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TRANSCRIPT
1
Welcome to our presentation!
• To participate you must first join our session.
• You do this by sending a text to this five digit number 22333.
• In the body of the text message, you’ll type Marylyons445
• You will get a confirmation message that you are now part of
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• Now you’re ready to reply to a polling question with your
response (A,B,C)…”
1
Please get your phone out and get ready to respond
2
Polling Question Practice
How many new professional contacts have you made since
arriving in Kentucky?
A. None, I’m still recovering from my travels
B. 1-4 Just getting warmed up
C. 5-10 I’m having fun
D. More than 10, I am the life of the party
3
2
APN-Led Initiative Creates MVP (Multiple Visit Patient) Care Plans to Decrease Readmissions and Length of Stay
Presented to: Insert relevant presenter information Calibri 16pt
Presented on: Month day, Year
Presented by: Insert relevant presenter information here
Presented to: ASPMN 26th National Conference
Presented on: September 9, 2016
Presented by: Pam Bolyanatz, MS, FNP-BC, RN-BCMary Lyons, MSN, APN/CNS, RN-BC, ONC
Objectives
5
• Describe the process for creating a
multidisciplinary team to reduce acute hospital
utilization for patients with persistent pain or
related conditions.
• Define metrics, care planning process &
implementation of a multi hospital procedure
to provide coordinated care for MVP patients.
• Summarize project outcomes and future
direction of MVP program.
Conflict of Interest Disclosure
Pam Bolyanatz, none
Mary Lyons, Mallinckrodt Pharmaceuticals Speaker’s
Bureau for non-branded presentation
3
7
Polling Question #2
How many of you work at an organization
that is concerned about readmissions?
A. Yes, my organization is very concerned
B. No, my organization is not concerned
C. I don’t work at an inpatient facility
8
So what’s the problem??
• Realization that pain patients frequenting the ED were at risk for
misunderstanding & lack of continuity of care
• Interface with Care Coordination who identified increasing readmission rates
• Evaluation of hospital “Top 100” list for hospital ED charges 5/2014-4/2015
− Top 3 Central DuPage Hospital patients incurred between 102K-126K each
− Top 3 Delnor Hospital patients incurred between 103K-210K each
• Benchmarking with local hospitals
− We’re not alone!
− Care plan templates
− Framework for patient and provider communications
− Procedure models
9
Self assessment at home and close to home
4
Literature Review• Pain and Emergency Medicine Initiative (PEMI) study involving 18 academic centers
across Canada and the United States1
• 20 percent of patient visits had chronic pain as the primary reason for their visit to the emergency department.
• Represents the largest percentage of visits to the emergency department for any one pathology.
Todd, K., Ducharme, J.
etal., 2007
• As substance use issues increase so does the number of patients utilizing the ED for chronic pain management. Given the complex correlation between pain and substance use, attention should be given to standardizing a plan of care and facilitating referrals to appropriate providers for structured treatment with focus on the patient’s physical as well as psychological well-being.
Neighbor,
Dance, Hawk, &
Kohn, 2011
• Substance use disorders (SUD) are a growing health concern, with non-medical usage of opiates at an all-time high. In the United States approximately 22% of all deaths are related in some way to substance use
Chang & Yang, 2013
• Pain management care plans allow ED staff to provide compassionate, comprehensive care while balancing risk.
• Patients will be empowered to become less dependent on the healthcare system with improved self management.
Allen, M, etal,. 2014
10
Utilizing the DMAIC Methodology
11
Trying to fix a broken process
Define
Team members
Define key terms/goals
High level process map
1st Charter
Scope
Measure
Analyze
Improve
Control
Project Team
Executive
SponsorSponsors
Improvement
Leader / PM Team Members
• Provides
overall guidance
and
accountability for
the project
• Addresses
project barriers
(organizational)
• Provides
strategic
oversight
• Accountable
for timely and
successful
implementation
of the project
• Addresses
project barriers
(departmental)
• Provides
tactical
oversight
• Accountable for
implementing,
controlling, and
measuring
project outputs
and
improvements
• May also be a
Subject Matter
Expert (SME)
Process
Owner
• DMAIC
methodology expert
•Accountable for
using DMAIC to
manage the project
and complete
deliverables
• As project reaches
control, manages the
process outputs and
transitions to the
Process Owner
• Makes significant and
focused contributions to
the timely and successful
implementation of the
project
• Contributes ideas and
significantly impact the
direction of the project
• May be involved in data
collection & analytics
•Consider “fresh eyes”
Clinical
Sponsor
• Accountable
for reaching
clinical
consensus on
guidelines,
protocols, and
other clinical
decisions
12
5
Project Team
Executive
SponsorSponsors
Improvement
Leader / PM Team Members
• Provides
overall guidance
and
accountability for
the project
• Addresses
project barriers
(organizational)
• Provides
strategic
oversight
• Accountable
for timely and
successful
implementation
of the project
• Addresses
project barriers
(departmental)
• Provides
tactical
oversight
• Accountable for
implementing,
controlling, and
measuring
project outputs
and
improvements
• May also be a
Subject Matter
Expert (SME)
Process
Owner
• DMAIC
methodology expert
•Accountable for
using DMAIC to
manage the project
and complete
deliverables
• As project reaches
control, manages the
process outputs and
transitions to the
Process Owner
• Makes significant and
focused contributions to
the timely and successful
implementation of the
project
• Contributes ideas and
significantly impact the
direction of the project
• May be involved in data
collection & analytics
•Consider “fresh eyes”
Clinical
Sponsor
• Accountable
for reaching
clinical
consensus on
guidelines,
protocols, and
other clinical
decisions
13
Project Team
Executive
SponsorSponsors
Improvement
Leader / PM Team Members
• Provides
overall guidance
and
accountability for
the project
• Addresses
project barriers
(organizational)
• Provides
strategic
oversight
• Accountable
for timely and
successful
implementation
of the project
• Addresses
project barriers
(departmental)
• Provides
tactical
oversight
• Accountable for
implementing,
controlling, and
measuring
project outputs
and
improvements
• May also be a
Subject Matter
Expert (SME)
Process
Owner
• DMAIC
methodology expert
•Accountable for
using DMAIC to
manage the project
and complete
deliverables
• As project reaches
control, manages the
process outputs and
transitions to the
Process Owner
• Makes significant and
focused contributions to
the timely and successful
implementation of the
project
• Contributes ideas and
significantly impact the
direction of the project
• May be involved in data
collection & analytics
•Consider “fresh eyes”
Clinical
Sponsor
• Accountable
for reaching
clinical
consensus on
guidelines,
protocols, and
other clinical
decisions
14
Project Team
Executive
SponsorSponsors
Improvement
Leader / PM Team Members
• Provides
overall guidance
and
accountability for
the project
• Addresses
project barriers
(organizational)
• Provides
strategic
oversight
• Accountable
for timely and
successful
implementation
of the project
• Addresses
project barriers
(departmental)
• Provides
tactical
oversight
• Accountable for
implementing,
controlling, and
measuring
project outputs
and
improvements
• May also be a
Subject Matter
Expert (SME)
Process
Owner
• DMAIC
methodology expert
•Accountable for
using DMAIC to
manage the project
and complete
deliverables
• As project reaches
control, manages the
process outputs and
transitions to the
Process Owner
• Makes significant and
focused contributions to
the timely and successful
implementation of the
project
• Contributes ideas and
significantly impact the
direction of the project
• May be involved in data
collection & analytics
•Consider “fresh eyes”
Clinical
Sponsor
• Accountable
for reaching
clinical
consensus on
guidelines,
protocols, and
other clinical
decisions
15
6
Project Team
Executive
SponsorSponsors
Improvement
Leader / PM Team Members
• Provides
overall guidance
and
accountability for
the project
• Addresses
project barriers
(organizational)
• Provides
strategic
oversight
• Accountable
for timely and
successful
implementation
of the project
• Addresses
project barriers
(departmental)
• Provides
tactical
oversight
• Accountable for
implementing,
controlling, and
measuring
project outputs
and
improvements
• May also be a
Subject Matter
Expert (SME)
Process
Owner
• DMAIC
methodology expert
•Accountable for
using DMAIC to
manage the project
and complete
deliverables
• As project reaches
control, manages the
process outputs and
transitions to the
Process Owner
• Makes significant and
focused contributions to
the timely and successful
implementation of the
project
• Contributes ideas and
significantly impact the
direction of the project
• May be involved in data
collection & analytics
•Consider “fresh eyes”
Clinical
Sponsor
• Accountable
for reaching
clinical
consensus on
guidelines,
protocols, and
other clinical
decisions
16
Utilizing the DMAIC Methodology
17
Trying to fix a broken process
Define
Team members
Define key terms/goals
High level process map
1st Charter
Measure
Defining outcome & process metrics
Operational definitions
Data collection plan
Procedure development
Analyze
Improve
Control
Utilizing the DMAIC Methodology
18
Trying to fix a broken process
Define
Team members
Define key terms/goals
High level process map
1st Charter
Measure
Defining outcome & process metrics
Operational definitions
Data collection plan
Procedure development
AnalyzeData analysis
Individual patient review
Process analysis
Ongoing identification of MVPs
Ongoing Charter updates
Improve
Control
7
Utilizing the DMAIC Methodology
19
Define
Team members
Define key terms/goals
High level process map
1st Charter
Measure
Defining outcome & process metrics
Operational definitions
Data collection plan
Procedure development
Analyze
Data analysis
Individual patient weekly & prn review
Process analysis
Ongoing identification of MVPs
Ongoing Charter updates
Improve
Generating solutions/interventions
Engaging executive sponsor support
Developing system & community partners
Applying evidence based guidelines
Control
Utilizing the DMAIC Methodology
20
Define
Team members
Define key terms/goals
High level process map
1st Charter
Measure
Defining outcome &
process metrics
Operational definitions
Data collection plan
Ongoing Charter updates
Analyze
Data analysis
Individual patient weekly & prn review
Process analysis
Ongoing identification of MVPs
Procedure development
Improve
Generating
solutions/interventions
Enlisting executive sponsors
Developing system & community partners
Applying evidence based practice
Control
Ongoing metrics & monitoring
Developing a sustainable plan
Partnering with Analytics to develop automated reports & data analysis
Dissemination of project plan, progress & possibilities
Charter: Multiple Visit Patient Care Planning
21
Exec Sponsors: Cori Zacher VP, Dr. Kevin Most & Dr. Mark Daniels Sponsor(s): Jeannine Harvell, Kim Czaruk
Process Owner(s): Delnor: Sherri Johnson, Kelly Ryan, Pam Bolyanatz CDH: Pam Nass, Mary Lyons, Carol Tulley
Team Members: See attached
Key Metrics
Outcome Metric(s):Reduce ED visits and/or hospitalizations (for the same condition) for patients with MVP
team interventions by 25% annually.
Process Metric(s): Care plan creation, ongoing evaluation and
compliance (patient and caregivers) with plan
Milestones
Description
� Charter completed/revised 06/15
� Multidisciplinary teams at Delnor & CDH 02/15
� Care plan template & communication plan developed
� Implementation of active care plans
� Creation & system approval of patient & provider communication letters &
guidelines 4/16
Date (MM/YY)
Project Overview
Problem Statement: Frequent emergency department & hospital admissions for pain and/or symptom related conditions create financial, throughput & system
resource strains on the healthcare system as evidenced by review of the Crimson Top 100 patient list, admission data & staff referrals for Delnor and CDH.
Goal/Benefit: Ensure patient access to the appropriate level of care through a coordinated care evaluation and creation of an individualized care plan for patients
with persistent pain or other related conditions/symptoms, there by reducing ED visits and/or hospitalizations by 25% annually for patients with MVP care plans.
Scope: Patients who have presented to the West Region EDs or have been hospitalized 3 times per month within the last 6 months for the same or similar pain
diagnosis. Individual exceptions may apply.
Excludes: Patients with terminal conditions such as cancer, ETOH dependency, drug overdose/suicide attempts
System Capabilities / Deliverables: Multidisciplinary assessment, evaluation and creation of an individualized care plan that will be placed in the Media section of the
EMR as communicated in the “FYI” Flag area. Ongoing evaluation & modification of plan based on discussion on a monthly or as needed basis.
Resources Required: Dedicated Care Coordinator, Social Worker, Pain Management APN, ED physician leadership and/or inpatient hospitalist or PCP to
endorse care plans and other specialists as needed. Financial and outcome analysis support.
Last Update: 4/27/2016
8
Scope of MVP Team/Project
• Scope includes
− Patients who have presented to the West Region EDs or have
been hospitalized 3 times per month within the last 6 months
for the same or similar pain diagnosis
• Scope excludes
− Patients with terminal conditions such as cancer.
− ETOH dependency
− Drug overdose/suicide attempts
• Individual exceptions may apply at the discretion of the MVP
Team
22
D =
Define
How do we know we’re making a difference?
• Outcome Metric(s):
Reduce ED visits and/or hospitalizations (for the same condition)
for patients with MVP team interventions by 25% annually
• Process Metric(s):
Care plan creation, ongoing evaluation and assessment of compliance (patient and caregivers) with plan
23
M =
Measure
MVP Individual “Root Cause Analysis”
Who?
• In depth psychosocial evaluation
What?
• The same pain complaint on a frequent basis
• A flare or exacerbation of pain
• A new acute pain complaint
• A patient with substance use disorder
Why?
• Unrelieved symptoms such as nausea
• Co-morbid diagnoses
When?
• Is there a pattern to their visits?
24
9
Evolution of a System Procedure for MVP Care Planning
Referrals are made via multiple
methods to the MVP Work Group.
Evaluation by MVP Work Group
Review the patient history
of system encounters
Review patient’s medical, social &
psychological history
Review the IL Prescription Monitoring
Program (ILPMP)
Complete MVP Care Planning Assessment
Contact the patient’s PCP and/or pain specialist.
Medical alert “FYI” flag added to the
EMR for communication to
team
25
Care Plan Communication
26
FYI Flag
Evolution of a System Procedure for MVP Care Planning
MVP Team Member meets
with patient Introductory Letter from
hospital administrators
Continued dependence
on system
MVP Care Plan developed
Care Plan disclaimer
Provider Communication
Letter
Ongoing monitoring
Generated by MVP Team
Hand delivery preferred
27
This care plan is intended to supplement, rather than substitute
for professional judgement and may be changed based on individual
needs
10
Introductory Patient LetterOur goal at Northwestern Medicine is to provide excellent care to you throughout our
health system. Excellent care means that we evaluate your condition and offer appropriate
treatment in a kind, respectful, efficient and caring manner…..
28
The Center for Disease Control (CDC) and many states have
developed guidelines for patients with chronic pain.
The focus is to make sure that patients with chronic pain receive
safe and effective pain care from their Primary Care Provider
or a Pain Specialist. We at Northwestern Medicine support
the CDC recommendations….
We’re concerned that receiving care in these settings may not
be in your best interest. Our goal is to help you receive the
coordinated care that your chronic pain condition requires in the
appropriate setting. Therefore, our clinical team at
Northwestern Medicine has reviewed your records and has
some important recommendations to assist you in managing
your chronic condition….We understand living with and managing a chronic pain
condition can be very challenging. Most patients find that a
combination of different types of treatments are needed to
improve pain relief and increase activity. Our clinical team will
meet with you to discuss your treatment options and if needed
create a care plan to coordinate your care within our health
system and with community providers….
Case Studies
Delnor Care Plan
30
11
Go Live!
31
52 yo female with chronic HA with psychiatric comorbidities, many years of hospital overuse. MVP Team Intervention: PCP established, scheduled appointments in OPIC for hydration & non opioid HA treatment. Established psychiatric providers, social support & Al-Anon referral
1st meeting Care plan Intensive intervention
32
Central DuPage Care Plan
2
3
1
0 0
1 1 1 1
0 0
1
0 0
1 1
3
2
0
1
00
1
2
3
4
Aug Sept Oct Nov Dec Jan Feb March April May June
Vis
its
2015-2016
MW
Inpt ED
33
1st Intervention Care Plan Initiated
12
CDH Individual Patient Outcome Data
34
2.1
1.7
3.8
7
2.3
1.21
6.5
1.7
0.7
-43% -41%
71%
-76% -70%
-2
-1
0
1
2
3
4
5
6
7
8
MW KRS BL TS JC
CDH Average Monthly Visits
Avg visits/mo Pre-Care Plan Avg visits/mo Post Care Plan % Change
Delnor Individual Patient Outcome Data
35
2.32.5
5
4.1
2.3
2
1.5
1.2
1.6
1.2
3.5
2.4
2.7
3
3.5
1.5
4.3
1.5
3.25
3.7
2.9
3.3
1.4
2.7
1.7
5.1
2.83
1.4
0.8 0.80.6
1.3
0.3
0.9
2.1
7.7
1
0.3
2.6
1.31.1
1.4
1.7
1.3
0.7
17%
-32%
2%
-32%
30%
-30%-47%
-33%
-63%
8%
-91%
-63%
-22%
157%
-71% -80%
-40%
-13%
-66% -62%-41%
-61%-50%
-2
-1
0
1
2
3
4
5
6
7
8
9
JA AB AMC TD CF HD DJ JK MK SL TM MMM MK TR MR GS QA RS TS LT RT CW RY
Avg visits/mo Pre-Care Plan Avg visits/mo Post Care Plan % Change
Delnor MVP Process Impact Metric
36
2.29 2.11
-7.55
1.11 1.44
30
-10
-5
0
5
10
15
20
25
30
35
MVP Avg ED Visits/mo 2015 MVP Avg ED Visits/mo 2016 Percent change No Intervention Avg ED
Visits/mo 2015
No Intervention Avg ED
Visits/mo 2016
Percent change
MVP Intervention vs No Intervention
13
Individual Financial Outcome Data 2015-16 (CDH and Delnor)
37
-76%-96%
-48%-100%
-77%-95%
-89%60%
-65%-80%
-29%-21%
-83%-89%
-13%-92%
194%-93%
-72%-71%
-84%-83%
-71%-48%
-25%-100%
79%83%
-150% -100% -50% 0% 50% 100% 150% 200% 250%
% Change Average Monthly Charges per Patient
Summary of Overall Financial Outcome Data 2015-16 (CDH and Delnor)
38
$22,679.79
$11,544.62
$-
$5,000
$10,000
$15,000
$20,000
$25,000
Pre-Intervention Post-Intervention
Overall Average Charges/Month
49% Decrease
39
Ba
rrie
rs
Patient
Lack of insightJudgement by healthcare professionals
Pre-existing maladaptive behaviorsPsychiatric Co-morbid
Caregiver
System
Societal
14
40
Ba
rrie
rs
Patient
Caregiver
Education to ED and PCP providersMisconceptions, previous negative
interactionsLabor/time intensive process to
individualize Care Plans & ongoing (sometimes weekly) follow up with
providers & patients
System
Societal
41
Ba
rrie
rs
Patient
Caregiver
System
Lack of referral sources for mental health providers to address co-morbid psychiatric conditions
Lack of referral sources to addictionologists& treatment for Substance Use Disorder
Limited dedicated resources
Societal
42
Ba
rrie
rs
Patient
Caregiver
System
Societal
Payer sourceOpioidphobia
Lack of family supportJudgement for chronic conditions limiting
15
43
Polling Question
• Which barrier do you feel is the most challenging and
impacts your ability to care for your Multiple Visit
Patients?
• Patient
• Caregiver
• System
• Societal
44
In Summary -Progress to date
Delnor begins
Patient Care Plans led by CC & Pain
APN
CDH creates Care
Planning Manage-
ment Team
Refined
process for
patient
identification &
care planning
Collaborate to refine NW
Region process
Implement MVP care plans at CDH
Ongoing care plans at Delnor
Development of MVP Procedure,
patient & provider letters &
care guidelines
Tracking patient and system outcomes
� Feb. 15 � Mar-April. 15 � April. 2015June, 2016
45
� Sept. 14 April, 2016
16
Next steps for growth & sustainability
1. Celebrate Success
2. Additional FTE for Care Coordination
3. Automated patient identification based on system utilization
4. Financial cost avoidance data
5. Readmission data after MVP team intervention
6. Partner with area hospital “MVP” teams
7. Development of evidence based care plans on common diagnoses
• Migraine Order Set (In Progress)
• Sickle Cell Crisis
• Cyclic Vomiting
• Opioid use disorder and withdrawal protocol
• Back pain
46
Thank you to our teams!
Central Dupage Hospital
• Carol Tulley, Co-Chair Professional Development
Specialist
• Pam Nass, Manager Care Coordination
• Dan Doebler, BHS Counselor
• Corinne Grotenhuis, Social Worker
• Katherine Ball, Chaplain, Ethics Committee
• Joe Merryweather, PA Emergency Department
• Dr. Tom Eiseman, Emergency Dept Director
• Dr. Stephen Graham, Emergency Dept Physician
Delnor Hospital
• Sherri Johnson, Co-Chair, Care Coordinator
Jana Hossli, Social Worker
• Kelly Ryan, Manager Care Coordination
• Dr Eric Nolan, Psychiatrist
• Dr Brian Dunleavy, Emergency Dept Physician
• Fran Strong APN, Emergency Dept
• Emily Rowell, RMG Care Coordination
• Richard Watts, Chaplain, Ethics Committee
47
System Support• Cori Zacher, VP Outpatient Services/Exec. Sponsor
• Jeannine Harvell, Director of Care Coordination
• Kim Czaruk, Director Patient Care Services
• Michael DeCrescenzo, Senior Analytics Consultant
References/Resources
• Allen, M., etal., (2014). A Framework for the Treatment of Pain and Addiction in the Emergency
Department. Journal of Emergency Nursing, 40(6), 552-559.
• Chang, Y,. & Yang, M. (2013). Nurses’ attitudes toward clients with substance use problems.
Perspectives In Psychiatric Care (49)2, 94-102.
• Gourlay, D., etal., (2005). Universal Precautions in Pain Medicine: A Rational Approach to the Treatment
of Chronic Pain. American Academy of Pain Medicine, 6(2), 107-112
• http://www.samhsa.gov/disorders/substance-use
• http://www.iasp-pain.org/Taxonomy#Pain
• https://intermountainhealthcare.org/ext/Dcmnt?ncid=521023323
• http://updates.pain-topics.org/2012/06/narcotics-vs-opioids-language-matters.html
• Institute for Clinical Systems Improvement
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_ne
urological_guidelines/pain/
• Kunz, D. (2012)The benefit of a nurse-run pain service to manage frequently admitted persistent pain
patients. Presented at the ASPMN National Meeting, Baltimore, MA.
• Neighbor, M., Dance, T., etal. (2011). Heightened pain perception in illicit substance-using patients in
the ED: Implications for management. American Journal of Emergency Medicine, 29(1), 50-56.
• Todd, K., Ducharme, J. etal., (2007). Pain in the Emergency Department: Results of the Pain and
Emergency Medicine Initiative (PEMI) Multicenter Study. Journal of Pain, 8(6), 460-466
48