CHF Longitudinal Workgroup Addressing readmissions from SNFs and - - PowerPoint PPT Presentation

CHF Longitudinal Workgroup

Addressing readmissions from SNFs and other PAC settings 3/2/17

Readmission Rate from SNF by Hospital (CHF)

2 4 6 8 10 12 14 16 10 20 30 40 50 60 70 80 Readmission Rate (%) Hospital Mean = 6.3% 13.6% 0%

Top 10 Primary Readmission Diagnoses

% Of Readmissions Primary Diagnosis 9.4% Unspecified septicemia 8.3% Acute on chronic diastolic heart failure* 7.0% Acute on chronic systolic heart failure* 4.8% Acute kidney failure 3.9% Acute on chronic combined diastolic/systolic heart failure* 3.6% Pneumonia, organism unspecified 3.3% Acute and chronic respiratory failure 3.1% Hypertensive heart and chronic kidney disease with heart failure* 2.8% Acute respiratory failure 2.4% Subendocardial infarction, Initial episode of care

Readmission Rate from SNF

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Readmission Rate Skilled Nursing Facility (N=98) readm_rate

Strategies to Reduce Readmissions from SNFs and other PAC settings

Review for CHF Longitudinal Workgroup March 2nd, 2017

General strategies

• Multicomponent interventions more likely to have sustainable

success1,2,3

• Most successful multicomponent interventions include:
• 1. Attention to medication reconciliation and discontinuation of high-

risk geriatric medications when not indicated4

• 2. Elimination of safety hazards: minimize use of urinary catheters and
• ther indwelling devices at time of discharge4
• 3. Advanced care planning: include information about short and long

term prognosis, expectations about PAC setting, discussion of goals

• f care3

Examples of Successful Interventions

• Interventions to Reduce Acute Care Transfers (INTERACT) –

most rigorously studied of multicomponent PAC interventions3

• Project ReEngineered Discharge (RED)
• Both include 3 important components mentioned on previous

slide, plus:

– Tools to enhance inter- and intra-facility communication – Training to manage common medical conditions that may precipitate rehospitalization – Enhanced follow-up procedures

INTERACT Model

• One study implemented model in 30 community-based nursing

homes in Florida, Massachusetts and New York. Administrative support and an on-site champion required for participation.2

• Facilities required to implement the following tools:

– Stop and Watch Tool – The Situation, Background, Assessment, Recommendation Communication Form – The Resident Transfer Form and Transfer Checklist – Quality Improvement Review Tools for residents transferred to acute hospital

INTERACT Model

• Following six months of biweekly training by an experienced

nurse practitioner:

– 17% reduction in self-reported hospital admissions compared to the same 6 month period from the year prior2 – 24% reduction among the most engaged facilities2

• All tools freely available at: http://interact2.net/

Project ReEngineered Discharge (RED)

• Comprehensive transitions of care approach

– Creation and review of personalized care plan with patients and families

• Medication lists
• Follow-up appointments
• PCP contact information
• Advanced directives

– Project RED software integrated into electronic medical record of SNF – One study conducted in a 50-bed subacute unit in Boston observed a 8.7% reduction in the rate of hospitalization during the intervention5 – More information here: https://www.bu.edu/fammed/projectred/index.html

In Conclusion

• Effective interventions share certain features

– Having multiple components that span the inpatient and outpatient setting – Delivery by dedicated transitional care personnel

• Use limited resources to focus efforts on patients at higher risk
• f readmission6, 7, 8:

– Advanced age – Polypharmacy – Decreased functional status

Sources

1. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann. Intern. Med. 2011; 155:520–528. Google Scholar 2. Ouslander JG, Lamb G, Tappen R, Herndon L, Diaz S, et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II collaborative quality improvement project. J. Am. Geriatr.

• Soc. 2011; 59:745–753. Google Scholar

3. Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission: Current strategies and future directions. Ann Rev Med. 2014; 65: 471-485. Google Scholar 4. Borenstein J, Aronow H, Bolton L, Choi J, Bresee C, Braunstein GD. Early recognition of risk factors for adverse outcomes during hospitalization among Medicare patients: a prospective cohort study. BMC

• Geriatr. 2013:13. Google Scholar

5. Berkowitz RE, Fang Z, Helfand BKI, Jones RN, Schreiber R, Paasche-Orlow MK. Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility. J. Am.

• Med. Dir. Assoc. 2013 Google Scholar

6. Evans RL, Hendricks RD. Evaluating hospital discharge planning: a randomized clinical trial. Med. Care. 1993; 31:358–370. Google Scholar 7. Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, et al. Reduction of 30-day post discharge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J. Hosp. Med. 2009; 4:211–218. Google Scholar 8. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999; 281:613–620. Google Scholar