Brainerd Community Team:
• Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis Health
•
Kathryn R. Miller, RN, BS, G-L C, Director Quality and Safety, Essentia Health St.
Joseph’s Medical Center
•
Gayle Nielsen, MSN, RN Care Coordinator, Essentia Health Clinics, Central Region
• Marie Michlitsch, RN, Director of Nursing, Good Samaritan Society - Woodland
•
Deanna Abramson, RN, Assisted Living Manager, Good Samaritan Society - Woodland
• Kayla Farr, RN, Good Samaritan Society, Home Care & Hospice
January 8, 2014

RARE Webinar – January 8, 2014, noon – 1 p.m.
Janelle Shearer, RN, BSN, MA
Program Manager
Stratis Health

• Describe a community-based approach to improve coordination between settings of care
• Identify how to collaborate with other organizations to improve care transitions
• Identify best practices you can implement to reduce avoidable hospital readmissions

• Independent, nonprofit, facilitating improvement for people and communities
• Funded by federal and state contracts, corporate and foundation grants
• Medicare Quality Improvement Organization (QIO) for Minnesota
• Focus areas include rural health, health information technology, patient safety, cultural competence, and long-term care

1. Beneficiary and Family Centered Care
2. Improving Individual Patient care
3. Integrating Care for Populations and Communities
– Improving Care Transitions Leading to the
Reduction of Readmissions
• Improving Transitions of Care – community-based approach
• RARE Campaign
4. Improving Health for Populations and Communities

Brainerd
Duluth
North Metro

Providers across the continuum of care
– Acute care hospitals
– Clinics
– Home health/hospice organizations
– Long-term care facilities
– Assisted living facilities
– Local public health departments
– Patients and/or patient advocates
– Other community partners

• Each organization conducted root cause analysis to identify gaps in care related to transitions of care and readmissions
• Identified community needs and resources
• Identified best practice interventions to improve the gaps

Kathryn R. Miller, RN, BS, G-L C
Director Quality and Safety

• Type of provider-Acute care 162 bed full service
JCAHO accredited hospital (exceptions: Cardiac and Neuro surgery) with on site Cath Lab
• Central Minnesota-Brainerd Lakes area
• Staff composition RN and CNA teams
• ICU, Telemetry, Medical, Surgical, Mental Health and Chemical Dependency Units
• EH is one of the first two organizations in the country (Essentia and HealthPartners) to attain highest level of recognition as an Accountable Care
Organization (ACO) by NCQA

• Needed to look at those diagnoses that had high readmission rates, particularly the Heart Failure population

• Developed an Interdisciplinary team that met monthly
• Initiated f/u telephone calls in 24-48 hours
• Developed a system for all d/c patients to be seen by PCP within 5 days of discharge

• Intensive effort to work in a small group setting with key community members (nursing homes, home care, etc.)
• Identified barriers to a smooth transition:
– i.e. Lack of; incomplete documentation (MAR)
SOLUTIONS:
• Worked with our IT department to allow the nursing homes view only access to our EMR
(Electronic Medical Record-Epic)
• Educated hospitalists on tying diagnosis with medication ordered on discharge

• We have begun to see a downward trend in our readmission rates for Heart Failure, COPD and
Pneumonia patient populations
• Work still needs to be done on:
• 1) Pharmacist reviewing medications with all patients at the time of discharge
• 2) Continued work on formation of a Palliative
Care Team to address end of life/quality of life issues with patients and their families

Kathy Miller RN, BS, G-L C
Director Quality and Safety
Essentia Health Central Region
St. Joseph’s Medical Center
523 North Third Street
Brainerd, MN. 56401
Email: kathryn.miller@essentiahealth.org
(218) 828-7435

Marie Michlitsch, RN

• Woodland has 41 Care Center residents. Roughly
25% are on a short term stay for rehab.
• Bethany has 124 residents. There is a subacute unit with capacity for 40 resident’s on this campus.
Roughly 25% of the campus is short term subacute residents.
• Whispering Pines in Pine River has 56 residents with roughly 20% residents on a short term stay.

• Noted increase in hospital readmissions within
100 days.
• Highest rate of readmission noted to be 6%.
• Increased cost with the readmissions to the hospital.
• Increased resident and family stress and depression with readmissions to the hospital.

• Noted problem with diagnosis listed on discharge orders.
• Staff unaware of off label use of medications unable to properly educate residents on medication use.
• Worked with the hospital on obtaining diagnosis for medications.
• Barriers noted with working with computerized charting systems.

• Hospital worked on obtaining access to their computer system for Care Center Staff.
• Care Center staff will have ability to review records from the hospital to ensure quality of continuum of care for the residents.
- This is a work in progress and all staff are thrilled to have the ability to review residents records to ensure quality care.

• Physicians Orders for Life Sustaining Treatment.
– Five staff trained as Advanced Care Planning Facilitators.
• INTERACT tools utilized for nursing staff included the following:
– Care paths for resident condition changes.
– Acute change in condition file cards available to all nurses.
– Stop and Watch forms utilized for early detection of changes in condition.
– SBAR - Situation Background Assessment or Appearance Request forms utilized in Point Click Care.
– Designated staff audits all hospital admissions and Emergency Room visits to determine if potentially preventable. Education occurs as needed if determined potentially preventable.
– INTERACT website: http://interact2.net/

Care Paths
• CHF
• UTI
• Pneumonia
• AMSC
• Fever
• Dehydration
23

Change in Condition:
When to report to the MD/NP/PA
Immediate Notification:
Any symptom, sign or apparent discomfort that is:
1. Sudden in onset
2. A marked change (i.e. more severe) in relation to usual symptoms and signs
3. Unrelieved by measures already prescribed
This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 8SOW-GA-NH-08-37
Sources:AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home.
McGraw-Hill, 1996 When to report to the MD/NP/PA Change in Condition:
© 2010. Florida Atlantic University
24

Vital Signs
(Report Why Vital Signs Were Taken)
Vital Sign
Blood Pressure
Pulse
Respiratory Rate
Weight Loss
Report Immediately Report on Next Work Day
• Systolic BP > 210 mmHg, < 90 mmHg
• Diastolic BP >115 mmHg
• Resting pulse > 130 bpm, < 55 bpm, or
>110 bpm and patient has dyspnea or palpitations
• Respirations > 28, < 10/minute
• Oral (electric thermometer) temperature >
101F
• Diastolic BP routinely > 90 mmHg
• Resting pulse >120 bpm on repeat exam
• New Onset of anorexia with or without weight loss
• 5% or more within 30 days
• 10% or more within 6 months
© 2010. Florida Atlantic University 25

EARLY WARNING TOOL
“Stop and Watch”
If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift.
Name of Resident ______________________________
S eems different than usual
T alks or communicates less than usual
O verall needs more help than usual
P articipated in activities less than usual
A te less than usual (Not because of dislike of food)
N
D rank less than usual
W eight change
A gitated or nervous more than usual
T ired, weak, confused, or drowsy
C hange in skin color or condition
H elp with walking, transferring, toileting more than usual
Staff_________________________________________________
Reported to ___________________________________________
Date _____ / _____ / ________ Time ________________
© 2010. Florida Atlantic University Adapted from Boockvar et al., J Am Geriatr Soc 48:1086 (2000) 26

SBAR
Structured and standardized communication format between health care workers.
S=Situation (a concise statement of the problem)
B=Background (pertinent and brief information related to the situation)
A=Assessment (analysis and considerations of options — what you found/think)
R=Recommendation (action requested/recommended — what you want)
27

28

• Noted decline in preventable hospital readmissions.
• Noted increase in changes in orders prior to admissions to the hospital in attempt to prevent hospital admission.

Marie Michlitsch RN
Director of Nursing
Good Samaritan Society Woodland
100 Buffalo Hills Lane
Brainerd, MN 56401 mmichlit@good-sam.com
(218)855-6601

Deanna Abramson
Assisted Living RN Manager
Woodland Campus

Bethany and Pine River Campuses
Bethany
• In Brainerd
• 37 Senior Living
Apartments
• 20-25 residents on A/L services
Pine River
• In Pine River
• 36 Senior Living
Apartments
• Recently added A/L services
• 1 Cottage Style House with 16 higher level A/L

Good Samaritan Society Woodland Senior Living
Apartments & Samaritan Houses
• Good Samaritan Society Woodland Campus in
Brainerd MN
• Senior Housing- Apartments with Assisted Living and
Cottage Style Units for Higher Level Assisted Living &
Memory Care
• Apartments- average 70 A/L residents (128 total
Apartments), 16 beds A/L in Cottage Style, & 32 beds
Memory Care
• Universal Workers (NARs) 5 RNs & 3 LPNs

• Admitting Residents with higher level of care needs
• Limited amount of Licensed Staff in our buildings to assess and monitor the resident’s health issues.
• Many times A/L staff not making the decisions for residents going to ED (residents / families)
• Hospital staff & Physicians unaware of the limitations the Assisted Living settings in meeting resident’s health/ care needs

• We want to give our Assisted Living residents the best nursing care that we can possible
• To decrease the ED visits and the hospitalizations for our residents.
• If possible we want to catch as many symptoms as necessary to alleviate the stress and discomfort of sending the resident into ED.
• Build communication and trust with local providers to give the residents a smooth transition when hospitalized and/or transferred back to home.

• Catch changes in condition early
• Empower our staff to bring up issues to Nursing Staff
• All staff/All departments are educated.
• Easy access to forms
• Get away from writing notes on all types of pieces of paper
• Education during our annual staff training
• Staff needs follow up & feedback
• At this point we haven’t seen too many utilized- oncoming reinforcement
• Challenge when have some residents who refuse to be seen by their Physician

Pilot to develop and begin tracking Assisted Living
Resident’s hospitalizations & re-hospitalization
• Look for trends and to look for ways to decrease some of our
ED visits and hospitalizations;
• Be part of our QI/QA process that will be required with our new Comprehensive License
• Using a tracking form and a Data sheet & QI form
• Need to get all staff to see importance of tracking & ways for reduction.
• Have data to show results
• Can be used for Marketing reasons, that if your facility can show the data that they have fewer ED visits the hospital and other would recommend your facility to the potential residents

Deanna Abramson
Good Samaritan Society Woodland
RN Assisted Living dabramso@good-sam.com
218-855-6632

Gayle Nielsen, MSN, RN Care Coordinator

• In-patient and ED Ward Clerks are now able to make visit appointments
– Within 5 days for high-risk readmissions
• Reserved anywhere from 0 to 4 slots daily for
Same Day Visits.
– Released 5 p.m. the evening before or 8 a.m. day of
• Reserved 0-2 slots a week for Hospital Followup visits
– Released 24 hours before

• Long term care leadership came to a
Baxter Clinic Department meeting for faceto-face discussion
• Doctors and nurses from the clinic attend
• Medication lists
• Orders

Triple Aim:
Improve Quality
Improve Patient Satisfaction
Reduce Cost

Program Goal #1 Improve Quality
•Regular contact, with one individual
•Pre-visit calls to “package the visit” for PCP
Updates from specialists visits
Changes in function/ clinical condition
Patient’s agenda
•Self management support, patient education
• Management of care transitions – post discharge, ER visits, other events

Program Goal #2 Patient Satisfaction
– Develop Care Plan with patient and family
• One stop summary of all problems, meds, instructions, plans
• Identify patient’s personal goals and match them with the medical plan
– One trusted person to call when urgent matters arise
– Advocate and system navigator

Program Goal #3 Reduce the total cost of care
– Prevent hospitalizations
• Improve patient and family understanding of the plan
• Attentive follow-up
• Arrange appropriate home support
– Prevent unnecessary ER Use
• Create a “Primary Care Home”
• Emergency plan of care – what to do when…

• Regular Care with 3 or more sub specialists for significant medical conditions
• >3Hospital readmissions in 6months
• Greater than 3 ER visits within 6 months
• Greater than 4 points noted on Risk Stratification Tool
• Threats to self care ability identified by RNCC
(inadequate support, financial barriers, impaired medical literacy, language barrier)
• 2 or more chronic conditions identified on problem list
(outside of quality targets).

• Two RN Care Coordinators
• Eight Clinics
• 33 Practitioners
• Total Number Patients Enrolled: 102
• 62 Female, 40 Male
• 73% of patients are Medicare
• 22% Medical Assistance
• ACO-BCBS and Medica

• 35 discharges involving 31 patients
• One Care Coordination Patients
• 9 readmissions involving 5 patients
• None of them were Care Coordination Patients
• Three patients had two readmissions each-one of them is deceased and one on hospice

Six months before enrollment
Six months after enrollment
• 13 ED visits
• 13 Hospital Admissions
• 4 ED visits
• 8 Hospital Admission
• 69% reduction in ED visits
• 61% reduction in Hospital
Admissions

Gayle Nielsen, MSN, RN Coordinator
Essentia Clinics
Email: gayle.nielsen@essentiahealth.org
218-454-5967

Kayla Farr, RN
Director

• Home Care
• Hospice
• Avg daily census
• HC- 72
• Hos-14

• Located in Nisswa, MN
• Coverage area within 45 miles from the office, remote locations we utilize telemedicine.
• We have nursing divided for both service lines.

• Return hospitalizations
• Notification from our home care patients of going into the hospital
• “Repeat offenders”
• Tracking of telehealth patients who go into the hospital.

• Reduction of our hospitalization rate
• Collaboration effort between providers
• Increase disease management for our patients.

• Identification of our hospitalizations
– Who/Why
– Stratis Health
– Acute Care Transfer Log (INTERACT tool) modified.
– Increase team awareness:
• Hospital
• Home Care
• Hospice

• Acknowledgment of issues that need to be addressed.
• How to stay focused on the collaboration for the “patient” versus feelings of “pointing fingers”.
• Getting team members to “attend” to a after hours call.

Kayla Farr, Director
Good Samaritan Society Home Care & Hospice kfarr@good-sam.com
218-963-9452

Janelle Shearer, MA, BSN, RN
952-853-8553 or 877-787-2847 jshearer@stratishealth.org

Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.
Prepared by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 10SOW-MN-C8-14-42 010214

Stay tuned for the next RARE Webinar…
Team Care for the Chronic Disease Patients:
Using lay “Care Guides”
February 21, 2014 (1-2 p.m.)