Series Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality - - PDF document

Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar 3/20/2014 1

2016 IHI Webinar Series

Rhonda Dickman, RN, MSN, CPHQ

Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association’s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement work, particularly in the area of

• readmissions. She is also the clinical manager of the

Tennessee Center for Patient Safety’s PSO (patient safety organization). Rhonda has worked in the field of hospital quality management since 2006 and has a clinical background in trauma, critical care, oncology, and organ donation.

rdickman@tha.com 615-401-7404

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Introduction to Webinar Series

Exclusive program for clinical leaders in hospitals that are part of the Tennessee Hospital Association Hospital Engagement Network (HEN) Focused on supporting clinical leaders who supervise front-line staff 18 webinars in total 1.5 contact hours for each webinar Transitioning to new webinar platform

How to chat

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How to chat How to chat

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How to chat How to chat

Roll Call

Please chat your name, organization, and number of people listening with you today

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How to communicate with presenters

How to make your mark

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How to make your mark How to point to a spot

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How to make your mark How to make your mark

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How to make your mark How to make your mark

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How to answer a poll How to find materials

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Kathy Duncan, RN

Kathy D. Duncan, RN, Director, Institute for Healthcare Improvement (IHI), oversees multiple areas of content, directs multiple virtual multiple learning webinar series. Currently she serves as Faculty for the AHA/HRET Hospital Engagement Network (HEN) 2.0 Improvement Leadership Fellowship

• Ms. Duncan also directed content development and spread

expertise for IHI’s Project JOINTS, an initiative funded by the Federal Government to study adoption of evidenced-based

• practices. In 10 US States, Project JOINTS spread three

evidence-based pre-and perioperative practices to reduce the risk

• f surgical site infections in patients undergoing total hip or knee

replacement. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She has also served as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care, Orthopedics and Neuro for a large community hospital.

Peg Bradke, RN, MA

Peg M. Bradke, RN, MA, has held various administrative positions in her 25-year career in heart care services. Currently she is Vice President

• f Post-Acute Care at St. Luke's Hospital in Cedar

Rapids, Iowa, where she oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. In her previous role as Director

• f Heart Care Services at St. Luke's, she managed

two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also serves as faculty for the Institute for Healthcare Improvement

• n the Transforming Care at the Bedside (TCAB)

initiative and the STAAR (STate Action on Avoidable Rehospitalizations) initiative.

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Gail A. Nielson, BSHCA, RT(R), FAHRA

Fellow and Faculty of the Institute for Healthcare Improvement (IHI). Nielsen is the former system-wide Director of Learning and Innovation for UnityPoint Health (formerly Iowa Health System). Her current work as faculty for IHI includes reducing avoidable readmissions and improving transitions in care, leading 2-day Reducing Readmissions seminars, improving the quality of care in nursing facilities, and other assignments. Nielsen’s ten years of experience in improving care transitions and reducing avoidable readmissions began during her 1-year IHI Fellowship. Her most recent experience includes system- wide work in Iowa; four years in the STAAR initiative across three states: Massachusetts, Michigan, and Washington; and support to Hospital Engagement Networks in multiple states. Additional past areas of expertise and work with IHI includes six years on the Patient Safety faculty; four years on the faculty for Transforming Care at the Bedside; engagement and patient-centered care; reducing falls and related injuries; spread and scale-up of innovations; and ACOs-Post Acute Care.

Objectives:

Assess their current challenges in reducing avoidable readmissions and identify opportunities for improvement. Use proven communication methods to better understand a patient’s post-acute care needs and capabilities Make their care more person-and family-centered to improve coordination and transitions across the continuum of care Describe methodologies for clarifying opportunities for improvement from the diagnostic review Assess current challenges in reducing avoidable rehospitalizations and identify opportunities for improvement Build an effective improvement team including patients and families as well as acute, post-acute and community care partners

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Action Period Assignment: Go Observe: “Be a patient”

The Always Use Teach-back! Toolkit www.Teachbacktraining.org (view at least one training module and review the site). Teach Back Observation tool with one patient being taught by a nurse. (this is also in the

• nline toolkit)

Teachback: How did it go?

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Developing Post- Hospital Follow-Up Care Plans and Real-time Handover Communications

Peg Bradke

These presenters have nothing to disclose

March 2016 : THA

Assume one of the following roles :

Patient Caregiver Sending Hospital dept. Receiving SNF Hospitalist Medical Director SNF Home Care Clinic Physician Outpatient Social Worker Community Serv. Agency

Chat in your ideal transition into the that setting……….(what would you need or

want in that transition)

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“….effectively communicate the plan of care (based on the assessed needs and capabilities) to the patient/caregiver and community-based providers of care?” How Might We….

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.

Simply What do we know about the patient/caregiver that will help

the next level provide the needed care in the transitions? How will we communicate that? Sender Role vs Receiver Role

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Identifying Opportunities

• Visually display the patterns of

return to hospital within 30 days; what questions arise?

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5 10 15 20 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

# of patients readmitted # of days between discharge and readmission

Frequency of Readmissions by Number of Days Between Discharge and Readmission

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Opportunities: Observe Current Discharge Processes

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.

Identifying Opportunities (cont.)

Follow a patient as they transition to a SNF facility, or home care visit.

– Was the information the receiver need there? – Did the patient see/feel that information important

to them had been communicated?

– Where were opportunities for improvement?

Interview a Primary Care Office to determine if they are receiving the appropriate information to receive the patient back in the clinic

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Recommendations

• Risk Level: Review daily the patient’s medical and

social risk and/or barriers that would contribute to a readmission.

• Customized plan of care: with real-time critical

information to the patient and next clinical care provider(s).

• Timely follow-up care: initiate clinical and social

services as indicated from identified post-hospital needs

• Determine capabilities of the patient/caregiver and the

post acute services to meet the identified needs

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.

High Risk

Risk

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Assess Risk of the Transition

Build risk-assessment into clinicians workflow in

• rder to identify patients/caregivers at risk

Number of risk-assessment tools are reported in the literature (BOOST, LACE, IHI, Transitional Care Model (TCM), etc.) Inconsistencies regarding which characteristics and/or variables are most predictive of patients who are at risk for readmissions Equip clinicians with the training and tools to match patients to the most appropriate level of care.

Eric Coleman, MD: Identification of Patients at Risk for Admission

Ideally a risk tool would not only identify those at high- risk for readmission but more precisely those who have modifiable risk.

– In other words, risk tools should be aligned with what we

understand about how our interventions work and for which patients our interventions work best

In the case of heart failure, we should be careful to not assume that the primary readmission for heart failure is after all…the heart

– Low health literacy, cognitive impairment, change in health

status for a family caregiver, and more may be greater contributors than left ventricular ejection fraction

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Eric Coleman, MD: Identification of Patients at Risk for Admission (cont.)

Asking the patient to describe, in her or his own words, the factors that led to the hospitalization and where they need our support may provide greater insight into risk for return- Non-patient factors may have a larger role in readmission rates, such as the health care system and access

Include the Patient’s Perspective

Ask patient/caregiver:

• What matters most to you during this

transition?

• What are your concerns or worries about

going home or to the next care setting?”

• Who do you want involved in your transition

(your Support person)

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.

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Proposed Agenda for Patient Care Rounds

Reasons for this admission? Are health care teams’ and patient’s/caregiver’s goals in sync? What needs to happen during this hospitalization? What post-acute plan of care will meet the patients’/ caregivers’ level of activation and comprehension of the plans? (using teach-back) Routinely ask: “what is the likelihood that this patient will be readmitted in the next 30 days?”

– If the likelihood is high, why? – What services can be put in place to mitigate potential

problems?

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

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.

High-Risk Moderate-Risk Low-Risk

 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 home  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

• ut self-care at home

 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 home

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Customized Plan of Care

Develop one comprehensive assessment and plan for patients post- acute care needs that integrates input from all members of the care team

– Make sure each member of the care team is clear about what

information they must bring to the assessment and plan

• Consider: Patients Preferences,

Patient Capabilities Activation Level. Change the focus on daily patient care rounds to include a discussion

• n current site but anticipating needs for next site

Develop Bidirectional dialogue and collaboration between sender and receivers

Key Elements in Transitions of Care

• Ensure that the patient and caregivers are present for

discharge instructions

• Provide both the patient and caregiver a copy of the written

discharge instructions

• Use Teach Back in your discharge instructions
• Highlight important points in the patient’s d/c instructions
• Provide instructions that give them actions of what to do
• follow-up care, list of reasons to call for help and phone numbers for

emergent and non-emergent questions.

• what to expect when they return home and medication instructions

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.

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If the patient is transitioning home and will be receiving care in primary care office or specialty practice:

• Ensure timely and action oriented discharge summary

that arrives prior to the patient’s visit

• Final reason for Hospitalization
• Recommendation for f/u
• Pending studies needing attention
• Arrange for access to patient discharge instructions in

the office practice

• Determine how you can add value to the TCM in the

Patient Centered Medical Home

Timely Follow Up Care Our Most Formidable Challenge

Year after year we try to improve med rec However gains have been modest Not due to lack of trying Why do you think medications represent

• ur most formidable challenge?

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Reconcile Medications

Review the patient’s pre-hospital and hospital medication regimens:

– Name each medication clearly and reason for taking – “Red stop sign” for discontinued medications – Highlight changes compared to pre-hospital medications – Clear instructions for medications that should NOT be

taken

– Reconcile medications with formulary of skilled nursing

facility

– Have both Generic and Brand names

Look for ways to simplify the medication regime. Identify medication schedules that are unrealistic in a home setting and propose a more realistic schedule. Use Teach Back to reinforce what the patient should take. Help the patient and family caregivers understand the importance of taking their list to all appointments and ensuring it is updated in real time. Emphasize the advantage of building a relationship with

• ne retail pharmacy.

Helpful Tips for Patients & Families

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Resources for Creating User-friendly Medication Lists

How to Create a Pill Card

For more information, please visit the patient safety and errors section at: http://www.ahrq.gov/

Iowa Healthcare Collaborative (IHC) Med Card

For more information, please visit: http://www.ihconline.org/aspx/consumerresources.aspx#MedCard_Anchor

Warm Handover to Community Partners

Written handover communication for the patient at risk is insufficient : direct verbal communication allows for inquiry and clarification

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Transition to Home Health Care, Long-term Care, Skilled Nursing or Other Community Settings

• Consider establishing HHC, SNF or LTC

liaisons that are based in the hospital (ex. HHC liaison helps MDs determine qualifications for HHC)

• Work with Liaisons and community partners

to standardize critical information to be included

Transition to Home Health Care, Long-term Care, Skilled Nursing Facility or Other Community Settings

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Transition to Home Health Care, Long-term Care, Skilled Nursing Facility or Other Community Settings

Co-design handover communication processes (i.e. preferred formats for information) Create processes for bidirectional communication for care coordination, continual learning and ongoing improvement efforts Handovers to Home Health Care, Skilled Nursing Facilities or Community Services

• Share patient education materials and

educational processes across care settings

• Offer education for the staff in HHC, SNF,

LTC and community services

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Post-hospital Follow-Up Phone Calls

Have been frequently cited as a cost-effective method to enhance communication with patient/caregiver in the critical period following discharge Give patient/caregiver the opportunity to reinforce education and assess self-care knowledge through the use of Teach Back There is little standardization or consensus on the timing and frequency of post-discharge follow-up calls

Johnson M, Laderman M, Coleman E. STAAR Issue Brief: Enhancing the Effectiveness of Follow-up Phone Calls to Improve Transitions in Care. Cambridge, MA: Institute for Healthcare Improvement; 2012.

How much coordination do you have?

• How many services are wrapped around the

patient/ caregiver?

• Are all the services communicating? Do they all understand the

Plan of Care?

• If there are multiple services involved is a “lead person” identified

and communicated to the patient/caregiver and the care team?

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How much coordination do you have?

• How many phone calls is that patient/caregiver

receiving after they get home?

• What are each of the calls purposes?

What Are We Learning About Providing Handover Communications?

• There are a “vital few” critical elements of patient

information that should be available at the time of transitions for the community providers

– “Senders” and “receivers” agree upon the information and design reliable

processes to transfer information effectively

• Written handover communication for an at risk patient is

insufficient; direct verbal communication allows for inquiry and clarification

• Written plan of care for patients and caregivers should

use clear, user-friendly formats for describing care at home

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Assignment for next session

Follow a patient as they transition to a SNF facility,

• r go with Home Care on a home care visit.

– Was the information the receiver needed there? – Did the patient see/feel that information important to

them had been communicated?

– Where were opportunities

for improvement? OR

Do an observation of a discharge process?

57

Observe Current Discharge Processes

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.

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Assignment Options for next session

Interview a Primary Care Office to determine if we they are receiving the appropriate information to receive the patient back in the clinic

OR

Do a random chart review and determine percentage of time post hospital appointments are made for the patient prior discharge.

Call Number 5

Developing Post Hospital Follow up care plans and real time handover communication March 16 – 1-2:30 EST

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