H.A.L.T.T. Hospital Admissions Lessened Through Therapy Tuesday, April 28, 2015 HALTT: Hospital Admissions Lessened Through Therapy Presented by Heather Meadows, SLP PREMIER THERAPY 701 Sharon Road Beaver, PA 15009 800.875.7041 www.EmbracePremier.com HALTT: Hospital Admissions Lessened Through Therapy OBJECTIVES 1. The attendee will be able to describe the prevalence of readmissions as well as the targeted diagnoses. 2. The attendee will identify the potential roles that OT, PT, and Speech could play in reducing readmissions. HALTT: Hospital Admissions Lessened Through Therapy 3 OBJECTIVES 3. The attendee will design a program which identifies at risk residents utilizing root-cause analysis and a comprehensive plan to address issues. HALTT: Hospital Admissions Lessened Through Therapy 4 The Accountable Care Act • Nearly 18% of hospitalizations of Medicare patients are the result of readmissions. HALTT: Hospital Admissions Lessened Through Therapy 5 The Affordable Care Act • To reduce these costs, the Hospital Readmissions Reduction Program was introduced through the ACA. • This requires CMS to reduce payments to hospitals with excess readmissions effective 10/1/2012. HALTT: Hospital Admissions Lessened Through Therapy 6 Readmissions Defined • Readmissions are defined as an admission to subsequent hospital within 30 days of a discharge from the same hospital. HALTT: Hospital Admissions Lessened Through Therapy 7 Adopted Readmission Measures • CMS targeted diagnoses: Breakdown of readmissions – CHF 24.8 % – Pneumonia 18.4% – Acute Myocardial Infarction 19.8% HALTT: Hospital Admissions Lessened Through Therapy 8 National Readmission Measures • In the fiscal year 2014, IPPS final rule, CMS adopted additional readmission measures for: – Acute exacerbation of Chronic Obstructive Pulmonary disease (COPD) – Elective Total Hip Arthroplasty (THA) – Elective Total Knee Arthroplasty (TKA) HALTT: Hospital Admissions Lessened Through Therapy 9 The Goal of ACA • Hospitals will receive bundled payments covering not just the hospitalization, but the care after the hospitalization. • Hospitals with high rate of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period with those targeted diagnoses. HALTT: Hospital Admissions Lessened Through Therapy 10 Expected Outcome • The combination of incentives and penalties should lead to better care after a hospital stay and result in less readmissions. • Savings of approximately $25 billion dollars over 10 years is expected. HALTT: Hospital Admissions Lessened Through Therapy 11 Current Data for SNF Readmission • 2011 Q4 – 18.2 % sent back to hospital within 30 days of their SNF stay • 2014 Q2 - 15.6 % sent back to hospital within 30 days of their SNF stay HALTT: Hospital Admissions Lessened Through Therapy 12 Results • This is a overall 14.3% decrease from the 2011 readmission totals. • An estimated 58,000 readmissions were prevented, saving the health care system almost $599 million. HALTT: Hospital Admissions Lessened Through Therapy 13 HR 4302 – Protecting Access to Medicare 2014-New for SNFs in 2015 and 2016 • A new bill calls for the U.S. Department of Health and Human Services (HHS) to introduce an “all-cause, allcondition” hospital Readmission Measure for SNFs by Oct. 1, 2015. • A Resource Use Measure began to reflect an all-condition, risk-adjusted, potentially preventable hospital readmission rate for SNFs by Oct. 1, 2016. HALTT: Hospital Admissions Lessened Through Therapy 14 HR 4302 – Protecting Access to Medicare 2014-New Bill • SNF performance would be reported publicly on the Nursing Home Compare website, but HHS also would be required to send quarterly reports to SNFs with confidential feedback on their performance against the measures beginning Oct. 1, 2016. • SNFs will have the opportunity to review and submit corrections prior to the information becoming public. HALTT: Hospital Admissions Lessened Through Therapy 15 HR4302 • You can access H.R. 4302 at: http://www.gpo.gov/fdsys/pkg/BILLS113hr4302enr/ pdf/BILLS-113hr4302enr.pdf HALTT: Hospital Admissions Lessened Through Therapy 16 Assess Facility Readiness • What corporate programs and outcomes are you using (Quality Assurance/Performance Improvement, QAPI)? • Do you have facility specific protocols in place? • What current opportunities exist? • Do you have tracking systems for readmissions? HALTT: Hospital Admissions Lessened Through Therapy 17 Partnering Opportunities • Do you have integrated coordination opportunities available? –ACOs (Accountable Care Organizations) –Bundled Payments for Care Improvement (BPCI) Initiative –Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents (RAVEN) UPMC HALTT: Hospital Admissions Lessened Through Therapy 18 Advancing Excellence • America’s Nursing Homes National Campaign was founded in 2006, by 28 organizations including nursing homes, quality improvement experts, and government agencies to improve the quality of nursing homes. • Evidence-based resources were developed to support quality improvement efforts in nursing homes, ensuring better care for the residents and staff that care for them. HALTT: Hospital Admissions Lessened Through Therapy 19 Advancing Excellence • It is the first national effort to measure quality in the nursing homes through measurable clinical quality goals and organizational improvement goals. • Every nursing home can participate by focusing on two or more goals, and utilizing resources developed by group to meet their goals. HALTT: Hospital Admissions Lessened Through Therapy 20 Advancing Excellence Goals choices are: Clinical quality goals Organizational improvement goals • • • • • • • • • reducing pressure ulcers improving pain management increasing mobility reducing infections reducing antipsychotic use increasing staff retention improving consistent staff assignment reducing unnecessary hospitalizations promoting patient-centered care HALTT: Hospital Admissions Lessened Through Therapy 21 Advancing Excellence • Many of these goals are interrelated. Improvement in one area can impact other goals, such as improving mobility with residents, and may reduce pressure ulcers or improve pain with the residents. HALTT: Hospital Admissions Lessened Through Therapy 22 Advancing Excellence • You are able to use resources from their website to initiate quality improvement in your facility, and utilize guidelines, forms, and tracking to report/track progress and show improvement with each goal. Source: Advancing Excellence, www.nhqualitycampaign.org, Accessed 3-23-2015 HALTT: Hospital Admissions Lessened Through Therapy 23 INTERACT 4.0 • INTERACT stands for Interventions to Reduce Acute Care Transfers. • It is a quality improvement program to improve the identification, evaluation, and communication about changes in the residents’ status. • Projects are supported by CMS and now funded through Commonwealth Fund, involving nursing homes in Florida, New York, and Massachusetts. HALTT: Hospital Admissions Lessened Through Therapy 24 INTERACT • The overall goal of the program is to reduce the frequency of transfers to the hospital, which have been proven to be both difficult and costly. • The program is comprised of communication, care path, clinical and advanced-care planning tools for care teams to use to reduce unnecessary readmissions to the hospital. HALTT: Hospital Admissions Lessened Through Therapy 25 INTERACT • Tools and algorithms are available for teams to use as guidelines to implement systems and improve readmission rates. • It is meant to improve the early identification, evaluation, management, documentation, and communication of acute care changes of the residents in SNF, HH, and AL environments. • Implementation guidelines , tools, and resources can be found on the website. Source: INTERACT website: http://interact.fau.edu HALTT: Hospital Admissions Lessened Through Therapy 26 INTERACT • Several of the tools can be utilized for at-risk quality improvement and tracking programs: – Stop and Watch Tool – SBAR Form – Hospital Rate Tracking Tool – Quality Improvement Tool You may use any of the resources from the website free of charge but cannot modify them in anyway. HALTT: Hospital Admissions Lessened Through Therapy 27 INTERACT TOOLS HALTT: Hospital Admissions Lessened Through Therapy 28 INTERACT/HALTT • The two programs are similar in that they both are designed to illicit early identification of problems, prompt timely and proper assessment of resident, and implement a care plan. • HALTT also allows for root cause analysis of resident issues and assignment of duties to the appropriate care team member to improve risk area of the resident. HALTT: Hospital Admissions Lessened Through Therapy 29 HALTT Risk Areas 1. Unstable blood sugar 2. CHF or COPD 3. Fall history 4. Reduced intake by mouth 5. Change in medications 6. Unstable or changes in vitals 7. Fluctuating functional status 8. Behavior changes 9. Change in lung sounds 10. Pain HALTT: Hospital Admissions Lessened Through Therapy 30 HALTT • Assignment of duties to IDT members are completed at the first Stand Up meeting and/or UR meeting following the identified issue of the resident. • Communication of plan of care is given to entire care staff and families. • Accountability to complete duties are checked at the next UR meeting when update to team is expected. HALTT: Hospital Admissions Lessened Through Therapy 31 Does Your Therapy Play a Role? • Therapy can help support the facility in decrease readmissions to the hospital through: – Comprehensive assessments – Alertness to vital signs and risk factors – Communication to nursing, families and physician – Education to caregivers – Monitoring of status – Consistent scheduling with resident – IDT involvement – Discharge planning with team HALTT: Hospital Admissions Lessened Through Therapy 32 What Role Can Therapy Play? How can therapy reduce the risk of readmissions to the hospital? 1. Complete comprehensive assessment with the appropriate plan of care. 2. Be an extra watchdog for changes in vital signs. HALTT: Hospital Admissions Lessened Through Therapy 33 What Role Can Therapy Play? 3. Timely communication of change in status to proper team members to address and possibly involve a physician early in process (written communication). 4. Get residents moving or in better positions to reduce risk of pneumonia, infection, or falls (greatest % of readmissions). 5. Participate in Falls, Wounds, and Pain programs consistently. HALTT: Hospital Admissions Lessened Through Therapy 34 What Role Can Therapy Play? 6. Educating resident and caregivers, so they understand their risks, is the best way to control disease process and achieve a safe and highest functional level. 7. Communicate to home health agencies, equipment companies, physicians, and caregivers the discharge plans/needs to help resident return to a safe environment . HALTT: Hospital Admissions Lessened Through Therapy 35 Begins at Admission Prior Level of Function 1. Eating- indicates risk of poor nutrition or assist needed 2. Dressing- indicates what level of independence resident may be 3. Ambulation/Transfers- indicates possible balance problems or fall risk 4. Bathing/Bathroom use- indicates level of independence 5. Cognition- indicates possible safety concerns HALTT: Hospital Admissions Lessened Through Therapy 36 Begins at Admission Prior Level Of Function – Swallowing- can indicate any choking or aspiration risks – Functional Decline/Falls- if falling at home more likely to fall in facility – Previous therapy in present year- could indicate ongoing problem – Medication Review-can indicate side effects or poor adjustment to new medications HALTT: Hospital Admissions Lessened Through Therapy 37 PLOF Form HALTT: Hospital Admissions Lessened Through Therapy 38 Vital Sign Checks • • • • • • • Temperature Blood Pressure Respiration Rate O2 Saturation Heart Rate or Pulse Pain Shortness of Breath HALTT: Hospital Admissions Lessened Through Therapy 39 Vital Signs • The vital sign check, along with our functional assessment, during treatment could really help with early detection of issues. HALTT: Hospital Admissions Lessened Through Therapy 40 Vital Signs Temperature – Baseline should be established and checked daily by nursing. – An increase of body temperature can indicate a systemic infection, inflammation or hyperthermia. – A spike in temp 20-30 minutes after eating could indicate possible silent aspiration. – A decrease in body temperature can also be a concern (i.e. poor circulation, heart problems). HALTT: Hospital Admissions Lessened Through Therapy 41 Vital Signs Heart Rate or Pulse – Pulse rate varies with age. – Normal adult beats per minute are typically 50-80 beats. – An increase in pulse rate can occur with, but not limited to, pain and infection. – A decrease or irregular pulse rate could indicate a serious health issue or illness. HALTT: Hospital Admissions Lessened Through Therapy 42 Vital Signs Respiration Rate – Should note if wheezing, exertion with breathing, and other sounds occur – Varies with age – Normal adult rates are 12-28 breaths per minute HALTT: Hospital Admissions Lessened Through Therapy 43 Vital Signs Respiration Rate – Increased respiration rate could mean possible infection or pain. – Decreased respiration rate could indicate weakness and system failure. HALTT: Hospital Admissions Lessened Through Therapy 44 Vital Signs Blood Pressure – It is indicative of how well the heart is functioning. – It is comprised of two measurements: • systolic pressure: measures the force of blood with maximal contraction of the heart • diastolic pressure: the resting pressure when the heart relaxes HALTT: Hospital Admissions Lessened Through Therapy 45 Vital Signs Blood Pressure – Normal blood pressure is 120/80 (systolic/diastolic). – Abnormal pressure would be anything over 130 systolic and 85 diastolic pressure. – Hypertension is when the systolic pressure is consistently between 140 -160 mmHg. – Hypotension is low blood pressure below 120 systolic pressure consistently. HALTT: Hospital Admissions Lessened Through Therapy 46 Vital Signs Pain – This is considered to be an important, but often overlooked, vital sign in adults. – It can greatly impair a person’s function and lead to other medical issues such as depression, contractures, immobility, sleep deprivation, and wounds. – Should be assessed at: • Admission, quarterly with nursing review, each shift if pain management is part of care plan, if change is noted during review, and when intervention is implemented to see if effective for pain reduction. HALTT: Hospital Admissions Lessened Through Therapy 47 Vital Signs Pain Scales are used to show changes (good or bad) with any intervention and to establish a baseline – Nonverbal Pain Assessment – Faces Pain Scale – Visual Analog Scale – Pain Thermometer Scale – Comprehensive Pain Assessment-cognitively intact HALTT: Hospital Admissions Lessened Through Therapy 48 Vital Signs Pain Scales – Brief Pain Inventory – Initial Pain Assessment Tool – Memorial Pain Assessment Card • Mood Scale • Relief Scale – Patient Comfort Assessment Guide Source: www.rehabmeasures.com HALTT: Hospital Admissions Lessened Through Therapy 49 Vital Signs Dyspnea- Shortness of Breath – It is normal with heavy exertion, but it is abnormal if it occurs with everyday functions. – It can indicate problems with asthma, pneumonia, cardiac ischemia, lung disease, congestive heart failure, acute MI, COPD, and panic or anxiety disorders. – It is important to report this to a nurse/physician in a timely manner. – Assess the intensity with any distinct sensation, such as (effort, chest tightness, and air hunger) distress involved and impact on daily functions. HALTT: Hospital Admissions Lessened Through Therapy 50 Vital Signs Standardized tests – Modified Borg Scale – MRC breathlessness Scale- 5 grades of dyspnea based on the circumstances in which it arises. HALTT: Hospital Admissions Lessened Through Therapy 51 Vital Signs Gait Speed – Gait requires input from many different systems in the body. – Proper coordination of all these systems produces normal gait, and if any systems are unhealthy then gait can be affected. – Gait speed changes or abnormalities can be an indicator of system problems or failures in the body. HALTT: Hospital Admissions Lessened Through Therapy 52 Vital Signs Standardized Tests – Tinetti – 6 minute walk test – Timed Up and Go test – Timed 10 meter walk test – Timed 10 meter walk test with 1-2 cognitive tasks HALTT: Hospital Admissions Lessened Through Therapy 53 Vital Signs • A decline in gait speed predicts a decline in attention. • A decline in gait speed predicts an increased chance of mortality. • The more normal gait speed ( 7 seconds = 3 mph for 10 meter walk) the better health and quality of life a person will possess. Source: Levine, Pete, BA, PTA, Using Gait Speed as a Marker for Progress, Advance for Physical Therapy and Rehab Medicine, Vol.21, Read 3-26-2015 HALTT: Hospital Admissions Lessened Through Therapy 54 Vital Signs • Abnormal vital signs could be the first warning that an impending medical decline may be occurring. • Early detection and then treatment could ward off intensifying symptoms and possible transport/admission to hospital. • Nursing monitors vital signs, but therapy could also report them and be an added watchdog for issues that may be arising with the resident. HALTT: Hospital Admissions Lessened Through Therapy 55 Know Your At Risk Patients • Add patients who trigger upon admission either from PLOF form or nursing/therapy assessments to Risk List. • Review these patients at the morning meeting or UR with IDT . HALTT: Hospital Admissions Lessened Through Therapy 56 Target List HALTT: Hospital Admissions Lessened Through Therapy 57 Root Cause of Issues • Use a tool to deep dive issues – Pause: What is the Root Cause? – Medical Necessity Form- Nursing Note to indicate medical need for therapy or other intervention. – If fall history or at risk- complete comprehensive Fall Assessment. – Look at all areas that could send patient back to hospital and also positively impact your QMs: Pain, Pressure Ulcers, Weight Loss, etc. HALTT: Hospital Admissions Lessened Through Therapy 58 Pause: What is the Root Cause? HALTT: Hospital Admissions Lessened Through Therapy 59 Medical Necessity Form HALTT: Hospital Admissions Lessened Through Therapy 60 HALTT: Hospital Admissions Lessened Through Therapy Current Quality Measures HALTT: Hospital Admissions Lessened Through Therapy 62 Utilization/Resident Review • This should consist of a weekly comprehensive review of all risk factors, not just for falls. • Proper referrals to address needs are determined by the IDT, and assignment sheets are completed. HALTT: Hospital Admissions Lessened Through Therapy 63 Assignment Sheet HALTT: Hospital Admissions Lessened Through Therapy 64 Daily/Weekly Monitoring • Each resident will continue to be monitored and their progress and status of plan reported in morning meeting. • Assignment sheets will be reviewed in weekly meetings, and modifications may be made by IDT. HALTT: Hospital Admissions Lessened Through Therapy 65 Communication and Training • Document all information during Falls meetings and interventions. • A log can be used but should have nursing note or IDT note 1x a week for everyone and everything discussed in meeting. (Can use Medical Necessity Note). HALTT: Hospital Admissions Lessened Through Therapy 66 Communication and Training • Once the end result is achieved, communicate to all care staff and make sure all training is complete. • Use sign off sheets during training with dates completed, who attended and who instructed. HALTT: Hospital Admissions Lessened Through Therapy 67 Communication and Training • Update documentation that plan was put into place, all care staff trained, and resident successful with adaptations. Nursing will follow for next two weeks for carry over. • Nursing should write a note on carry over and positive impact to function and quality of life for resident. HALTT: Hospital Admissions Lessened Through Therapy 68 Nursing Log and Note HALTT: Hospital Admissions Lessened Through Therapy 69 Communication and Training • Team will recommend discharge from At Risk List. • Written status/adaptation should be present in a private place, so care staff can access it easily during care. • Residents will be reviewed quarterly. HALTT: Hospital Admissions Lessened Through Therapy 70 Discharge • Review of Discharge Checklist by the IDT will be completed prior to discharge. • All training of care staff and families must be done prior to discharge from program. • Updates are given at the morning meeting and the resident is removed from target list. HALTT: Hospital Admissions Lessened Through Therapy 71 Discharge Checklist HALTT: Hospital Admissions Lessened Through Therapy 72 Case Scenario • New admit from hospital status post CVA. – 80 year old female admitted post CVA two weeks ago with L- sided hemiparesis – Past Medical History: DM, atrial fib, and right hip fracture two years ago HALTT: Hospital Admissions Lessened Through Therapy 73 Case Scenario (con’t) • Prior to a hospital stay, the resident was independent with all ADLs, ambulation without a device, homemaking skills, and lived in her own apartment with supportive family nearby. She was able to do light housekeeping and drove a car. HALTT: Hospital Admissions Lessened Through Therapy 74 Case Scenario (con’t) • She has reported, and family indicates, a fall about two weeks before going into the hospital. • She has numbness in her feet from DM. • Family reported that she has lost motivation since her husband passed away two months ago. HALTT: Hospital Admissions Lessened Through Therapy 75 Case Scenario (con’t) • New Admit: Nursing/MDS complete: – PLOF assessment – Fall Risk assessment – What’s Your Risk assessment • Resident triggered as a high risk for falls on the assessments due to decreased functional ability, significant decline from PLOF, uncontrolled DM, and fall history. HALTT: Hospital Admissions Lessened Through Therapy 76 Case Scenario (con’t) • Nursing places resident on Target List as “at risk”. • Resident is discussed with IDT in next morning meeting as having issues, and all therapies are ordered to complete evaluations. HALTT: Hospital Admissions Lessened Through Therapy 77 Case Scenario (con’t) • Resident is discussed in morning meeting, and update is given as preliminary plan. • Resident discussed in Weekly UR/Resident Review meeting by entire IDT. • Utilize Tool for Root Cause. HALTT: Hospital Admissions Lessened Through Therapy 78 Case Scenario (con’t) • Assignment sheets are completed by Nursing in UR with issues identified, persons responsible, and date of completion. • Document on Log brief explanation of IDT decisions and refer to assignment sheets. HALTT: Hospital Admissions Lessened Through Therapy 79 Progress and Review • Update team each morning on plans. • Review Assignment sheets at Weekly UR meeting – Hold staff accountable. • Write in actions taken for the previous week and if completed or ongoing. • Add new assignments if needed. HALTT: Hospital Admissions Lessened Through Therapy 80 Discharge • IDT can recommend removal from Target List when all parts of plan completed. • Review Discharge Checklist in UR with IDT to make sure all is done. • IDT will recommend in next morning meeting to remove resident from “at risk” target list. HALTT: Hospital Admissions Lessened Through Therapy 81 Quarterly Review • This person, unless discharged to another environment, would be reviewed quarterly upon clinical rounds to make sure plan still appropriate or if a comprehensive assessment is needed again. HALTT: Hospital Admissions Lessened Through Therapy 82 QUESTIONS? HALTT: Hospital Admissions Lessened Through Therapy 83 THANK YOU! HALTT: Hospital Admissions Lessened Through Therapy 84 Resources 1. 2. 3. 4. Centers for Disease Control and Prevention. Adult Falls. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Accessed February 2014. Tools to Implement the Otago Exercise Program: A Program to Reduce Falls 1st Edition, CDC. Accessed October 2013 Tinetti, Mary E. M.D., www.fallprevention.org/pages/fallfacts.html 2005. Root Cause Analysis: www.health.state.mn.us/patientsafety/toolkit.html Accessed April 1, 2014. HALTT: Hospital Admissions Lessened Through Therapy 85 Resources (con’t.) 5. 6. 7. 8. Comprehensive Accreditation Manual for Long Term Care Refreshed Core, January 2011 Internet: http://www.jointcommission.org Accessed February 3, 2014. Internet: http://www.primaris.org/sites/default/files/resources Accessed April 3, 2014 Internet: http://www.ahrq.gov/professionals/systems/longtermcare Accessed April 3, 2014. HALTT: Hospital Admissions Lessened Through Therapy 86 Resources (con’t.) 9. Currie, Leanne, D.N.S., M.S.N., R.N., assistant professor, Columbia University School of Nursing, Patient Safety and Quality: An EvidenceBased Handbook for Nurses. Chapter 10, 2007. 10. Centers for Disease Control and Prevention, STEADI-Stopping Elderly Accidents, Deaths and Injuries: Fall Risk Checklist: Accessed February 4, 2014. 11. Taylor, Jo. A., R.N., M.P.H., Parmalee, Patricia, Ph.D., Brown, Holly, M.S.N., A.P.R.N.-B.C., Ouslander, Joseph, M.D. The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities: AHRQ, October 2005. HALTT: Hospital Admissions Lessened Through Therapy 87 Resources (con’t.) 12. Guidelines for Nursing Homes: OSHA 3182-3R, 2009. 13. Internet: http://www.cms.gov/regulationsandguidance Accessed February 2014. 14. The Centers for Medicare and Medicaid Services. MDS 3.0 Quality Measures: User’s Manual v.5.0 03-01-2012 15. Bischoff-Ferrari, Heike, A., M.D., M.P.H., Dawson-Hughes, Bess, M.D., Willett, Walter, C., M.D., P.H.D., Staehelin,Hannes, B., M.D., Bazemore, Marlet, G., M.D., Zee, Robert, Y., M.D., Wong, John, B., M.D., Effect of Vitamin D on Falls, A Meta-analysis. April 28, 2004 HALTT: Hospital Admissions Lessened Through Therapy 88 Resources (con’t.) 16. Internet: http://www.jama.jamanetwork.com/article Accessed April 4, 2014. 17. Rubenstein, Laurance, Z., M.D., M.P.H., Merck Manual Professional. Falls in the Elderly. November 2013. 18. Journal of the American Geriatric Society. AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: March 2012. 19. The AGS Foundation for the Health in Aging: www.healthinaging.org Accessed February 4, 2014. HALTT: Hospital Admissions Lessened Through Therapy 89 Resources (con’t.) • https://www.interact2.net, INTERACT Tool, Accessed 3/5/2015 • https://www.nhqualitycampaign.org, Advancing Excellence, Accessed 3/23/2015 • Measuring Vital Sign’s, http://www.healthline.com,2/24/2009 • Rehabilitation Measures Database, http://www.rehabmeasures.org, accessed 3/5/2015 HALTT: Hospital Admissions Lessened Through Therapy 90 Resources (con’t.) • Vital Signs, http://en.wikipedia.org, accessed 3/5/2015 HALTT: Hospital Admissions Lessened Through Therapy 91