Collaborating with Community
Nursing Homes to Improve
Transitions and Care
Patrick Schultz, MS, RN, ACNS-BC
Director of Quality and Patient Safety
Sanford Medical Center Fargo, ND
Roadmap
•
•
•
•
•
Who We Are
What Drove Us
What We Did
Where We’re At
Where We’re Going
Who We Are
Sanford Health







Serving 2.3 million people
27,000 employees including 1,400 physicians
43 hospitals
45 long-term care facilities
243 clinic sites
92,000 health plan members in four states
$3.2 billion in annual net operating revenue
Barney
What Drove Us
Drivers
• Readmission Reduction Program
– Began October 1, 2012
• Professional Practice Review (Peer)
• Medicare Spending per Beneficiary
• Sepsis Measure
Readmission Reduction Program
FFY 2017 Readmission Reduction Program
Diagnoses
Discharge Dates Payment Impact
AMI
July 1, 2012
3%
HF
through June 30,
PN
2015
COPD
THA/TKA
Isolated CABG
Professional Practice Review
Caregivers of HF Patients Can Have Unrealistic Hopes for
Prognosis –Steve Stiles, September 28, 2015
More often than not, family members caring for loved
ones with advanced heart failure don't understand how
serious the disease is, have unrealistic expectations
about the patient's chances for survival, and even may
be looking forward to recovery, suggests a study based
on interviews of 80 such caregivers.
http://www.medscape.com/viewarticle/851630
Medicare Spending per Beneficiary
• Value Based Purchasing
– Began October 2012
– An MSPB Episode includes all claims between 3
days prior to index admission to 30 days after the
hospital discharge
Sepsis
• Sepsis as an Inpatient Quality Reporting
measure
– 10/01/15 – 06/30/16 Discharges
Proposed
Measure
Dry Run/
Voluntary
Pay for
Reporting/
Penalty for
not
Reporting
Public
Reporting
Pay for
Performance
Focus
•
What We Did
One Care for Seniors
• Started 09/2011
• Purposes
– Improve transitions from hospital to nursing homes
– Reduce readmissions from nursing homes to hospital
Call for Partners
• Bethany—288 Skilled Nursing beds
• Eventide—260 Skilled Nursing beds
• Elim—136 Skilled Nursing beds
One Care for Seniors
• New leadership 1/2013
• Expanded work
– Advance Care Planning
– Heart Failure, Sepsis, Renal Failure
Challenges
• How to measure readmission?
• How to measure advance care plan use?
• How to know transitions went well?
Overcoming Challenges
• How to measure readmission?
– First try: Hired PhD part time to collect data
– Next: Epic report with discharge destination
triggers when a patient returns to Sanford within
30 days (dependent on proper entry)
Overcoming Challenges
• How to measure advance care plan use?
– Epic report includes presence or absence of
Advance Care Directive
Overcoming Challenges
• How to know transitions went well?
– Monthly meetings 0700
– HF mismatches
– ACPs not entered
– NP issues
– Xrays done in the nursing homes
– Connection with Director of Quality
Overcoming Challenges
• Added a Partner—QIO
– CMS Data Reports
Home
Interventions
• One call back phone number for questions
• EpicCare Link
• Interventions to Reduce Acute Care Transfers
(INTERACT) tools
https://interact2.net/index.aspx
• Increased Nursing Home capabilities
EpicCare Link: Access to EMR
• EpicCare Link is Epic’s web-based application
for connecting organizations to their
community affiliates.
INTERACT: Care Paths
INTERACT: Care Paths
INTERACT: QI Tool
INTERACT: Advance Care Planning
INTERACT: Communication
INTERACT: NH Capabilities
Traveling Dentist
Heart Failure Actions
• Education
– CNS and NP sessions for partners
– Expanded to 5 teleconference sites which reached
87 rural nursing home workers
– Weigh daily (dehydration a problem also)
– IV diuretics and IV fluids
Risk?
Sepsis Actions
• Education
– CNS presentation to combined group
– UTI antibiotic stewardship program (symptomatic
with UC+)
– Emphasis on INTERACT Care Paths
– Discussion with providers regarding trusting Xray
Advance Care Planning Actions
• ACP education for all Nursing Homes
• Increased number of facilitators
• Created HF referral for ACP for all NYHF Class
III & IV
• Added NYHF Class to order sets
Where We’re At
Heart Failure Data
• Private data
Sepsis Data
• Private data
Acute Renal Failure Data
• Private data
Advance Care Planning Data
• Private data
Mellow
Where We’re Going
SIM-ND
SIM-ND
Training for Nurses and Unlicensed Personnel
•
•
•
•
•
•
•
Geriatric MI in LTC “There is an elephant on my chest” Geriatric CVA in LTC “What about the droop”?
Geriatric DVT/PE in LTC “My leg hurts”
Geriatric GI Bleed “It won’t stop”
Geriatric HF in LTC “Why are my ankles so fat?”
Geriatric Progressive from Admit to Fall in LTC “I need the bathroom”
Geriatric UTI in LTC “What day is it again?”
Telemedicine
• Partners have all put telemedicine into their
budgets
• Challenge: CMS payment only for a rural
Health Professional Shortage Area (HPSA)
located either outside of a Metropolitan
Statistical Area (MSA) or in a rural census tract
Next Steps
• ACP for COPD
• State of ND following WI and MN lead
• HF education and expectations to RN Health
Coaches and Provider Panel Specialists in our
clinics
• Palliative care clinic (may change name)
No Readmission/ACP in place!