Ideal Patient Care Across the Continuum:
Reducing Preventable Readmissions
April 17 IHS Forum
Peg Bradke RN MA
St. Luke’s Hospital
Director of Heart and Vascular Services
Where We Have Been
• Engaged Cross Continuum Teams
• Condition focused
• Learned about patients who are readmitted
– By condition, 3 readmissions in 180 days
• Used IHI Change Package for hospitalbased transitions
• Learned to see and solve at the front line
– Started to see from another care site perspective
Where We Are Going
2012 Clinical Priorities
Clinic
Quality
Patient Experience
Hospital
Home Health
Adherence to
Diabetes Bundle
Reduce
Readmissions
Reduce Acute
Hospitalization
Improve
Press Ganey
Scores
Improve
HCAHPS
Scores
Improve
HHCAHPS
Scores
2011 Results
Improved
Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations
Post-Acute
Care
Activated
Evidencebased Care in
Community
Care Settings
(Better Models
of Care)
Alternative or
Supplemental
Care for HighRisk Patients *
* Additional Costs
for these Services
Transition
from Hospital
to Home
Patient and Family Engagement
Cross-Continuum Team Collaboration
Health Information Exchange and Shared Care Plans
Co-designing Processes to Improve Transitions
Hospitals
• Perform an
enhanced
assessment of
post-hospital
needs
• Provide effective
teaching and
facilitate enhanced
learning
• Ensure posthospital care
follow-up
• Provide real-time
handover
communications
Office
Practices
• Provide timely
access to care
following a
hospitalization
• Prior to the visit:
prepare patient
and clinical team
• During the visit:
assess patient and
initiate new care
plan or revise
existing plan
• At the conclusion
of the visit:
communicate and
coordinate ongoing
care plan
Home Care
Skilled
Nursing
Facilities
• Meet the patient,
family caregiver(s),
and inpatient
caregiver(s) in the
hospital and review
transition home
plan
• Assess the patient,
initiate plan of
care, and reinforce
patient selfmanagement at
first post-discharge
home care visit
• Engage,
coordinate, and
communicate with
the entire clinical
team
• Ensure that SNF
staff are ready and
capable to care for
the resident
patient’s needs
• Reconcile the
Treatment Plan
and Medication List
• Engage the
resident and their
family or caregiver
in a partnership to
create an overall
place of care
• Obtain a timely
consultation when
the resident’s
condition changes
Analysis of Results to Date
• Reducing readmissions is dependent on highly functional
cross-continuum teams and a focus on the patient’s journey
over time.
• Explicit focus on patient and family-centered work.
• Importance of engaged Executive Leadership and Physician
Leadership.
• Improving transitions in care requires co-design of transitional
care processes among “senders and receivers”. Frontline
clinicians and staff involvement in developing the process
improvements.
• Stories are as important as data.
• Providing intensive care management services for targeted
high-risk patients is critical.
• Reliable implementation of changes in pilot units or pilot
populations requires 18 to 24 months.
• Information Technology design is part of the work.
Barriers to Improving Care Transitions
and Reducing Rehospitalizations
• Cost of copayments for medications and follow-up visits.
• Lack of coverage for home health services if patients did
not meet regulatory requirements.
• Lack of reimbursement for transitional care services such
as post-discharge phone calls, coaches and dedicated
clinicians to provide extra support for patients and family
caregivers.
• Limitations of the electronic medical record to capture and
transmit information.
• Access to physician offices for follow-up visits.
• Complexity of patients with multiple co-morbidities.
• Challenges to completing reliable medication
reconciliation.
•
•
•
•
How, exactly, does IHS deliver on the Triple
Aim?
Align providers with a common quality
agenda
Use Analytics to identify at-risk patients for
clinical intervention
Design a care management infrastructure
to follow the patient across a highly
integrated provider network into all care
settings
Deliver comprehensive care aimed to attain
and maintain health in the outpatient setting
PLA-MLA Joint Meeting: February 2012
Linking the Patient Experience
and Reducing Readmissions
Patient/Family as Full Partner
• Partner with patient/family in the way they
want to be
• They will speak up more if involved
• Look for the patient/family clues
• With their input look at what you
specifically do at each transition
• The patient is not discharging from the
Army – they need a transition (K. White)
Key Changes to Improve the
Transition from Hospital to Home
1.
Perform an Enhanced Assessment of
Post-Hospital Needs
2.
Provide Effective Teaching and Facilitate
Enhanced Learning
3.
Ensure Post-Hospital Care Follow-Up
4.
Provide Real-Time Handover
Communications
Understanding of the comprehensive assessment of
the post-discharge needs of patients
• Streamline paperwork for nurses and enhance the work
environment to free up time for nurses to spend more time
with patients (TCAB changes: move laptops to patient rooms;
admission nurse; bedside change-of-shift report)
• Front-line nurses complete a more comprehensive
assessment of home-going needs (need to specify the openended questions); bring this information plus “what the patient
is worried about” to daily Care Rounds
• How best to use white boards in patient rooms to assess
comprehensive needs of patients?
• Develop standardized processes for getting information from
family caregivers and community providers
Patient and family caregiver understanding and
comprehension of clinical condition, plan and self-care at
home
• Create standard process to involve family caregivers
• Ensure that all nurses, hospitalists and residents are
competent to facilitate health literacy teaching sessions (Ask
Me 3 and Teach Back)
• Incorporate patient teaching into routine daily processes such
as the bedside change-of-shift report
• Change documentation fields in EMR from “what has been
taught” to “what is the patient’s understanding of……?”
Post-acute Follow-up Care
• No universally agreed-upon risk assessment tools; may
be difficult to mitigate some medical and social risks
• Continue to assess utility of assessing patient’s
understanding of home care and meds (using Teach
Back); look at agenda of Patient Care rounds
• Appropriate and timely FU care is dependent on
availability and payment for services
• Plan post-discharge follow-up care taking into
consideration assessed needs and capabilities of the
patient and family caregiver;
• Chronic Disease Management/ Advance Medical Team
Proposed Agenda for
“Patient Care Rounds”
1. What are the goals/reasons for this admission? Are the
health care team’s goals and the patient/families’ goals
in synch?
2. What needs to happen during this hospitalization?
What are the criteria for the discharge readiness?
3. What is the likelihood that this patient will be readmitted
in 30 days? Why (predictions re: potential problems)?
4. What post-acute care plan should be put in place to
meet the patient’s level of activation and to mitigate
potential problems?
5. Activate and communicate real-time post-acute care
plans to patients, family caregivers and community
providers
Handover Communications
• Co-design of communication and information
needed for next level of care
• After care summary
• Agenda for f/u office visit
• Utilizing Interact tools for Nursing Facilities
• Utilizing Health Coaches/Navigators
• Determining who is the most appropriate
individual to make the follow up calls.
• Don’t confuse information with communication
Scale-up and Spread
•
Spread: Taking a system or intervention and replicating it in an
independent site
– Replication without new learning or structural changes.
– Ex: A pilot unit at a hospital implements changes to reduce patient injury
from falls >> successes are shared with nurses in an educational forum and
changes are promoted and spread hospital-wide
•
Scale-up: The progressive design of a system of interrelated parts;
moving from one setting to a larger setting and then an even larger
setting within an interrelated system
– Expect new learning and structural changes to achieve results at scale.
– Ex: A pilot unit at a hospital successfully implements TeachBack as the
standard approach to patient education >> TeachBack is an annual core
competency for all nurses and residents in the hospital and EHR has fields
where nurses and doctors document “patient understanding…”
Source: API and IHI Retreats
Critical Capabilities for Care Redesign
Include:
• Cross-continuum participation and alignment
• The development and use of standardized tools
and compatible information infrastructure
• Horizontal Leaderships and executive
sponsorship; and engaged physicians
• Effective external and internal learning
Scale up changes cannot be a “project”, they must become
the new way to do work, built into the culture
20
Reducing Readmissions with
Integrated Chronic Care Disease
Management
Vicki Wildman, RN, MSN, Edu
Iowa Health Home Care
Cause of Crisis: Poor Management
“Patients can undo a
month’s worth of
expensive and
intensive care just
going home
and going about their
normal routines.”
John Charde, MD
VP Strategic Development, Enhanced Care Initiatives,
Inc (April 2006)
Before
Informed,
Activated
Patients
Prepared
Prepared
Practice
Practice
Team
Team
•Motivation
•Information
•Skills
•Confidence
•Patient information
•Decision support
•Resources
Home-Based Chronic Care Model
High Touch Delivery
Specialist Oversight
Self-Management Support
Technology
After
Lesson’s Learned
Commitment
Education
Competency performance testing
Hardwiring evidence-based practices
Future Opportunities
• Expansion of the curriculum cross
continuum
• Sustaining the education, training, and
competency
• Evidence based medicine implementation
project
• Hardwiring best practices related to chronic
conditions
• Individual employee outcome scorecards
The Future
•
Rehospitalizations are frequent, costly and many are avoidable;
•
Successful pilots, local programs and research studies demonstrate
that rehospitalization rates can be reduced;
•
Individual successes exist where financial incentives are aligned;
•
Improving transitions state-wide requires action beyond the level
of the individual provider; systemic barriers must be addressed;
•
Leadership at the provider, association, community and state
levels are essential assets in a state-wide effort to improve care
coordination across settings and over time.