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A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association
NYSPFP Preventable Readmissions Initiative:
Pilot Review and Post Hospital Care
June 17, 2014
NYS PARTNERSHIP FOR PATIENTS
Agenda Topic Speaker
I. Welcome Elaina Heagerty, Project Manager NYSPFP Staff
II. Readmission Pilot Project • Revisiting goals and objectives • Where are we now?
NYSPFP Staff
III. Hospital Experiences • Successes • Challenges • Lessons Learned
St. Barnabas Hospital St. Joseph’s Hospital Health Center
V. Question and Answer Session Maria Stala Sacco, Project Manager NYSPFP Staff
VI. Next Steps • Fall Regional In-person Sessions • Hospital Story Board Preparation
NYSPFP Staff
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NYS PARTNERSHIP FOR PATIENTS
Review of Pilot Objectives o Phase 1 – Admission
o Identify patients on admission who are at risk for readmission using an “any risk” approach.
o Assemble a multidisciplinary team to address interventions that will mitigate risks for readmission.
o Phase 2 – Hospital Stay o Prepare patient and caregiver for discharge, beginning at admission. o Conduct ongoing patient reassessment to identify new or changing risk factors. o Ensure systems for multidisciplinary communication, coordination, planning, and
evaluation.
o Phase 3 - Discharge o Ensure patient and family/caregiver are fully prepared for post hospital care. o Provide timely and thorough communication to post hospital providers.
Background
SBH is a not-for-profit, nonsectarian, 435-bed, acute care, 911-receiving hospital that holds state designations as a regional trauma center, stroke center and AIDS center.
The hospital’s emergency department has nearly 100,000 visits annually.
Preventable Readmission Initiative - Phase 1
Risk assessment for hospital readmission – 2 week pilot project
Implementation of a tool to identify potential readmissions
• The modified LACE tool was utilized
Unit identified – 3 North
Team identified – geographic to 3N
Communication between teams during daily multidisciplinary rounds
Team Members
Name Title
Manisha Kulshreshtha Hospitalist Director
Mohammad Azam Hospitalist Attending Physician – 3N
Abdurhman Ahmed Hospitalist Attending Physician – 3N
Ricardo Velasquez Medical Resident – Lead Resident 3N
Naldeen Hector Case Manager – RN – 3N
Sally Lebron Medical Social Worker – 3N
Wanda Kelly Director – Case Management
Grace Ortiz Associate Director–Case Management
Lorraine Barnett Associate Director – Social Work
Marie BonTemps Nurse Manager – 3N
Rachel Sussman Clinical Pharmacist
Rebecca Ditkoff Nutrition
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Referrals/ Interventions Risk Factor Category Referral/ Intervention
Medications Clinical Pharmacist Referral
Psycho-social Barriers/ Clinically Complex Social Work Department Nursing/Clinicians
Financial Barriers Credit Department
Nutritional Limitations Nutrition Department
Limited Patient Understanding/ Health Literacy
Nursing/Clinicians
Mental Health/ Substance Abuse Psychiatry/ Addiction Medicine Referral
Palliative Care Palliative Care Referral
Calculate LACE score for all patients on 3N on admission
Share LACE score with team during WhiteBoard (WB) Multidisciplinary Rounds
High Risk (HR) magnets placed on WB if score greater than 11
Interventions according to issues identified by physicians/ social worker/ case manager/ nutrition/nursing
Appropriate referrals made
Interventions put in place
Checklist completed Patients tracked for readmission 30 days after discharge
Results
Total of 76 patients reviewed over a 2 week period
9 patients were identified as high risk for readmission
67
9
Patients at Risk for Readmission
Low Risk
High Risk
tool for
risk classifica
tion
Length of stay Number of patients
Less 1 day 0
1 day 4
2 days 2
3 days 1
4-6 days 2
7-13 days 0
14 or more days 0
Acute Admission In patient 9
Observation 0
Comorbidity No prior History 0
DM no complications, Cerebrovascular disease, Hx of MI, PVD, PUD 2
Mild liver disease, DM with end organ damage, CHF, COPD, cancer, leukemia, lymphoma, any tumor, cancer, moderate to
severe renal disease 3
Dementia or connective tissue disease 0
Moderate to severe liver disease or HIV infection 7
Metastatic cancer 0
ER visits during previous 6 months 0 0
1 1
2 3
3 1
4 or more 4
Results
Specific Risk Factors
5
1 1 0
2 2
1
3
2
3 3
2
0 0 0 1 1
0 1 1 1
2
1 1
0
1
2
3
4
5
6
Referrals Given
100%
0%
Referrals Given
Yes No
Disciplines Involved
1
1
6
4
2
2
1
1
1
1
0 1 2 3 4 5 6 7
GI
ID
Medicine
Social Worker
PMD
Addiction Medicine
Dietician
Heme/Onc
Palliative care
Surgery
Disciplines Involved
High Risk Patients – ED Visits/ Readmissions in 30 Days
4
1
7
2
0
1
2
3
4
5
6
7
8
Readmitted Against Medical Advice ED visits No ED visits
Follow Up of High Risk Group
0
1
2
3
4
5
6
7
8
Yes No
Clinic Follow Up - High Risk Group (n=9)
Number of Patients
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Yes No
Clinic Follow Up - High Risk Readmitted Group (n=4)
Number of Patients
Next steps - Sustainability
High risk(HR) magnets as part of all whiteboard rounds on all units
LACE tool auto-calculation being incorporated into the EMR
Ongoing communication with Allscripts (EMR) to have the LACE score available on the header of the patient medical record based on the previous visit
Admission/Discharge reconciliation – clinical pharmacist interventions; clinician education
Preventable Readmission Initiative- Phase 3
Identify PCP (on admission) – completed
Identify Pharmacy – eRx, map of local pharmacies – in progress
Contact PCP – Resources: little blue book, community physician list; training and education of clinicians; CCDA
Patient Portal
Pilot on 3N – phone calls post discharge
Identifying PCP on Admission
e-Prescribe
Patient’s preferred pharmacy identified
Interdisciplinary Discharge Summary
Medications electronically prescribed and indicated on the interdisciplinary discharge summary
Map of Local Pharmacies
Map of local pharmacies to be provided to patients
Communication with PCP
Clinician education on communication with PCP ongoing
Dispense history on Allscripts EMR
The Little Blue Book app
Contact numbers of community (out of network) physicians available on all medical units
In-network physicians contacted using secure health messaging in the Allscripts EMR for communication regarding patient follow up care
Patient Post-Discharge Call - Pilot
In progress on 3N - initiated 2 weeks ago
Unit nurse manager responsible for calling all discharged patients within 24-72 hours of discharge
Script and a list of questions provided
Important information regarding gaps in transitions of care being obtained
Algorithm for taking care of issues arising from the follow up phone calls in progress
Meaningful Use 2 (MU2)
Meaningful Use 2 (MU2) incorporates many elements of post discharge care coordination
Patient Portal
E-Prescribe
Patient Education (Info Button)
CCDA – Consolidated Clinical Document Architecture
o Planning Goal, Goal Instructions, Plan of Care Goal types incorporated into the discharge summary
SBH –Care Coordination
Preventable Hospital Readmission Initiative (PHRI) – 11.5% reduction in all cause readmissions in 2013 compared to 2012
Readmission alerts, teach back, transmitting discharge summaries to PCPs, ED case management, interdisciplinary discharge summary, intensive patient education on CHF & glucose monitoring
Readmission Committee; Transitions of Care Committee
Incorporating Meaningful Use 2 (MU2) in the post hospital care coordination process
Summary: What are Readmissions
“Readmissions are not primarily about people being re-hospitalized because of mistakes made in the hospital.”
“Reducing readmissions is about making transitions of care more effectively.”
“When transitions of care are not done well,.. evidence suggests they wind up back in the hospital.”
Prevention of Readmissions
What we were doing…
• Multidisciplinary daily rounds. Physical therapy, case- management, nursing, attending physician, pharmacy and third year resident discuss discharge barriers and patient condition.
• As an organization we recognized that our readmission rates proved an area of opportunity.
How we were doing… All Cause 30-Day Readmissions to Same Facility –Green, Orange & Red Hospitalist Attending at Discharge
Initial Encounters Discharged 1/1/13-3/31/14, Readmissions through 4/30/14 - data shown by initial discharge date
Making the change…
• Agreed to participate in NYSPFP Preventable Readmissions pilot program.
• Developed the initial committee to discuss implementation. Team consists of physicians, nursing, nutrition, pharmacy, physical therapy, performance improvement team member, director of medical surgical nursing, social work, and case management.
Making the change… • It was crucial to have nurse buy-in. Maria Stala Sacco
from NYSPFP initially met with the nursing staff discuss the pilot and to explore the feelings of this group.
• Nurses identified early on that there were key indicators that were present on admission that could impact readmission. Agree that focus would need to be on early intervention
• Utilizing the input from the nursing staff, the committee developed a plan for implementation.
Perceived Barriers
• The nursing staff identified several potential barriers. – Implementation of the new EMR (EPIC) network
wide during the same time frame as the pilot. – Staffing ratios. – Patient acuity. – Nurse work load.
Making the change…Phase 1
• We selected to utilize the NYSPFP Readmission Any Risk Assessment tool at the time of admission to identify potential readmission risks.
• We placed a flowchart and a breakdown of identified risks with possible interventions as a reference for the health care team.
• In addition this guide listed the drivers of specific interventions according to their scope of practice.
Implementation of risk identification tool
• Nursing was initially slow to incorporate the tool into their admission process workflow. They gradually adapted their routine to include the tool just as the EPIC EMR was launched.
• EPIC implementation started, which required all staff to focus on the EMR.
• To keep the pilot going each unit educator took responsibility of the process while nursing focused on EPIC.
• Now that EPIC has been assimilated into the nurse workflow, we are reengaging the nursing staff to utilize the readmission risk tool during the admission process.
Phase I Recap • The initial plan was to have nursing drive the risk tool. There was a
need based on competing priorities to incorporate other resources to support Pilot.
• Prior to the implementation of EPIC the majority of nursing staff identified readmission risks per the admission process these aligned with what we were seeing in early audits; medications and psychosocial barriers.
• Referrals for specialties were made by the nurse at the time of admission and on identification of specific risks.
• Weekends and nights referrals were delayed. • Identified that a risk assessment tool is built in new electronic
medical record system for case management. Plan is to expand the tool, create automatic referrals when physician order is not required and make it risk assessment score available to all disciplines.
Phase II: Teach-Back
• A teaching action plan was developed to implement the Teach-Back method for all disciplines. – Reviewed NYSPFP website and current literature for teach back
information. – A power point was developed for use by all disciplines to educate on
the Teach-Back method. Utilized video’s displaying correct and incorrect forms on teach-back.
– Developed education plans for nursing, pharmacy, residents and Physical Medical rehabilitation.
– Audit teach-back method at the bedside with immediate coaching if needed.
Next Steps
• The committee continues to meet to review the process and to identify areas of opportunity for improvement and sustainability.
• Work with Business Analysis unit to review readmission data and drill down on opportunities.
• Implement a more robust pharmacy consult process. • Implement Phase III- Evaluate and Refine discharge process
including current use of D/C phone-calls. • The committee will develop strategies for hospital wide
implementation.
NYS PARTNERSHIP FOR PATIENTS
Next Steps o June – September, 2014:
o Continue pilot activities and one-on-one work with NYSPFP project manager
o Begin developing your team’s Story Board for the Fall 2014 sessions o NYSPFP to provide template for hospitals to use o Project managers available to assist with Story Board
development
June 16, 2014 4
NYS PARTNERSHIP FOR PATIENTS
NYSPFP Resources and Support o NYSPFP Project Managers
o Address questions from the team and assist with identifying next steps o Participate in team meetings and discussion of outcomes o Clarify the use of tools and resources o Convene regional in-person meetings and/or calls to facilitate sharing of
ideas, practices, challenges, and successes
o NYSPFP Tools and Resources
o NYSPFP Website Preventable Readmission Initiative Page o Pilot Phases 1, 2, and 3 Tracking Tools o Preventable Readmissions Action Planning Resource Guide
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NYS PARTNERSHIP FOR PATIENTS
Preventable Readmissions In-Person Sessions – Fall 2014: Upstate sessions: o October 21 –Batavia o October 22 – Syracuse Downstate sessions: o October 29 – New York City o October 30 – Long Island
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