12/3/2012
Session M1 This presenter has nothing to disclose
IHI’s Approach to Reducing Rehospitalizations in the STAAR Initiative: Overview Pat Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement, Co‐Principal Investigator, STAAR Initiative Orlando, FL December 10, 2012
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Minicourse Objectives After this session, participants will be able to: • Describe common problems that contribute to rehospitalizations and identify promising approaches to reducing them • Describe the STAAR initiative’s two concurrent strategies to reduce avoidable rehospitalizations • Compare and contrast case studies from sites that have implemented improvements to dramatically reduce avoidable rehospitalizations • Identify strategies to remove systemic barriers and policy implications
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12/3/2012
UCSF Medical Center Heart Failure Program
Maureen Carroll RN, CHFN Heart Failure Program Coordinator Orlando, Florida December 10, 2012
University of California, San Francisco • One of ten campuses in University of California system • Medical Center and graduate level schools in health sciences only • Extremely research intensive • Magnet status 2012
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University of California, San Francisco • Tertiary care; world wide referrals • Operating at capacity with need to grow • 722 licensed beds; 28,000 admissions, nearly 2,000 births; average census = 523 • 100 clinics with 880,000 outpatient visits including 39,000 Emergency visits • $1.6 billion, self‐supporting enterprise • 7,000 employees; 2,000 MDs
Why is Reducing Readmissions Strategic for UCSF? • UCSF is committed to improving patient care in both the inpatient and outpatient setting • Medical Center Support through a multidisciplinary Readmissions Task Force to focus on systemic improvements to reduce all readmissions • Increasing bed capacity for patients requiring specialty care
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Heart Failure Program Profile of Our Patients • ~ 2000 Admissions • ~50 patients/month • Average Age: 80 years – ( Recently expanded program to 18 years and older ) • Race: – White 45%, Asian 19%, African American 13%, Hispanic 5%, Other 18% • Languages: – English ~ 70%, Cantonese 11%, Russian 8%, Spanish 5%, Mandarin 2%, Other 6% (10+ languages represented)
Gordon and Betty Moore Foundation Grant • $ 575,000 grant over two years (11/08 ‐2/11) • Written by Karen Rago RN, MPA and Maureen Buick RN MS • 1 of 4 Bay Area Hospitals chosen • In collaboration with Institute for Healthcare Improvement (IHI) and TCAB community • Patients 65 years and older with a primary or secondary diagnosis of Heart Failure on 3 pilot units
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Aim Statement for Grant • Reduce 30 day readmissions by 30% for all cause heart failure patients 65 years and older – 2006 Data: 22.5% – Goal: 16%
• Reduce 90 day readmissions by 30% for all cause heart failure patients 65 and older – 2006 Data: 45.2% – Goal: 31%
It all began with… a Grant and a Storage Closet!
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The First Two Months • Face‐to‐face with over 50 people – bridging the gaps • Process map‐ Patients Journey • Reviewed and revised education materials • Analyzed patient charts with readmissions • Data Tracking System Developed • Key Changes in IHI How‐to Guides; IHI Seminar in New Orleans • Assessment of quality measures – Nursing assessment, discharge process, home care referrals, follow‐up appointments
IHI’s Key Changes for Creating an Ideal Transition Home • Perform an Enhanced Assessment for Post‐ Hospital Needs • Provide Effective Teaching and Facilitate Enhanced Learning • Ensure Post‐Hospital Care Follow‐up • Provide Real‐Time Handover Communications …and Communication is the Foundation
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The First Year ~ 2009 was Inpatient Focused • Monthly Heart Failure Grant Meetings with Multidisciplinary Team • Comprehensive Patient Education with complete Discharge Binder • Implemented IHI Evidence Based Interventions • Developed Data Collection System • Patient Advisory Group, Heart Healthy classes on unit • Palliative Care Collaboration • Trained Staff on Teach Back & HF Education • Importance of the patient stories to drive change
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The Second Year ~ 2010 was Outpatient Focused • Collaboration with Outpatient Providers – Skilled Nursing Facilities, Home Care Agencies, Primary Care Physicians and Cardiologists – “Virtual Team” Email to connect providers (in/outpatient) • Geriatric Transitions, Consultation, and Comprehensive Care (GeriTraCCC) – MD House Calls for High Risk HF Patients (began Aug 2010) • Heart Failure Clinic; High Risk NP appointments • Palliative Care (ELNEC Trained) • Senior Leadership Meetings
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The Third Year ~ 2011 Sustainability & Collaboration • HF Readmission Taskforce • Moore Grant completed, HF Program funded by Medical Center • Continued work with Outpatient Providers – Home Care referrals for HF patients – HF NP Outpatient visits for high risk patient & GeriTraCCC – Increased collaboration with SNF and Community agencies
The Fourth Year ~2012 Sustainability and Spread • Research Studies: – BEAT HF study – Palliative Care Study – Spanish speaking patients with Heart Failure • Expansion of Heart Failure Program‐ 18 years and over • Hospital Wide Readmission Work
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Heart Failure Program: Interventions • Patient Identification‐ Chart Reviews • Extensive patient education (Teach Back) • Follow‐up appt made within 7 days of discharge for primary heart failure patients, 14 days for all others • Follow‐up phone calls within 7 days of discharge (72 hrs) and 14 days • Referrals: CM/SW, dietitian, PT/OT, Spiritual Care, Palliative Care, Home Care, Heart failure clinic NP, GeriTraCCC Program (Geriatrics, Transitions, Consultation, and Comprehensive Care) • Readmission Data and Analysis • Focus on Continuum of Care: Inpatient/Outpatient Communication and Collaboration
Patient Education • Teach Back Technique • Health Literacy Principles • Four languages, use of interpreter • Input from patients and caregivers • Same materials and technique across the Continuum of Care • Educate patient regarding diagnosis, self –care management, and importance of follow up • Lesson Learned: Listen before we teach. Ask open‐ended questions • Goal for Patient: Take action when you notice a change in your health
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12/3/2012
Readmission Interview
Post Acute Care Follow‐Up • Follow‐up calls – Within 7 Days (72 hrs) of discharge and by 14 days – Valuable time to troubleshoot • Home care encouraged for all HF patients • Heart Failure Clinic NPs visits for high risk patients • GeriTraCCC Program • SNF Communication • Additional Calls with Medicine • Cardiology, outpatient • Duplication of calls‐ manage
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What is Covered on the Phone Calls?
Multidisciplinary Rounds ‐‐ Before
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Multidisciplinary Rounds ‐‐ After • Quiet, private area • Comprehensive team addressing patients needs • Next steps in care • Reliably address risk of readmissions • Includes Pharmacist
What is Teach Back? • Teach Back is a patient education technique that … –
Asks people to explain in their own words what they need to know or do, in a friendly way.
–
A way to check for understanding and, if needed to re‐ explain the information, then check again.
–
Provides education with health literacy principles (plain language, shame‐free environment, responsibility is on the teacher)
• Identify and teach to the primary learner • Keep sessions short and frequent if possible • Use open ended questions, avoid yes/no questions • Starts on Admission
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Why Use Teach Back? • 1/3 (90+ million) of American adults lack sufficient Health Literacy • What is “sufficient”‐ the information and skills required to manage ones healthcare • Poor Learning Environment – Patients sleep deprived, pain issues, anxious, not feeling well • Average amount of time nurses use for discharge nationally = 8 minutes • 40‐80% of info given is forgotten & almost half is remembered incorrectly • More information given – the more forgotten
Heart Failure Teach Back Questions • What is the name of your water pill? • What change in weight gain should you report to your doctor? • What foods do I need to avoid? • What symptoms would prompt you to call your doctor?
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Teach Back is Not Enough In addition to Teach Back and Heart Failure education, chronic diseases require life style changes. This requires: Time, Trust, Support
and Accountability
The Cross Continuum Team
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The Heart Failure Program Team • 1.6 FTE Heart Failure Program Coordinators – 7 day a week coverage
• Multidisciplinary Team – Includes Executive Leader, Hospitalists, Cardiologists, Home Care RNs, Case Managers, Social Workers, Pharmacists, Dietician, Spiritual Care Chaplains, Educators‐ School of Nursing, Geriatric CNS, Med/Surg CNS, SNF representatives, PCPs, Outpatient Clinic NPs, Palliative care, Patient representative, Skilled Nursing Facility Representatives
The Role of Leadership in Readmission Work Executive Leader: • Promotes HF Program and opens doors • Assists with overcoming barriers • Reviews Financial Implications of HF Program • Develops Business Case for sustainability
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HF Program Coordinators Activities & Roles Daily interventions with patients in hospitals Ensures appropriate consults Coordinates discharge support Post‐discharge calls Data collection & analysis Coordinates outpatient program In‐services for staff, home care, skilled nursing Work with hospital wide projects to standardize and improve discharge process and readmission projects • Community work • • • • • • • •
Real‐Time Handover Communications • “Warm Hand overs” to Skilled Nursing Facilities • Medication Reconciliation – Increasing Pharmacist consults on discharge – New patient friendly medication tool – Electronic discharge summary has started – EPIC Journey • Email‐notifications to inpatient team, case manager, consultants, HF clinic, home care RNs, SNF and PCP on admission – Creates a “ Virtual Care Team” – Time consuming but valuable – Unites the entire team working on transition – of care
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Communication:
The Thread Across the Continuum • Patients and Families – Teach Back, health literacy, educational materials, follow‐up calls, classes • The Team‐ Communication – Wrap Up newsletter, Heart Matters newsletter, weekly updates, meetings • Hospital Wide – Presentations to Senior Leadership, Staff Meetings, Grand Rounds – Patient Education Council, Patient Relations Council, BOOST, Readmission Task Force • Community Partners – Home Care Agencies, Skilled Nursing Facilities
Email to Team on Admission Dr. Smith (Inpatient Attending), Dr. Jones (Inpatient Resident), Dr. Moore (PCP), Dr. May (Cardiologist) Vicki (Home Care RN) and Lily (Case Manager RN) – We just wanted to let you know that we will be following patient Bob Brown (MRN XXX) in the Heart Failure Program. This is Mr. Brown’s 5th admission in the past year and a 90 day readmission. I have met with Mr. Brown and his daughter, Melanie today and reviewed HF education. We will continue to follow them through post discharge phone calls. Please schedule a follow up appt with Dr. Moore (PCP) or his cardiologist, Dr. May, within one week as well as order Home Care RN with HF Protocol. The Heart Failure program is for patients 65 and older who are admitted to the hospital with a primary or secondary diagnosis of Heart Failure. Our program entails thorough patient education on heart failure, follow‐up phone calls after discharge, and assistance with other discharge planning needs. We encourage all physicians to order Nurse Home Care visits for HF patients at time of discharge and to have a scheduled follow up appt with their PCP or Cardiologist within one week. Our goal is to reduce readmissions and improve patient care. If we can help with any of these planning needs or answer any questions, please feel free to call us at 353‐1897. Thank you, Eileen Brinker, RN Heart Failure Program Coordinator UCSF Medical Center
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GeriTraCCC Program • Geriatrics, Transitions, Consultation, and Comprehensive Care • Geriatrician provides home visits for high risk patients, works with family, home health nurse, and providers • Criteria for referral: – – – – – –
Multiple admissions in the past year Missed appointments Cognitive concerns Medication concern Palliative Care / Goals of Care Caregiver adequacy concerns
Dr. Helen Kao, Medical Director
• 70 Referrals over last 2 years
Palliative Care with HF Patients • Risk of sudden death means that palliative care must be integrated into care at every stage of illness • Frequent exacerbations leading to re‐admissions where palliative care can intervene • Palliative care proven to improve symptoms, quality of life, satisfaction, and patient and family outcomes • Why Push for a Consult? • 25% of our Heart Failure patients die within one year • Up to one‐ half of deaths with Heart Failure are due to Sudden Death • Palliative care prompts patients to think about all their options in the future and to start the important discussions for making plans…… • Standard‐ consult on 3rd Readmission /Year
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12/3/2012
Heart Failure Stickers As improving communication is one of our primary goals we would like to notify all the Skilled Nursing Facilities and Home Care agencies of patients in our Heart Failure Program. Please put a HF Program sticker on the PDP for all patients in our HF Program who are being transferred to SNF or home with Home Care.
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Key Metrics 30-day readmissions all cause HF 90-day readmissions for all cause HF Home care referrals Scheduled follow-up appointments
2006
Goals
2009
2010
2011
22.5%
16%
24%
19%
13%
45.2%
31%
40%
31%
26%
n/a
90%
51%
63%
74%
n/a
90%
77%
91%
96%
Financial Implications • Key Findings: – The 30‐day readmission rate has 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. • Last calendar year 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 $1.1M annual savings to Medicare
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Keys to Success • Collaboration with IHI – essential at the start and guidance throughout process • Dedicated Heart Failure Program Coordinators • Senior Leadership and Physician Champions • Cohesive, committed Multidisciplinary Heart Failure Team Engaged Palliative Care and increased consults • Outpatient program & Community Partners • Results are not immediate – takes time to show improvement • Teach Back works – focus on Health Literacy • Power of the patient story to learn from and drive change
Photo used with permission and signed consent by the patient.
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