing homes
7
Nursing Home Value Based Purchasing Demonstration Project (NHVBP)
CMS selected three states to host the demonstration: Arizona, New York, Wisconsin As of June 30, 2010 there were 78 participating nursing homes in New York, 61 in Wisconsin and 38 in Arizona Comparison group nursing homes were selected either through random assignment or matching The Hebrew Home at Riverdale was selected as a participating nursing home for the duration of the demonstration project – July 1, 2009 to June 30, 2012
8
5/6/2013
5
Overview of NHVBP Design Objective: To improve the quality of care furnished to all Medicare beneficiaries residing in nursing homes
Approach: Assess nursing home performance based on selected measures of quality Make annual payment awards (if savings are achieved) to those nursing homes that achieve the best performance or the most improvement based on the performance measures
9
NHVBP Performance Payments
In each State, a payment pool will be determined each year The payment pool will be based on the estimated Medicare savings achieved by the participants Higher quality of care is expected to result in fewer avoidable hospitalizations If no savings are achieved, then no payment pool
10
5/6/2013
6
NHVBP Performance Measures Each year of the demonstration, CMS will calculate an overall quality score by summing the scores in four domains NHVBP Demonstration Project included four domains/performance measures:
Nurse staffing Outcomes from State survey inspections Outcomes on selected MDSbased quality measures Rates of potentially avoidable hospitalizations
11
12
20 pts.
Potentially avoidable hospitalizations
NHVBP Performance Measure Staffing (30 Pts.)
RN/DNS hours per resident day Total licensed nursing hours (RN/DNS/LPN) per resident day Certified Nurse Aide (CNA) hours per resident day Nursing staff (RN, LPN, CNA) turnover rate Agency staff count 80% of staff level measure Case Mix adjusted Quarterly Payroll data will be source for staffing levels and turnover measures
13
NHVBP Performance Measure State Survey Inspections
(20 pts.) Deficiencies are assigned values based on scope and severity Return visit to correct deficiencies will be considered Facilities cited for substandard care will be ineligible for an incentive payment FTags only, no life safety
14
5/6/2013
8
(from MDS) (20 Pts.)
Chronic Care (LT Stay) Points reduced for percentage of residents:
whose need for help with ADL has increased whose ability to move in & around their room became worse who are considered high risk residents with pressure ulcers who have had a catheter left in their bladder who were physically restrained
15
NHVBP Performance Measure Quality Measures (from MDS) (20 Pts.)
PostAcute Care (shortterm) Points gained for percentage of residents:
with improving ADL’s. who improve status on midloss ADL functioning. with failure to improve bladder incontinence.
16
5/6/2013
9
NHVBP Performance Measure Potentially Avoidable Hospitalizations
(30 Pts.) “Avoidable” is defined as hospitalizations with any of these diagnoses:
• Heart Failure • Respiratory Infection • Electrolyte Imbalance • Sepsis • Urinary Tract Infection • Anemia (Long Term Residents Only)
17
NHVBP Implementation Strategies Protocols Developed for Reducing Unnecessary Hospitalizations:
All RN’s IV certified Increased inhouse Lab hours to 6 days per week and oncall for 7th day Established outpatient transfusion capabilities without hospitalization Purchased EKG machine for stat EKGs onsite Implemented Care Paths for the identified diagnoses
18
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10
Creation of NHVBP Committee comprised of: Executive VicePresident / Chief Operating Officer Associate Administrator Medical Director Director of Nursing Services Director of Clinical Documentation and Reimbursement Infection Control Nurse
19
Concurrent Evaluation Strategies
NHVBP Committee objectives: To track all hospitalizations for all diagnostic categories To review biweekly data to identify patterns of incidence of hospitalizations by diagnostic categories To complete indepth medical and nursing audit for a sample of all residents hospitalized To review audit results for identification of patterns/trends
20
5/6/2013
11
Concurrent Evaluation Strategies NHVBP Committee objectives continued:
To complete an indepth audit of a selected sample for comparison to the defined clinical care path To review audit findings discussed at biweekly committee meetings with the clinical team To revise clinical pathways based on audit results To further develop strategies to reduce hospitalizations
21
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• The Hebrew Home is committed to treating patients in place
• The Hebrew Home chose to participate with the Continuing Care Leadership Coalition (CCLC), an affiliate of the Greater New York Hospital Association (GNYHA), in implementation of the INTERACT II program
23
The INTERACT II Program INTERACT: “Interventions to Reduce Acute Care Transfers”
Is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition Includes evidence and expertrecommended clinical practice tools, strategies to implement them, and related educational resources
24
5/6/2013
13
The INTERACT II Program Goal To improve care, not to prevent all hospital transfers Can help with more rapid transfer of residents who need hospital care Can help your facility safely reduce hospital transfers
25
Early Warning Tool – Stop and Watch SBAR Quality Improvement Tool
26
5/6/2013
14
Improve management of acute changes in clinical status: Identification Assessment Treatment in the facility Documentation Communication
Internal With hospitals
Early Warning Tool Stop and Watch
Utilized by clinical and nonclinical staff who have direct resident contact Utilized when an important change in condition is noted when caring or interacting with the resident Presented to the charge nurse before the end of the shift Utilized by charge nurse in evaluation and treatment of the resident Results in earlier identification of subtle changes in resident condition
28
5/6/2013
15
EARLY WARNING TOOL “Stop and Watch” If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Name of resident: __________________________________________ Seems different than usual Talks or communicates less than usual Overall needs more help than usual Participated in activities less than usual
Ate less than usual (not because of dislike of food) No bowel movement in the last 48 hours Drank less than usual
Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual Staff: ____________________________ Reported to: _______________________________ Date: _____ / _____ / ________ Time: ____________________ 29
SBAR: Physician/NP/PA Communication
and Progress Note
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and Progress Note Before calling the MD/NP/PA the Nurse should:
Evaluate the resident – complete the SBAR form Check vital signs Review the medical chart – including recent labs Review an associated clinical care path if applicable Have relevant information available when reporting – including advanced directives, allergies, medication list, and the medical record
31
SBAR
SBAR provides clear guidelines for communication around a resident’s change in condition SBAR utilization results in more efficient and effective transmission of important information SBAR form can also be used in place of a nursing progress note
32
5/6/2013
17
33
34
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18
35
Purpose of this tool is to retrospectively review acute care (nonelective) transfers to an emergency department or for direct admission to the hospital Tool should be completed within 24 to 48 hours after a resident is transferred Utilization of this tool helps facility staff:
Understand the reasons for acute care transfers Identify possible opportunities to prevent avoidable transfers Identify common patterns among the acute care transfers
36
5/6/2013
19
The QI Review Tool 1. Background Information 2. Change in Condition 3. Evaluation and Management 4. Transfer Information 5. Opportunities for Improvement
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Quality Improvement Tool Retrospective review of quality improvement tool information is used to determine if the patient transfer might have been prevented Opportunities for improvement are discussed to determine if the team thinks the transfer might have been prevented:
The new sign, symptom or other change might have been detected earlier The condition might have been managed safely in the facility without transfer Advance directives and/or palliative or hospice care could have been discussed Other
41
Summary of Interventions Utilized to Reduce Unnecessary Hospitalization
Stop and watch early warning tool utilized by care team members SBAR tool utilized by nursing staff in communicating with MD/NP/PA Quality improvement tool utilized for retrospective audit of staff performance, clinical team education, and identification of opportunities to prevent avoidable transfers
42
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22
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Assessment Clinical assessment is about asking the right questions It is a datadriven process Improving the process will improve the outcomes
45
CHF Interventions Ongoing continuing medical and nursing staff education utilizing evidencebased medicine guidelines as well as clinical care paths, including INTERACT, for each diagnostic category
Raised level of awareness of physicians to manage the patients inhouse
46
5/6/2013
24
CHF Interventions Baseline numbers low to start as medical staff vigilance was focused
INTERACT NY quality improvement review tool is used for the retrospective chart review comparing the care path with actual practice – Medical Director provides feedback to the Attending Physician regarding their decision to transfer
48
5/6/2013
25
49 • 60% Decrease in CHF Discharges
Electrolyte Imbalance Interventions Improved monitoring via increased availability of labs onsite and over the weekend Availability of STAT labs with results available within 30 to 45 minute timeframe Increased utilization of IV fluids Increased nursing vigilance for symptom management Utilization of care paths for medical and nursing staff education
50
5/6/2013
26
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27
Anemia Challenges Most patients with chronic anemia and a low hemoglobin do not need to be admitted to hospital Many can be managed on site (eg. iron, erythropoetin) Some do need a blood transfusion Patients presenting to the emergency room for a blood transfusion are ADMITTED
53
Consequences of the Elderly Being Admitted to the Hospital
Loss of physical function due to prolonged immobility Development of new decubitii Nosocomial infections (MRSA, VRE) Acute adjustment reaction
54
5/6/2013
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Asking the Question… How can our facility send patients for a blood transfusion without them getting admitted?
Hematologists send their patients living in the community to the blood bank for transfusions.
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Anemia Interventions • Developed anemia care path for education and audit purposes
• Created outpatient transfusion protocol • Developed anemia / transfusion transfer tool which is completed by MD.
• Scheduled transfer to blood center the following day • Same day return to nursing facility
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Objective: To develop a favorable alternative to the unnecessary hospitalization of nursing home residents requiring blood transfusion Through clinical collaboration with a geriatrician liaison at a local hospital, the transfusion protocol transfer form was developed.
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Anemia Interventions The protocol was developed for the nursing home resident who is evaluated for anemia and a clinical decision is made for a blood transfusion without pursuing an extensive diagnostic workup and an inpatient admission.
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Anemia Interventions: Clinical Collaboration
Developed transfusion transfer form Transfusion transfer form is faxed to the hospital geriatrician Hospital geriatrician coordinates with the hospital blood center for an outpatient transfusion the following day Resident is transported to the hospital blood center for transfusion and returned to the nursing home later that same day, avoiding an inpatient hospital stay
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Exclusion Criteria Active bleeding Hemodynamic instability Family request for admission
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Transfusion Protocol
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Anemia Interventions From 7/1/09 through 7/31/11 there were 78 residents with hemoglobin values less than 8 mg/dl on evaluation 31 of these residents (40%) were successfully transfused through use of the outpatient transfusion protocol
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Reducing Hospitalizations: Technological Interventions
Nearly 20% of Medicare hospitalizations are followed by readmission within 30 days Early detection and timely intervention is a key element in preventing adverse events Provision of realtime alerts transmitted to the nurse control station and directly to caregivers using handheld devices enables timely intervention by the medical staff
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Technological Intervention: EarlySense
The system is a patient status monitoring solution for currently unmonitored units EarlySense measures changes in patients’ respiration rate, heart rate, patient movement and turn status EarlySense provides continuous, contactfree bedside monitoring with realtime alerts Builtin management tools include a wide range of patient status and alert reports
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mobile devices
Delayed activation feature
Wandering patients feature
Personalized Sensitivity level
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5 months with EarlySense
Sustained, more predictable results
Reduction in hospital acquired
Actual clinical data of 6 months: CHW site #2 2010
# of pressure ulcer events 75%
# of patient falls 62%
# of ICU transfers 63%
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Problem Assessment InterventionRecognition
Reducing Hospitalizations: Impact of an Institutional Special Needs Program
A Medicare Advantage health plan available to nursing home residents who meet certain eligibility requirements Residents receive an extra layer of care through the personal support of a Nurse Practitioner (NP) NP helps anticipate and identify health concerns early, before they become more serious
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Institutional Special Needs Program The Nurse Practitioner:
builds oneonone relationships with the resident and their family provides handson care and monitoring acts as a communication link to the doctor, nursing facility staff and family coordinates and integrates the different aspects of the resident’s care
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Institutional Special Needs Program NP provides the following services, under a physician’s direction:
Conducts physical examinations Manages chronic conditions Orders lab tests Writes prescriptions (in most states) Quickly determines need for preventive or diagnostic services Communicates with all parties to coordinate services Ensures that treatments are working well together
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Institutional Special Needs Program NP assists with analysis of resident transfers to hospital Transfers are investigated to determine:
Who transferred the resident What day/time the transfer occurred
Transfers are categorized as: Avoidable Unavoidable but potentially preventable transfer Appropriate hospital admission
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Institutional Special Needs Program Results of Analysis of Transfers from August 2011 to July 2012:
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13%
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Care Transition Efforts In 2010, The Hebrew Home worked with one of our hospital partners in the “Hand Off Communication Project” This project was a quality and patient safety collaborative with the Joint Commission and peer collaborators across the country The goal of the project was to improve care transitions by providing all critical information needed for medical management and discharge planning
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“Hand Off Communication Project” Project involved the use of a revised resident transfer form Transfer form was paper based Project initially focused on hospital and nursing facility staff completion of a survey at the time of specific patient transfer Provider input was utilized in identifying required transfer documents for both hospital and nursing facility Development of transfer documents for both hospital and nursing facility utilization was achieved
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“Hand Off Communication Project” Hospital and nursing facility providers were surveyed to determine if they:
Received the handoff communication in a timely manner Received all of the relevant medical and social information to provide safe/quality care for the patient Provided sufficient time for the handoff Experienced limited interruptions during the handoff Communicated directly with the sender regarding any questions and concerns for safe care of the patient
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ACUTE CARE TRANSFER DOCUMENT CHECKLIST These documents should ALWAYS accompany patient: • Resident Transfer Form • Face Sheet • Current Medication List or Current MAR • Advance Directives • Care limiting Orders • Out of hospital DNR • Bed hold policy Send these documents IF INDICATED: • SBAR/Nurse’s Progress Note • Most Recent History & Physical and any recent hospital discharge • summary • Recent MD/NP/PA Orders related to Acute Condition • Relevant Lab Results • Relevant XRays
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Care Transition Efforts Currently working with Continuum of Care Improvement Through Information New York, Inc. (CCITI NY) – a notforprofit corporation engaged in health information exchange CCITI NY:
received health information technology grants from NY State related to improving care transitions determined transfer form data elements by working with a team of clinicians from numerous institutions around the country
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Care Transition Efforts CCITI NY received additional NYSDOH grant funding to conduct a project to improve care transitions between acute and postacute settings The project is piloting the use of an interoperable electronic transfer form with Hebrew Home, New York Presbyterian Hospital and several other facilities Utilization of Regional Health Information Organizations (RHIO) facilitates information exchange between sites The system allows for clinical data from an EMR to be leveraged in the sending of the transfer form
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Care Transition Efforts
Currently, CCITI NY is modifying the transfer form to more closely resemble the INTERACT transfer form CCITI NY plans to offer a less complex web based version of the transfer form for organizations who are not part of a RHIO Beta testing of the electronic transfer form is in progress
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Care Transition Efforts The Hebrew Home at Riverdale utilizes an EMR Clinical providers initiate transfer of patient demographic information and clinical data from our EMR to the Healthix RHIO CCITI System transfers patient and clinical data from RHIO into the transfer form Demographic information and clinical data is prepopulated onto the CCITI NY transfer form from the RHIO
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Care Transition Efforts Provider logs into transfer form and completes additional information
Reason for transfer Updated problems, medications, allergies Most recent vital signs, pain Immunizations Functional status including advance directives Follow up interventions Additional comments
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Care Transition Efforts Clinical decision support is integrated into the computerized transfer form
Drug – drug interactions Drug – allergy interactions
Nursing facility provider selects the receiving hospital Hospital ED registration of SNF patient triggers alert within the ED EMR Alert directs hospital staff to log into the RHIO to access patient transfer form Patient specific information is available prior to patient arrival at ED
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Care Transition Efforts Use of the electronic transfer form is intended to:
Improve staff efficiency in completing transfer form Provide automated clinical decision support to clinicians managing medically complex patients Facilitate efficient and timely exchange of accurate information between care providers in advance of patient arrival Reduce the incidence and cost of avoidable readmissions to acute care facilities Improve quality of care
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Patient ready for discharge
Provider logs into EMR, reviews documentation and launches CC Transfer form
CCITI System transfers patient and clinical data from RHIO into the CC Transfer form
Hebrew Home to Hospital RHIO
Internet
Hospital Admits Patient and Receives Transfer Form
Provider logs into system and accesses transfer form
Patient arrives at Hospital
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Conclusion • Clinical staff communication tool utilization contributed to achieving a decrease in hospitalization rates
• Diagnostic care paths continue to be utilized and refined as needed
• The quality improvement tool provides timely and specific feedback to clinicians responsible for resident transfer
• An electronic transfer form is being developed to improve care transitions between providers
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Conclusion
Effective care transitions Enhanced care across settings Improved quality of care during transitions
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Conclusion
The Hebrew Home was recently selected to participate with the Greater New York Hospital Association/Continuing Care Leadership Coalition in the CMS Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
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Strengthen nursing homehospital partnerships Provide for engagement of registered nurse care coordinators to implement INTERACT and other evidence based practices Provide the support of an electronic information and exchange system Assist with monitoring care coordination and the transfer process
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The INTERACT II Program Acknowledgement
The INTERACT Program and Tools were initially developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP at the Georgia Medical Care Foundation with the support of a contract from the Center for Medicare and Medicaid Services The current version of the INTERACT Program was designed by the INTERACT team, with input from many direct care providers and national experts in projects based at Florida Atlantic University and supported by the Commonwealth Fund. The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.
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Speaker Contact Information David Weinstein, EVP, COO Executive Vice Present, Chief Operating Officer [email protected]
Mary Frances Thaler, P.T., M.H.A. Vice President of Administration [email protected]
Zachary Palace, M.D., C.M.D. Medical Director [email protected]
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