4/26/2018

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Partnering for a “Quality Care Culture” to Reduce Avoidable Readmissions

Angela Booher, MAN, RN, CCM Director of Care Transitions Fairview Health Services

Fairview Readmission Goals

Fairview/UMMC Readmission Rates

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Definition of a Culture

According to Merriam Webster

the set of shared attitudes, values, goals, and practices

that characterizes an institution or organization a corporate

culture focused on the bottom line

https://www.merriam-webster.com/dictionary/culture

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Readmission Culture Planning Areas

Quality Culture• Standardized• Measurable• End-Product Goal• Adaptive Change• Takes a Villiage

Continuous Improvement

• Diet and Exercise

• Innovation• Metrics• Aligned

Communication

Patient Focused

• Listen Leading• Quality focused• Efficient• Individualized• Standardized Tools• Resources

How we “Focus” our Perspective Lens

Patient FocusedPatient

Focused

Quality not CostQuality

not Cost

EfficiencyEfficiency

Innovation Thinking

Innovation Thinking

TransitionsTransitionsMetricsMetrics

ToolsTools

Fairview Alignment of Goals

Readmissions

Length of Stay

Optimal Patient Experience/Care

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Patient Focused

Fairview Care ContinuumA “continuum” of nets and coaches to assist you when your health care needs make you feel as though you and your support system are walking a “tight rope” and risk falling

Balancing Pole: Advocacy and Autonomy tools and resources for your care to be tailored to your needs and wants

Ambulatory/Outpatient Support: Clinics, Outpatient Therapy,

Pharmacy, Community Services

Post Acute Facilities: Transitional Care Facilities, Long-Term Care, Assisted Living, Stay By The Day,

Group Home

Home Services Support: HOMECARE, Home Therapy, Social Worker Care Coordination, Lifeline,

Medication Support, Tele-health

Inpatient Support: Inpatient, Observation and Emergency Room

Goal of Partnership with aligned culture of patient and Healthcare Teams

1. Aligned communication

2. Improved Patient Experience

3. Improved Family Experience

4. Improved Staff Experience

5. Improved Collaboration of all key players

1. Decreased Hospitalization Admissions

2. Decreased length of stay for appropriate admissions

3. Decreased Costs

Goals

Measurable Outcomes

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Why Quality focus and not Cost?

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Why do we want to decrease hospitalization Admissions and utilize Community More

Everyone always thinks it’s about Cost but it’s really about quality

Decreased Autonomy of

choicesDeconditioning

Post-Hospital Acute

Syndrome

Hospital Acquired

Conditions

Increased Costs to payers/ families/

Patient(s)

Halo Effect is Financial with optimized efficiency of a Quality perspective

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Why is Efficiency Important?

Readmission Bucket Lists

Discharge Planning

Medication Management

Transition Communications

Transition Care

Support

All work associated with coordination across

settings and making sure the plan of care once discharged is followed

All work associated with discharge planning and the process at a Health

Facility prior to the patient moving to their next level

of care

All work associated between communications

about the patients care between the sending and

receiving caregivers

All work associated with the patient understanding

the purpose of their medications and is taking

them appropriately

Patient and Family Engagement and Experience goal setting with the patient voice in all core processes

System Alignment• RAM Screening• Workflow Optimization & Alignment

Outlier Escalation Process

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Evidence Based Innovation and creating

Evidence based interventions (The feedback loop of

continuous improvement)

System Analysis of Readmission Workflow

Patient Admitted to

Hospital

Patient Discharges

Readmission within 30

days

RAM Risk (appropriate Interventional matrix

initiated)

RAM Risk (appropriate Interventional matrix

initiated)

Transition ConferenceTransition

ConferenceCommunication

Hand-offCommunication

Hand-off

Discharge Planning Tool

Discharge Planning Tool

Root Cause Analysis

Root Cause Analysis

Qualitative Analysis

Qualitative Analysis

QlikviewDashboard

QlikviewDashboard

Intranet Site

Intranet Site

RAM is a Screening Tool that guides Clinicians Drive Decision

• Only pulls discrete data from inpatient utilization history

• Clinical assessment should drive interventions

• Additional Consult reasons define Care Coordination populations

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Model Overview

Readmission Risk Screening with the Readmission Assessment Measure “RAM”

• The RAM is a logistic regression model that calculates a patient’s risk of readmission using:AgeLength of StayLocation

– North (Northland / Lakes / Range)

– South (Southdale / Ridges)

– UMMC

Acuity

– Through ED?

– Transfer?

Select admitting diagnoses

– High Risk Dx Group = Diseases of the Blood and Blood-forming Organs and Certain Disorders

– Elevated Risk Dx Group = Certain Infectious and Parasitic Diseases

Cancer Treatment?Birth?Hospital History (6-month)

– Inpatient

– ED

– Observation

Scoring Categories1-2% 30-day Risk

1-2% 90-day Risk

5-6% 30-day Risk

9-10% 90-day Risk

11-12% 30-day Risk

19-20% 90-day Risk

22-23% 30-day Risk

37-38% 90-day Risk

33-37% 30-day Risk

53-57% 90-day Risk

44-49% 30-day Risk

66-71% 90-day Risk

62-69% 30-day Risk

80-85% 90-day Risk

Extreme

High

Very High

Elevated

Average

Low

Very Low

• Define Workgroup Expectations of Care for each RAM category

• Create Communication Plan for implementation of new workflows

• Develop measurement strategy for appropriate interventions per category on outcome Readmission scores

• Develop and implement a efficient, standardized, patient friendly system-wide strategy, workflow and measurement plan that reduces avoidable readmissions to a Fairview hospital

Objectives Goal

Readmission Assessment Measure (RAM)

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Risk Screening and Standardizing Best Practice along the Continuum

Patient has an inpatient

Stay

Patient has an inpatient

Stay

R.A.M. category

assigned in EPIC

header

R.A.M. category

assigned in EPIC

header

Care Coordinator Assesses Risk for

elevated and up

Care Coordinator Assesses Risk for

elevated and up

Clinic Care Coordination – Primary /Specialty

Clinic Care Coordination – Primary /Specialty

HomecareHomecare

PharmacyPharmacy

Skilled Nursing FacilitiesSkilled Nursing Facilities

Primary CarePrimary Care

Geriatric ServicesGeriatric Services

Best Practice Protocol based

on Category initiated prior to

discharge

Best Practice Protocol based

on Category initiated prior to

discharge

Extreme Very High High Elevated

Inpatient

• Home Assessment within 24 hours

• Follow-up Appointment within 24 hours of discharge

• Transition Conference

• Home Assessment within 24-72 hours

• Follow-up Appointment within 24-72 hours of discharge

• Pharmacy MedicationReconciliation

• Follow-up within first week

• Care Transitions Assessment• Follow-up within first week to 10

days• Communication Hand-off• MTM appointment scheduled • Specialty Scheduled• Complex Barrier Assessment

completed

Clinic (Primary/ Specialty_

• PCP/Specialist conference with RNCC

• RN call patient 48-72 hours post discharge and initiate clinical pathway for patients:

• Transplant• Oncology• HF

• RN CC attends Drappointment with the patient.

• RN call patient 48-72 hours post discharge.• RN visit with patient for post-discharge for

care management within 7 days of discharge.

• Review diagnosis• Focused physical assessment• RN initiate clinical pathway for

patients with high risk diagnosis: • Update and review care team• Social Services consultation• Update and provide care plan

• RN call patient 48-72 hours post discharge

• Targeted education• Add patient to patient panel/list

with scheduled follow-up outreach (may be completed via phone)

• Office visit with provider within 14 days post discharge

Homecare

• Visits daily for first 3 days• Enlist assist from Manager to reschedule all patient cancelled visits, or

refused services• Patient Rounds with Care Team within first week • SOC within 24 hours• Include all identified Disciplines in POC SN, PT, OT, ST, SW and HHA• Targeted consistency with staffing • Reschedule all patient cancelled visits• Medication Management including MTM and Mediation set up • Initiate Telemonitor

• Frontload visits at least 3 visits in first 7 days• Falls risk interventions

including Lifeline• Add SW / Verify Caregiver

Support• Verify PCP/Specialty Appts.

made / transportation• Initiate Stoplight Tool• Assess for Rehosp. Risks not

included in RAM score

“Discharge Planning Tool” Goal of Work

More Efficient Communication on Key patient discharge information from all key stakeholders to all (Efficiency)

System wide standardized best practice documentation expectations from Health Care Team (Quality)

Advantages

Adaptive Change for System (not entity specific)

IT build and goal of not having duplicate documentation

Barriers

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Discharge Planning ToolTool built into Electronic Health Record to capture most updated information from Healthcare treatment team for discharge planning

•Patient plan for D/C•Current status•Barriers to retain to prior living situation/rationale for D/C recommendation•Recommendations for D/C•Summary from each Therapy Specialty

Therapy Services

•Prior authorization requirements/formulary•Restrictions (provider/pharmacy, etc.)•Drug follow-ups (INR checks, abx levels, etc.)•Home med/TCU recommendations•Adherence concerns – (cost, formulary, knowledge, additional education)

Pharmacy

•Accomplishments needed for discharge•In nursing shift notes•Barriers (1:1, Foley, Central lines, Wound Care, BM•Ride informationNursing

•Expected discharge to (home/TCU/***) in *** days or living arranged Once ***•Not clinically improved•Message enter required specific goals hereHospitalist

•Date of expected discharge (MD source of truth)/ time and mode of transportation•Disposition and services needed•Barriers (e.g.financial)•Where we are in the planning process

RN/SW Care Coordinator

Quarterly Quality Connections

Metrics/ToolsMetrics/Tools

ObjectivesObjectives

ScopeScope

MembershipMembership

SNF/TCU Team• Administrator• Director of Nursing• Nurse Manager• Admissions• Nurse Practitioner

As Needed:Therapy ServicesPharmacyMedical Director

Hospital Team• Director of Care Transitions• Manager of Care Transitions• Medical Director and others

as needed

• Quarterly Readmission• ED visits• Observation Stays• Referrals

• Length of Stay• Avoidable Days • Best Practices

• Goal Plans for identified work• Process Improvement Plans• Root cause analysis and trend identification• What is going well and what can be improved

g y

• Chart Audit Tool• Reports• Readmissions• Utilization• Referrals• Length of Stay

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Transition Conferences

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Criteria for Transition Conference

• RAM Very High, Extreme• Unplanned Readmission of 30 days based on patient choice or

adherence concerns from patient and family • Avoidable days attributed to family or patient decision making • Multiple co-morbidities that could contribute to Post Hospital

Syndrome and impact healing at home • Complex discharge plan with multiple agencies or departments

that is dependent on adherence to multiple interventions • Patient or family refusing key interventions at discharge for

achieving health goals (pt/family may or may not agree to the conference if they are refusing other key interventions – need to know why they are refusing first, etc.)

Transition Conferences

• Very High and Extreme Patients- Identified by the RAM

• Meeting to determine the patients discharge goals, the patients families discharge goals and the health care teams goals (How can we make the patients wishes a safe reality)

MD (as needed)

Bedside RN

CTS RN/SW

Patient/Family

Post Acute Providers

Primary MD/Clinic Coordinator

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What is the difference between a

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Care Conference and Transition Conference

“Connect the Dots” SBAR Tool

• Prioritizes patient clinical need

• Standardized clinical assessment for all nurses

• Standardized clinical information provided to Providers

• Ease of Use for employee satisfaction

• Nurse brain to Doctor brain focus

• Decreased movement for patient

• Prioritizes patient clinical need

• Standardized clinical assessment for all nurses

• Standardized clinical information provided to Providers

• Ease of Use for employee satisfaction

• Nurse brain to Doctor brain focus

• Decreased movement for patient

Reasons for Declination of Referral

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Level of Care Tool “Guide”

HomeHomeOutpatient ServicesOutpatient Services

HomecareHomecare

LTACHLTACH

ARCARC

SNF/TCUSNF/TCU

Discharge Disposition Guidelines

• Assess for impairments that may impact self-care

• Assess level of independence or if there is a willing and able caregiver

Home

• Same as Home• Assess need for skilled home

care services for assessment, treatment, monitoring or education

• Set expectation that home care services are temporary and intermittent while skilled need exists

• Discuss reason for need and goals of care to be achieved with care team and patient

Home Care• Skilled Nursing Facility • Outpatient or home care services unavailable or

inappropriate due to clinical complexity • Patient or caregiver unable to manage care that is a

change from their baseline level• Cognitive limitation without appropriate support

• Communication deficit prevents learning care tasks• Memory deficit prevents managing care tasks• Perception or processing deficit

• Physical Limitation• Physically unable to render care (e.g. obese, wound

location, contractures, unable to lift patient)• Lacks dexterity, motor strength, or skills required to

manage care• Co-morbidity prevents management of care (e.g.

blindness, paralysis)• Medical practitioner oversight at least 1 time per week• Nursing daily or skilled therapy 1-2 hours per day at

least 5 days per week

(SNF)

Process for Disposition Decision

Step 1Determine Medical Plan needed for discharge (goals and medical needs)

Step 2Assess Barriers to dischargeAssess ability to mitigate barriers

Step 3Determine appropriate disposition to meet plan and goals

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Top Twenty Readmission Initiatives

1. Readmission Assessment Measure (RAM) Risk Scoring2. Evidence Based Workflows across the continue for each risk category

• Homecare• Inpatient• Outpatient• Geriatric Services• Therapy Services• DME Services

3. Communication Hand-offs to next level of care providers4. Aligned Care Coordination across the system5. Post Follow-up Calls triaged for Risk6. Extended time Follow –up Primary Care or Specialty Visits7. Aligned System work group for continuous process improvement8. Transition Conferences and Care Conferences9. Community Paramedic Program10. Medical and Behavioral Health Home Models11. Patient Activation Measure (PAM) Assessments 12. System Evidence Based Educational Materials13. Data tools to identify Risk areas within system within 48 hours14. Readmission Best Practice Alert in EPIC15. Pharmacy Medication Reconciliation at discharge for high-risk patients16. Medication Therapy Management (MTM) appointments and counseling17. Skilled Nursing Care Quality Improvement Quarterly Meetings18. Geriatric Services Triage Line19. Evidence Based Chart Audits to trend for optimization20. Evidence Based Readmission Assessment Root Cause analysis tool and summary data reports for

optimized quality improvement

Transitions

Fairview Care Continuumanalogy of a relay race is suggested, where success is influenced by four factors: sequence, timing, baton-passing technique, and communication. These four factors are used as a framework for professionals assisting the patient and their support system along the care continuum

The Place in between passing the baton to another person is the Hand-off or Transitions time

For the pieces to be put together for the patient and their support system the hand-off participants must know what the expectations are and convey to one another and the patient and who they are

handing off next in the rely

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Inpatient enrolling Patient in Clinic Care Coordination

Patients attend Follow-up appointments for high-risk patients

Triage Risk

Triage Risk

Assess Patient

Activation

Assess Patient

Activation

Assess BarriersAssess Barriers

GoalsGoals

ScheduleSchedule

Work with FacilitiesWork with Facilities

Sell the appointment

Sell the appointment

Audit and Improve

Audit and Improve

• Lifeline

• Assisted Living w/o Services

• Assisted Living w/Services

• Group Home

• FMG• Primary Care• Geriatric

Services• Complex Team• Integrated

Team

• UMP

• FPA

• TCU

• Assisted Living

• Acute Rehab

• LTACH

• Homecare

• Hospice

• Independent Residence

• Tele-Monitoring

• Private Pay Services

• Senior Services

• Care Coordination

• Parish Nursing

• County

• External

Communication across the Continuum Hand-off

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Transition Communications

Next Steps:1. Define impact tracking

1. How do we measure1. Readmission Impact2. Value add to patient care3. How do we tie “key

recommendations” to plan of care goals and next levels of the continuum

4. What are the workflows from Receiving and sending staff with hand-offs

5. Formulate Work-groups

Primary Care/

Specialty

Primary Care/

Specialty

Care Coordination

Care Coordination

Geriatric ServicesGeriatric Services HomecareHomecare

TCUs/ LTACHs/

ARUs

TCUs/ LTACHs/

ARUsMTMMTM

Areas ImpactedAreas Impacted

Standard Communication Hand-off

Building a Communication Hand-in ToolFor patients with cognitive deficits

What is the patient's normal morning routine (early rises, sleep in,

assistance needed, time they eat meals etc)

What is the patient's normal evening routine

Preferred bathing routine

Favorites:snack, beverage, music,

location to sit, stuff animal or other security

blanket, etc

Does the patient typically get up at night?

How often? Times?

What are stress inducers for the

patient?

What tactics do you use to calm or what soothes the patient? Or if they have

paranoia or delusions what can distract them? What

helps the patient/client calm down.

Who is important in the patient's life - who can

help in stressful moment? maybe have a video clip or picture to

pull out.

What assist do they need with ambulation

or cares?

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“Heads Up” to Homecare

Metrics/Tools

Fairview Health Network Readmission Tools

Discharge Planning

Tool

Continuum Hand-offs

Dashboard Qlikview

Optimization Meetings/

Root Cause Analysis

Readmission Assessment

Measure “RAM”

prioritization workflows

Transition Conferences

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Readmission Dashboard

• Develop a scalable level approach that is both effective and sustainable

• Focus on Readmissions that are avoidable• Identify areas of improvement to the discrete

level

Goal

• Team approach• Rapid Performance Improvement focused• Just in Time data that is actionableStrategy

• Which interventions have the greatest impact?

• What is the best timing for interventions?• Where is the intervention needed?• Where are the gaps for the patient needs?

Questions to Answer

Mock – Up of Post Continuum Qlikview

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Patient Transitional Care Continuum Model (Patient Centered) {APPLES to APPLES data}

Hospital Post-Acute Clinic Homecare Hospice

Services Provided (Utilization)

Psychosocial Physical

SNF/TCU

LTACH

Assisted Living

Psychosocial Physical

Psychosocial PhysicalPsychosocial Physical

Psychosocial Physical

• Each box or point of service is a perspective and place of service to the patient with a short-term goal based on criteria that sent them to that point of care which that place is responsible for until they transition the patient to the next level of care based on gaps identified in the assessment and outcome data from the assessment

• Each point of service has an aligned assessment criteria to document and track that includes both psycho-social and physical components to assess and identify needed services and goals to achieve in each area (e.g. no support system – referral to clinic or homecare to work with patient to identify a support system)

• The development of criteria and aligned assessment criteria builds a walk-way between each of the silos in healthcare so the patient visits the appropriate area and understands when they are transitioning to the next area.

• Benefits to aligned assessments and standardized criteria

Long Term Goal is patient goal and determines different services along the continuum – each point of care has a short-term goal to determine graduation or need from one point of service to another

• Support system

• Payer• Living

situation• Future needs• Quality goals• Support

needs

• Ambulation• Medications• Chronic

Conditions• DME current• DME needed• Pain• Cognition

Examples of Assessment Metrics

SAME ASSESSMENT QUESTIONS ALONG EACH POINT IN THE CONTINUUM

Supplies in the Suitcase

Discharge on the Double Reports Metrics tracking

Quality Improvement Meetings Outlier Escalation Process/Avoidable Day Tracking Discharge Criteria Tool Tours (in person/virtual) Scripting Communication SBAR Tool Readmission Chart Reviews Community Resources Tracking Patient Needs Assessment for Utilization/Barriers Patient Choice (STARS, location, word of mouth,

expectation) System Standardization for metrics tracking and

efficiency

Packing List for Outcomes