hospital to home to primary care provider/community...
TRANSCRIPT
Hospital to Home to Primary Care Provider/Community Care: Achieving Effective Transitions through the New CCAC Rapid Response Nursing Program
Janet McMullan, RN, BScN, MN, Client Services Specialist, Project Lead RRNP, OACCAC Dilys Haughton, RN(EC), BScN, PHC NP, GNC(C), MHSc, CHE Director, Client Services Operations , HNHB CCAC
Outstanding care – every person, every day
OACCAC, June 21, 2013
Agenda
Objective
Learn about the new CCAC Rapid Response Nurse Program, designed to facilitate safe transitions for patients from acute care in the hospital to their homes and/or primary care provider and community supports.
Agenda
1. Review Project Background and Evidence
2. Provide an Overview of Rapid Response Nurse Program
3. Consider Lessons Learned & Preliminary Performance Measurement from one CCAC
4. Highlight Key Learnings
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Background
3
• Effective transitions between hospital and home are recognized as critical to achieving better patient outcomes and avoiding rehospitalisation.
• Many patients have sub-optimal experiences in care transition
between hospital and home/community care. Problems include: • Medication discrepancies • Confusion about post discharge care plans
• Hospital readmission rates for COPD / HF ~30%
• Risk of readmission is significantly lower when:
• 1st home care visit take place within 24 hours of discharge • Primary care visit occurs within 7 days of discharge
1Nurses in CCACs: Providing Care and Creating Connections Across Sectors, P. 4
Governance Structure
Provincial Client Service
Committee
Provincial RRNP Working Group
RRNP Work Stream 1 –
Roles & Responsibilities
RRNP Work Stream 2 –
Communication
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Evidence: Effective Transitions
Research for care transitions in specific diagnoses has been ongoing for decades!
• Common elements from the literature include:
• In-home follow-up care (24-72 hours)
• Care coordination across transitions
• Medication management/reconciliation
• Patient education/empowerment (Coleman) or care management (Naylor)
• Patient-centered care
• Patient enabled with personal health record
• Follow-up with primary care provider
(Rich et al, 1995; Naylor et al., 1995; Coleman et al., 2006)
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Program Goals
• Reduce rehospitalization and avoidable emergency department visits by improving the quality of transition from acute care to home care for two population groups:
• Frail adults and seniors who are medically complex or have chronic diseases that tend towards frequent hospitalization, unstable health and costly treatments.
• Medically complex/vulnerable children, and their families
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Rapid Response Nurses
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Home
Hospital
24 hours 7 days
Care
Coordinator
Rapid
Response
Nurse
Primary Care
Home/Community Care
Care Coordinators
Hospital
-Case finding
-Screening for eligibility
-Identify RRN involvement Pre D/C
-Collection of D/C information
-Overall Service Planning
-Service Ordering of RRN
-Consent for Tx
-Problem-based assessment using common tool
-Teach back approach to education
-Medication Reconciliation
-Confirm medical tests
-Update In-Home Health Record
-Linking with PCP
- Ongoing problem- based assessment to ensure client stable & safe
-Address ongoing medication issues
-Linking with PCP
-Contribute to Service Planning
-Joint visit/phone with CC and SP to transition care
Emergency Dept.
-
-Arrange PCP appointment if needed
-Update PCP about acute care event/ post D/C plan
-Share contact information
-Share problem based assessment & medication reconciliation
-Discharge from RRN Program
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Referral
Source Intake by Hospital CC
RRN
Visit
Follow-up
Care
Transition to
PCP/SP/Community CC
Target Population - Complex and Chronic Using CCM: * Medically complex/vulnerable children, and their families
* Frail adults and seniors that are medically complex or have chronic diseases that tend
towards frequent hospitalization, unstable health and costly treatments, including: CHF,
COPD, Diabetes, Other Ambulatory Sensitive Conditions
Model of Care Discharge from
Hospital
24 Hours
7 Days
Integrated Care Transitioning from Hospital to PCP/Community Providers
LOS 2-3 weeks
Key Performance Indicators Client Information
• Number / % of patients served (by type/profile children, adults, seniors; by ambulatory sensitive condition*)
Access • # of visits; average number of visits per patient • Average Length of Stay • Number / % of in-home visits within 24 hours of hospital discharge* • Reason for not receiving service
Health System Impact / Cost Effectiveness • Number / % of emergency visits within 30 days* • Number / % of hospital re-admissions in 30 days* • Number / % of primary care appointments within 1 week of hospital discharge*
Quality Measures
• Patient / informal caregiver experience & Provider Experience –overall satisfied with transition care, perception of care connections and integration(TBD)*
Health System Outcomes
• Measure of physician engagement - contacts between RRN and PCP*
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Learnings from Local Implementation
HNHB CCAC Implementation
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January to March 2012: HNHB LHIN funding (to reduce ALC) Design and implementation in 2 branches (Hamilton and Burlington) April to June 2012: Implemented a consultant pharmacy programme July to September 2012: Spread programme across the LHIN (Haldimand Norfolk, Brant and Niagara) October to December 2012: Full implementation of Adult Rapid Response Programme Consolidated clinical programme infrastructure (e.g. P and Ps) January 2013 ongoing: Partnered with hospital Bundled Transitions Project test of change Developing Paediatric focus of intervention Knowledge transfer Service provided 6 days / week
Improving the Transition to Primary Care
Mr. J. was in hospital for 9 months following a stoke and was discharged home. He requiring total care and was awaiting a move into Long Term Care.
PMHx: Longstanding epilepsy, osteoarthritis, osteoporosis - experiencing fracture of the hip and wrist, depression, non insulin dependent diabetes, indwelling by catheter. Recent UTI x 3 with the onset of delirium.
• No primary care provider visits in the last 6 years.
Issue: Patient is sleeping 23 hours / day. Why: Drug toxicity? Infection? Blood sugars? Pneumonia? UTI? Narcotic influence? Depression?
Key success factors: Access to hospital information (clinical connect); collaboration with primary care (blood work / CXR); consultation with pharmacist
Outcome: The patient woke up! Up in the chair 5 – 6 hours / day. Socializing with others. Avoid hospital readmission. Able to moving successfully to Long Term Care.
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Patient Characteristics: Diagnoses
• ~25% HF / heart related disorders
• ~25% COPD
• ~25% geriatric giants (e.g. pain, cognition, continence, mobility, falls)
• Unique features at HNHB CCAC
• Support transition of high risk patients awaiting LTC (Home First)
• Support complex community patients at risk of ED visits / hospitalization
• Clinical pharmacy programme
• Most patients have multiple conditions, and multiple physicians involved
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Rapid Response Referrals
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0
10
20
30
40
50
60
70
80
Number of Weekly Referrals (N=2,177) (May 28, 2012 – June 15, 2013)
Patient Characteristics: Care Requirements
15
0
50
100
150
200
250
300
MAPLe 1 MAPLe 2 MAPLe 3 MAPLe 4 MAPLe 5
MAPLe Score by Age Group
75+
0 - 74
• MAPLe measures ability to care for self / care requirements
• 72% patients are > age 75
• 47% patients could
move into LTC (MAPLe 4, 5)
• Another 35% are at the “tipping point” (MAPLe 3)
• 18% of RRTT patients have an active placement file
Patient Characteristics: Medical Complexity
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0
50
100
150
200
250
300
350
400
450
CHESS 0 CHESS 1 CHESS 2 CHESS 3 CHESS 4 CHESS 5
Patients by CHESS Score (N=1315) • CHESS, a subscale of the RAI HC instrument, measures medical frailty
• Higher CHESS, lower life expectancy
• 66% patients have CHESS >2
• 30.4% patients >3
Clinical Pharmacy Consultations
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Performance Metrics
Performance Output Indicator (2012 – 2013) Actuals
# of new hospital patients discharged home to CCAC RRTT program 911
(60.9%)
# of existing CCAC patients referred to CCAC RRTT program 584
(39.1%)
% of high risk patients from hospital that require readmission within 7 days of discharge (81 of 911 patients)
8.9
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Time to First Visit
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# of
Referrals
(May 2013)
Total First Visit
< 24 Hours
First Visit
< 48 Hours
First Visits
< 72 Hours
Visits
within
72 hours
Visits
> 72
hours
No
contact
Total
N = 278
48.92 %
8.99 %
7.91 %
65.8 %
21.22 %
12.59 %
• Data for May 2013
• Excludes Sundays visits
• Includes referrals from community care coordinators (standard < 72 hours)
Hospital Readmissions
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0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
% R
ead
mis
sio
n
RRTT 7 Day Readmission Rate
Avg hospital readmission rate 8.9%
Hospital Readmissions
Hospital readmissions within 7 days
• Patients discharged from hospital and readmitted
• N = 81 (8.9%)
• 82% > age 70
• 63% patients have CHESS >2
• 72% patients have MAPLe >3
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0
5
10
15
20
25
30
<50 51-60 61-70 71-80 81-90 91-100 >100
Patients Readmitted to Hospital by Age (N=81)
Key Learnings
• Bridging the patient to home is an effective strategy to reduce hospital readmission rate
• Programme supports integration of patient care across sectors (hospital / home care / primary care)
• Identification / hospital screening for risk is important: need appropriate hospital risk screening process
• All medical patients at risk of readmission using LACE screening tool. Hospitals across the LHIN will implement a Bundled Transitions Project using teach back techniques to further screen patients
• Hospital engagement is required at the front line, middle and upper management levels
• Timely transfer of accurate information such as medication lists and in-hospital record of care is important
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Key Learnings
• Medication reconciliation is a key strategy
• Focus on specific populations helps concentrate efforts and help reduce hospital readmission (e.g. HF)
• About half of all patients have diagnosis of COPD or HF
• Many patients have multiple diagnoses and multiple physicians involved – who is the lead?
• Patients often become disconnected from their primary care physicians: making the connection with PCP is important but can be challenging (physicians away, may not know the patients well). However, the number of orphaned patients is small.
• Data collection across sectors is important to determine impact of programme on readmission rate
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Outstanding care – every person, every day