ucsf transitional care program -...

UCSF Transitional Care Program

Maureen Carroll RN CHFNTransitional Care Manager

Heart Failure Program CoordinatorNovember 1, 2016

Session Objectives

Describe elements necessary for building a cross continuum team

Summarize interventions to improve transitions in care after hospitalizations and to reduce avoidable readmissions

Discuss the ROI and processes implemented to sustain improvements

Describe post acute projects to decrease readmissions

Review what UCSF is doing to improve hospital flow

UCSF Health2

UCSF Health

Mission: UCSF is advancing health worldwide

2015 – 2016 U.S. News Best Hospitals Surveys #8 overall

UCSF is the second largest employer in San Francisco, paid employees about 25,000

UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco have 722 beds and generate 763,000 outpatient visits per year

UCSF is the nation’s top public recipient of funding from the National Institute of Health (NIH). In 2014, receiving $538.1 M through 1,210 NIH research and training grants.

Earned Magnet designation for excellence in nursing by the American Nurses Credentialing Center (ANCC).

UCSF Health3

Why focus on Readmissions?F

req

uen

t 20% Medicare beneficiaries readmitted within 30 days

Co

stly $17B in

Medicare spending

*Estimated $60B by 2030 Im

pro

vem

en

t 76% of readmissions are avoidable

UCSF Health4

MedPAC Report to Congress. Promoting Greater Efficiency in Medicare. June 2007

Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008.

Commonwealth Fund State Scorecard on health System Performance. June 2009

5

Institute of Healthcare Improvement

Care Transition Models – The Good News

The Care Transitions Program - Eric Coleman MD

The Transitions Care Model - Mary Naylor PhD, RN-

Institute of Healthcare Improvement- STAAR Initiative-

Avoiding Readmissions Through Collaboration – ARC- Gordon and Betty Moore Foundation – SF Bay area

Project BOOST ( Better Outcomes for Older Seniors through Transitions) Mark Williams MD

Project Red- Brian Jack MD

Interact Project- Improved communications with SNFs

6

What do these Models have in common?

Comprehensive patient and family

education

Medication reconciliation

Discharge planning

Post hospital Follow up

Coaching- Primary convener

Coordination of Care

Readmissions- We’ve come a long way

CMS Hospital Readmission Reduction Program

• Focus on “potentially preventable “ readmissions

• Focus on patients most at risk

• National Medicare all-cause 30-day readmission rates decreased-

‒ 19.8% - 2010 -- 18.02% - 2014

‒ Goal is lower readmission not zero readmissions

‒ Possible moving toward 90 days oversight

10/28/2016Presentation Title and/or Sub Brand Name Here8

Cross-Continuum Teams- STAAR

• STAAR Initiative –

• CCTs are one of the most transformational changes we found

• CCTs reinforce the reality that avoidable readmissions are not solely a hospital problem

• Involvement is needed at two levels:

1) At the executive level to remove barriers and develop overall strategies for ensuring care coordination and support

2) At the front lines, power of “senders” and “receivers”

co-designing processes to improve transitions of care

Institute of Healthcare Improvement

UCSF Heart Failure Program… Our Story and Building a Team

Gordon and Betty Moore Foundation Grant

GOAL: Reduce all cause Heart Failure

Readmissions

Began November 2008 – February 2011

Collaboration with Institute for Healthcare Improvement

(IHI)

Patients 65 years and older

Primary AND Secondary

diagnosis of Heart Failure

on 3 pilot units

1 of 4 Bay Area Hospitals chosen

30 and 90 day readmissions

by 30%

UCSF Health11

Why Heart Failure?

• Hospital admissions per year with primary heart failure1.1 Million

• Hospital admissions per year with primary and secondary heart failure3 Million

• People in US with heart failure5.7 Million

• Cost $32 Billion Year # 1 Medicare Discharge diagnosis

• Expected by 2030- Silver TsunamiOver 8 Million

Mozaffarian D, Benjamin EJ, Go AS; for American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and

stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.

Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart

Association. Circ Heart Fail. 2013;6(3):606-619.

Heart Failure Program

Heart Failure Program Coordinators

1.6 FTE

7 days a week coverage 2008-2014

Current coverage 5 days a week

Supported by Large Multidisciplinary Cross Continuum team

Patients Enrolled

500 Admissions a year

~ 50 patients per month

Average Age: 80 years old

Culturally diverse

Multiple Languages – 30% non English speaking

10/28/2016UCSF Health13

Building the Team

Team Meetings

Gathering Multidisciplinary team frequently Working towards common goal

Learning about each other’s Roles

Gaining an understanding of work flows Getting “Buy In”

Building Relationships

Meeting face to Face Moving out of the “silos”

UCSF Health14

The Team… it takes a village!

The Patient and Family/Caregiver

PhysiciansSenior

Leadership

Case Managers

Social Workers

Dietitians

Pharmacists

Home Care Team

Palliative Care

Chaplains

Managers and Nurses

Community Partners

SNF Partners

Outpatient Clinics

UCSF Health15

IHI: Creating an Ideal Transition Home

Pillar One

• Enhanced Admissions Assessment for Post-Discharge Needs

Pillar Two

• Enhanced Teaching and Learning/Patient Readmission Interview

Pillar Three

• Patient and Family Centered- Handoff Communication

Pillar Four• Post Acute Care Follow Up


Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to

Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.

http://www.ihi.org/

Timeline of Heart Failure Program Transitional Care Program

• Inpatient Focused2009

• Outpatient Focused2010

• Sustainability & Community Collaboration2011

• Research & Expansion2012

• Hospital Wide Readmission & Transition Work2013

• Quality Division and expanded Disease Management Programs2014

• Office of Population Health, Expansion in outpatient setting2015

• Expansion of populations, SNF Collaborative2016

UCSF Health17

The First Year ~ 2009: Inpatient Focused

Developing “The Team” with

monthly meetings

Comprehensive Patient Education

Care Coordination

Implemented IHI Evidence Based Interventions

Development of Data Collection

System

Heart Healthy Classes on unit

Patient Advisory Group

Palliative Care Collaboration

Staff trained on teach Back & HF

Education

Patient Stories Shared to drive

change

Focus on Continuum of

care –Communication

and Collaboration

UCSF Health18

The Second Year~ 2010: Outpatient Focused

Collaboration with outpatient providers

“Virtual Team” email to connect providers

MD House Calls Program for High Risk

HF Patients

Project BOOST Collaboration

In-services for staff, home care, skilled

nursing staff

High Risk Pt F/U at Advanced HF Clinic

with NP

Hospital wide projects to standardize and improve discharge

process and readmissions

UCSF Health19

UCSF Health20

Interventions and Readmissions...Fundamentals are Essential

Interventions

• Daily Chart Reviews

• Multidisciplinary Rounds

Patient Identification

• Teach Back method, Meeting Family and Caregivers

• Four different languages for HF printed materials

Patient Education

• Inpatient/Outpatient – consult and referrals

• Virtual “Team Email”,

• Care at Home Programs

• Community resources, Post acute facilities, outpatient program referrals

Coordination

• F/U Appts: Within 7 days

• Follow Up Calls

• Initially – Manual calls 7, 14 days

• Currently – 5x month automated

Follow Up

UCSF Health22

Email to “Virtual Team” on Admission:

Dear Medical Team,We wanted to let you know that we are following Mr. XXXXXXXXXXX in the Heart Failure / Transitional Care Program . We are very familiar with this high risk patient from previous admissions (5th in past 4 months). We have provided education, initiated palliative care consults, and coordinated services in the past . We would like to provide as much support as possible for the patient and family.

Recommendations:1. Bridges Program- MD home visits 2. UC RN home care 3. Pharmacist consult for discharge medications4. Follow up appointment within 7 days5. Goals of care discussion/Palliative care consult

The goal of the program is ….

Please let us know if there is anything that we might do to assist and thank you for the great care that you provide our patients!

UCSF Health23

TEACH BACK

Evidence based technique of patient education that assesses the patients’ and family caregivers understanding of instructions and ability to do self-care.

In Teach Back, the caregiver explains important information to the patient or family caregiver and then asks in a non-shaming way for the individual to explain in his or her own words what was understood.

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Teach Back is not enough…In addition to Teach Back and Heart Failure education, chronic diseases require life style changes.

Time Trust Support Accountability

UCSF Health25

UCSF Health26

Readmission Interview: Patient Perspective

UCSF Health27

Why?

Why?

Why?

Why?

Why?

Find the

barriers…

Avoidable Readmissions…

Inadequate support,

caregiver fatigue, lack of self

management skills

Medication issues, lack of access,

multiple co morbidities

Low health literacy,

unable to Teach Back

UCSF Health28

IHI’s Approach: Assess the Patients Medical and Social Risk for Readmission

UCSF Health29

• Admitted two or more times in the past year

• Patient or family caregiver is unable to Teach Back, or has a low confidence to carry out self-care at homeHigh Risk

• Admitted once in the past year

• Patient or family caregiver is able to Teach Back most of discharge information and has moderate confidence to carry out self-care at home

Moderate Risk

• No other hospital stays in the past year

• Patient or family caregiver has high confidence and can Teach Back how to carry out self-care at homeLow Risk

Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings

to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.

http://www.ihi.org/

Risk Stratification ToolsModified LACE Tool

Attribute Value Points Prior

Admit

Present

Admit

Length of Stay Less 1 day 0

1 day 1

2 days 2

3 days 3

4-6 days 4

7-13 days 5

14 or more days 6

Acute

Admission

Inpatient 3

Observation 0

Comorbidity

(Comorbidity

[points are

cumulative to a

maximum of 6

points)

No Prior history 0

DM no complications,

Cerebrovascular Disease, Hx

of MI, PVD, PUD

1

Mild Liver Disease, DM with

end organ damage, CHF,

COPD, Leukemia,

lymphoma, any tumor cancer,

or moderate to severe Renal

Disease

2

Dementia or connective tissue

Disease

3

Moderate or severe Liver

Disease or HIV infection

4

Metastatic Cancer 6

Emergency Room

visits during the

previous 6 months

0 visits 0

1 visits 1

2 visits 2

3 visits 3

4 or more visits 4

Sum of the points

UCSF Tool

Risk Level Criteria

HIGH

Four or more admissions in the past 12

months

Readmission within one week

Lack of social support

GOC/End of life/PC/Hospice

Max needs (functionally)

Medically complex

Advanced Disease Process

Low Health Literacy

History of Substance abuse

Adherence issues – medications, dietary,

f/u appointments

Psych history

MODERAT

E

Three admissions in the past 12 months

Multiple Co-morbidities

Lack of social support

Psych history and/or substance abuse

Decreased functional status

Low health literacy

Adherence Issues (Meds/diet)

Patient nor family speaks/reads English

LOW

First or second admission in the past 12

months

Minimal co-morbidities

High health literacy30

The role of Palliative Care with Heart Failure Patients

Goals of Care Conversations


There is a need to have GOC discussions documented in EMR to ensure continuity

across settings

Palliative Care

Proven to improve sx,

QOL, satisfaction

25% of our HF die

within one year

Up to 50% of deaths

with HF are due to

sudden death

Standardize –consult on

3rd

readmission/year

Advanced Care

Planning

Fewer late-life hospital admissions

PC MD now on Advanced Heart Failure

Service

UCSF Health33

Pantilat and Steimle JAMA 2004;291:2476-82Wright et al. JAMA 2008;300:1665-73Morrison J Palliat Med 2005;8:S79-87

UCSF Palliative Care Collaborative


Increased Advance Care Planning

Increase PC inpatient consults

Increased outpatient PC programs-clinics

Coordination of UCSF Palliative care programs

Longitudinal Care across settings

Effective GOC discussion documentation in EMR

Data and Business Case…

30 Day Readmissions:Primary & Secondary Heart Failure 65+

UCSF Health36

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

30 Day ReadmissionsPrimary & Secondary Heart Failure

UCSF Medical Center Heart Failure Program

Goal Line:

Annual Averages

2009 = 24%

2010 = 19%

2011 = 13%

2012 = 12%

Financial Implications during grant period to UCSF, of Reducing Medicare HF Readmissions

UCSF Health37

Compared utilization and financial outcomes for four different study periods: Pre grant, first and second year of

grant and the year following the grant…

30D Readmission

Rate decreased from 22.5% to 12.6% in the

year post grant

As a result, the overall number

of bed days per 100 unique MRNs is also

declining

Average LOS for

readmissions CY2008 = 5.3 CY 2011 =

8.0

Financial Implications

UCSF Health38

In calendar year 2011, Medicare payment for all cause Heart Failure primary or secondary diagnosis was

$23,239 per case

The number of UCSF avoided readmissions at a 12.6% readmission rate would result in approximately

$1.1 MILLION

Annual savings to Medicare

Report generated by Karen Rago, RN, MPA, FAAMA, FACCA

UCSF Primary HF Readmissions 65+ CMS

UCSF Health39

Quarterly Chart ~ Progress over 8 yearsMedicare pts 65+ with Primary Dx of HF

UCSF Health40

10/28/201641

AMI, CHF, COPD, PNA,

STK, THA, CABG

11.34% ↓ 9.53%

UCSF Readmission Dashboard

UCSF Health42

Outpatient FocusFollow Up Calls, SNF Collaborative and more

10/28/2016

Office of Population Health &

Accountable Care

Health Care Navigators

Complex Care with

NPs

BRIDGES and Home

Based Palliative

Care

Ortho Bundled Payment

PRIME/ DSRIP

Transitional Care

ACO work

Follow Up Call

Program

UCSF Health44

Office of Population Health and Accountable Care

Prepare UCSF for Payment Reform & Succeed in current risk arrangements

• Accountable Care (50,000 lives in risk based payment)

‒ CANOPY Health

• Bundle Payment (CMS Ortho Bundle payment program)

• PRIME

Design, Develop & Implement Clinical Programs to Fill Gaps that must be filled in new payment paradigms

• Care Support

• Care at Home

• Discharge Phone Call Program/Transitions

Analytic Capabilities to support transition to

Value based payment

• Analytic team

• Ambulatory Quality

Forge partnerships necessary to take and

succeed in new payment world

• Canopy

• Post Acute Care Collaboratives

• Provider and Payer partnerships

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California’s Medicaid Waiver

Source: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/1115/section-1115-demonstrations.html

CMS approved CA’s 1115 application for the “Medi-Cal Hospital/Uninsured Care Demonstration.” This allowed CA to create a Safety Net Care Pool (SNCP) to fund uncompensated care and the expansion of health care coverage to the uninsured in certain counties.

CA’s demonstration was renewed and renamed “California Bridge to Reform.” This demonstration included new Delivery System Reform Incentive Payments (DSRIP) which promoted the development of programs that improve quality of care in our public hospital systems.

CMS approved California’s demonstration extension through 2020. The new redesigned pool, now called the Public Hospital Redesign and Incentives in Medi-Cal (PRIME), is meant to support the state's efforts to prepare public hospitals for success under alternative payment models focused on health care value.

Sept 2005: CA Safety Net Care Pool

Nov 2010: CA Bridge to Reform

Dec 2015: Public Hospital Redesign and Incentives in Medi-Cal

(PRIME)

UCSF Follow Up Calls Program

• Automated Calls with UCSF Nurse voice

• Original content

• Alerts to email, dashboard if patient needs call backCipher Health

• Receive a discharge phone call within 48 hours

• RN available for assistance- trouble shooting

• F/U Appt, Symptoms, Home Care, Medications, SatisfactionAll Patients

• Heart Failure & COPD

• One call weekly for 5 weeks

• Disease specific questions

• Currently only in English, working on Spanish, Chinese and Russian

Disease Management

UCSF Health47

Post Discharge Automated Calls

UCSF Health48

Initial F/U Heart Failure Call Evaluation

Initial evaluation: August –

November 2015

119 HF patients

94% of patients who engaged with the HF

Follow Up Call program were

NOT readmitted within 30 days

UCSF Health49

Program Evaluation done by Cipher Health, Kristen Gagliardi and team. November 30, 2015

96% reach rate

Co-Design and Coordination

Real-Time Handover Communications

• Skilled Nursing Facilities

• Home Care Agencies

• Outpatient Clinics

• Providers

“Warm Hand overs”

• Creating a “Virtual Team”

• Time Consuming but valuable

• Inpatient team, case manager, consultants, HF Clinic, Home Care RNs, SNF and PCP on admission

Email Notifications

• Medication Reconciliation

• Focus on self management skills

• Match appropriate care with individualized needs of the patient and family

Home Care Referrals

UCSF Health51

Changes in Law and Incentives

Affecting skilled nursing facilities (SNF), home health agencies, inpatient rehabilitation facilities (IRF), and long-term care hospitals (LTCH).

Financial penalties for failing to report quality measures beginning 2019.

Since January 2015,MDs, NPs. PAs, and clinical nurse specialists can start receiving separate Medicare fee for chronic care management for seniors with 2 or more chronic conditions, delivered outside regular office visits

Transitions Care Management Codes- designed to promote and incentivize face to face and non face to face encounters

Compensation for End of Life discussions

UCSF & SNF Collaborative

UCSF & 6 local SNFs

Senior Leadership & key stakeholders

Communication

Accountability

Reliability

Transparency

Encouragement

Collaboration

Quarterly Collaborative Meetings

Quarterly 1:1 meetings

Staff In-services

Weekly Huddle calls

MD:MD and RN:RN Warm Hand Overs

Metrics/Patient Stories

30 D Readmissions

Falls -5% relative decrease

Discharge before noon

LOS, Acceptance rates

Readmission Analysis

Patient issues shared across settings

UCSF Health53

UCSF SNF Collaborative Improvements

Identification of processes in need of improvement on bothends

Discharge Packets- collaborative effort – What is essential info needed?

Communication Improvements- Falls risk, RN – RN, MD-MD calls, Readmission reviews

Relationships established- discuss shared concerns, high risk pts, plans of care

Metrics and best practices shared- collective lessons learned


Interventions to Reduce Acute Care Transfers (Interact) Website

UCSF Health55

http://interact2.net/

• Designed to improve identification,

evaluation, and communication

about changes in resident status.

• The overall goal of the INTERACT

program is to reduce the frequency

of transfers to the acute hospital.

• Three basic tools:

• Communication tools

• Care Paths or Clinical tools

• Advance Care Planning tools

Root Cause Analyses of Transfers of Skilled Nursing Facility Patients to Acute Hospitals:

Lessons Learned for Reducing Unnecessary Hospitalizations

UCSF Health56

http://interact2.net/docs/publications/RCA%20on%20SNF

%20Transfers%20Overview%20JAMDA%20March%202016.

pdf

After completing the RCA, SNF

staff identified 1044 (23%) of the

transfers as potentially preventable.

Lessons LearnedImprovements, Changes, Work in Progress

Lessons Learned

Collaboration with IHI

Dedicated Coordinators

Test, trial and change

interventions

Exec Leadership and

Champions necessary

Committed multidisciplinary

teams

Palliative Care Team

CollaborationHome Care Collaboration and referrals

Communication and Relationship

Building

Teach Back and Health

Literacy focus essential

Change is the Norm

Technology has incredible potential

Power of the PATIENT and Family STORY

UCSF Health58

Improvements

SNF Collaborative

Transitions Executive Steering

Committee-Hospital wide goal

UC Care at Home, MD Home visits

expansion

Increased access for patients – Doc of the Week, NPs in clinics, increased

open appointments

Readmit reviews –Roundtable

Readmission, Cardiology faculty

meetings

Disease management workgroups (COPD, HF)

Readmission Data Dashboard – all

readmissions

Cipher Follow Up Phone Call Program

Shared work between Teams-

ACO, Transitions, SNF, Palliative Care

UCSF Health59

What is UCSF doing to improve hospital flow?

Efforts to Increase Access

• Doc of the Week- open cardiology appointments

• Cardiology Outpatient Recovery clinic – COR

Discharge Calls program- prevent ED visits

Discharge Before Noon ( DBN) – Goal- 20% before noon

ED Efforts-

• Clinical Decision Unit- decrease admissions- strict criteria

• High Utilizer efforts

OR, Periop, PACU - Efficiency Work/Consultants

Efficiency Improvements in Transfer Center

Focus on Prevention programs- Admission prevention

10/28/201660

True North Boards


Posted on several units

Increased visibility

Involving all in goals

Patient Stories…

UCSF Health62

Patient pictures used with permission.

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