Supporting Patient Transitions to Improve Client and Health System Outcomes: CCAC Rapid Response Nursing Program

Dilys Haughton RN(EC), BScN, PHC-NP, GNC(C), MHSc, CHE Director Client Services Operations and Professional Practice Lead Colleen Lackey RN, BScN Manager Client Services

Outstanding care – every person, every day

National Health Leadership Conference June 11, 2013

Overview

Objective

Learn about the provincial CCAC Rapid Response Nurse Program

• facilitates safe transitions from acute care to home, primary care provider, and community supports;

• Reduce hospital readmission rates

• Review lessons learned and key success factors

1. Project Background and Evidence

2. Overview of Provincial Rapid Response Nurse Program

3. Local Experience

4. Summary

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Background

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• Effective transitions between hospital and home are recognized as critical to achieving better patient outcomes and avoiding rehospitalisation.

• Many patients have sub-optimal experiences in care transition

between hospital and home/community care. Problems include: • Medication discrepancies • Confusion about post discharge care plans

• Hospital readmission rates for COPD / HF ~30%

• Risk of readmission is significantly lower when:

• 1st home care visit take place within 24 hours of discharge • Primary care visit occurs within 7 days of discharge

1Nurses in CCACs: Providing Care and Creating Connections Across Sectors, P. 4

RRNP -The Journey Ahead

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March 2013

RRNP Go LIVE

January 2013

Communication Plan Confirmed

Policy/Procedures Gaps Addressed

Documentation Processes Set

Training/Orientation Plan

RRNP Role Defined

Scheduling Model Set

Relationships Clarified

Common Equipment Determined

Intake/Screening Processes Defined

Stakeholder Engagement Planned

December 2012

November 2012

Goal & Objectives Refined

RRNP Model Developed

Target Pop/Eligibility Clarified

Recruitment Process Occurring

Work Streams Established

Provincial RRNP

Working Group Initiated

October 2012

Clinical Supervision Processes Set

Alignment with CCM Determined

February 2012

Ongoing Refinement of

RRNP Model

June 2013 & Onward

TBD

Funding Accountabilities Capabilities

Measurement & Reporting Processes Confirmed

BTS in Place

RRN Allocation by LHIN

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LHIN/CCAC RRN (Minimum # for Care of Complex Children)

Erie St. Clair 8 (1)

Southwest 13 (3)

Waterloo-Wellington 6 (1)

Hamilton Niagara Haldimand Brant

14 (2)

Central West 6 (1)

Mississauga Halton 7 (1)

Toronto Central 10 (2)

Central 10 (2)

Central East 11 (2)

South East 7 (1)

Champlain 11 (2)

North Simcoe Muskoka 5 (1)

North East 13 (3)

North West 5 (1)

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Evidence: Effective Transitions

Evidence to support care transitions and prevent hospital readmission (models and for specific diagnoses)

• Common elements from the literature include:

• In-home follow-up care (24-72 hours)

• Care coordination across transitions

• Medication management/reconciliation

• Patient education/empowerment (Coleman) or care management (Naylor)

• Patient-centered care

• Patient enabled with personal health record

• Follow-up with primary care provider

(Rich et al, 1995; Naylor et al., 1995; Coleman et al., 2006)

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Program Goals

• Reduce rehospitalization and avoidable emergency department visits by improving the quality of transition from acute care to home care for two population groups:

• Frail adults and seniors who are medically complex or have chronic diseases that tend towards frequent hospitalization, unstable health and costly treatments.

• Medically complex/vulnerable children, and their families

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Rapid Response Nurses

8

Home

Hospital

24 hours 7 days

Care

Coordinator

Rapid

Response

Nurse

Primary Care

Home/Community Care

Care Coordinators

Hospital

-Case finding

-Screening for eligibility

-Identify RRN involvement Pre D/C

-Collection of D/C information

-Overall Service Planning

-Service Ordering of RRN

-Consent for Tx

-Problem-based assessment using common tool

-Teach back approach to education

-Medication Reconciliation

-Confirm medical tests

-Update In-Home Health Record

-Linking with PCP

- Ongoing problem- based assessment to ensure client stable & safe

-Address ongoing medication issues

-Linking with PCP

-Contribute to Service Planning

-Joint visit/phone with CC and SP to transition care

Emergency Dept.

-

-Arrange PCP appointment if needed

-Update PCP about acute care event/ post D/C plan

-Share contact information

-Share problem based assessment & medication reconciliation

-Discharge from RRN Program

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Referral

Source Intake by Hospital CC

RRN

Visit

Follow-up

Care

Transition to

PCP/SP/Community CC

Target Population - Complex and Chronic Using CCM: • * Frail adults and seniors that are medically complex or have chronic diseases that tend

towards frequent hospitalization, unstable health and costly treatments, including: CHF,

COPD, Diabetes, Other Ambulatory Sensitive Conditions

• Medically complex/vulnerable children, and their families

Model of Care Discharge from

Hospital

24 Hours

7 Days

Integrated Care Transitioning from Hospital to PCP/Community Providers

LOS 2-3 weeks

RRN Role – Transitional Care • First visit within 24 hours at a time when caregiver

available

• Conduct clinical problem-based assessment

• Use “teach back” techniques to provide education about care plan, treatment, symptom management, and when/who to ask for help

• Perform medication reconciliation

• Confirm and arrange for follow-up tests

• Follow-up visit/phone call to provide further assessment or address ongoing medication issues

• Arrange follow-up appointment with primary care within 7 days of hospital discharge

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Client Care Model

Key Performance Indicators Client Information

• Number / % of patients served (by type/profile children, adults, seniors; by ambulatory sensitive condition*)

Access • # of visits; average number of visits per patient • Average Length of Stay • Number / % of in-home visits within 24 hours of hospital discharge* • Reason for not receiving service

Health System Impact / Cost Effectiveness • Number / % of emergency visits within 30 days* • Number / % of hospital re-admissions in 30 days* • Number / % of primary care appointments within 1 week of hospital discharge*

Quality Measures

• Patient / informal caregiver experience & Provider Experience –overall satisfied with transition care, perception of care connections and integration(TBD)*

Health System Outcomes

• Measure of physician engagement - contacts between RRN and PCP*

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Learnings from Local Implementation

HNHB CCAC: Overview

HNHB CCAC

• Hamilton, Niagara, Haldimand Norfolk, Brant, Burlington

• HNHB LHIN has 11% of Ontario population

• Older than average population

• CCAC70,000 patients / year

• 10 hospital corporations, 21 hospital sites

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Implementation

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January to March 2012: Design and implementation in 2 branches (Hamilton and Burlington) April to June 2012: Implemented a consultant pharmacy programme July to September 2012: Spread programme across the LHIN (Haldimand Norfolk, Brant and Niagara) October to December 2012: Full implementation of Adult Rapid Response Programme Consolidated clinical programme infrastructure (e.g. P and Ps) January 2013 ongoing: Partnered with hospital Bundled Transitions Project test of change Developing Paediatric focus of intervention Knowledge transfer

Patient Story: Improving the Transition

Mr. J. was in hospital for 9 months following a stoke and was discharged home. He requiring total care and was awaiting a move into Long Term Care.

PMHx: Longstanding epilepsy, osteoarthritis, osteoporosis - experiencing fracture of the hip and wrist, depression, non insulin dependent diabetes, indwelling by catheter. Recent UTI x 3 with the onset of delirium.

• No primary care provider visits in the last 6 years.

Issue: Patient is sleeping 23 hours / day. Why: Drug toxicity? Infection? Blood sugars? Pneumonia? UTI? Narcotic influence? Depression?

Key success factors: Access to hospital information (clinical connect); collaboration with primary care (blood work / CXR); consultation with pharmacist

Outcome: The patient woke up! Up in the chair 5 – 6 hours / day. Socializing with others. Able to moving successfully to Long Term Care.

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Patient Characteristics: Diagnoses

• ~25% HF / heart related disorders

• ~25% COPD

• ~25% geriatric giants (e.g. pain, cognition, continence, mobility, falls)

• Most patients have multiple conditions, and multiple physicians involved

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Patient Characteristics: Care Requirements

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0

50

100

150

200

250

300

MAPLe 1 MAPLe 2 MAPLe 3 MAPLe 4 MAPLe 5

MAPLe Score by Age Group

75+

0 - 74

• MAPLe is a subset of the RAI HC instrument

• Measures ability to care for self / care requirements

• 47% patients could move into LTC (MAPLe 4,5)

• Another 35% are at the “tipping point”

• 18% of RRTT patients have an active placement file

Patient Characteristics: Medical Complexity

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0

50

100

150

200

250

300

350

400

450

CHESS 0 CHESS 1 CHESS 2 CHESS 3 CHESS 4 CHESS 5

Patients by CHESS Score (N=1315) • CHESS is a subscale of the RAI HC instrument

• Measures medical frailty

• Higher CHESS, lower life expectancy

• 66% patients have CHESS >2

• 30.4% patients >3

Performance Metrics: 2012 – 2013

Performance Output Indicator Actuals

# of new hospital patients discharged home to CCAC RRTT program

911 (60.9%)

# of existing CCAC patients referred to CCAC RRTT program

584 (39.1%)

% of high risk patients from hospital that require readmission within 7 days of discharge (81 of 911 patients)

8.9

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Hospital Readmissions

22

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

% R

ead

mis

sio

n

RRTT 7 Day Readmission Rate

Avg hospital readmission rate 8.9%

Hospital Readmissions

Hospital readmissions within 7 days

• N = 81 (8.9%)

• 82% > age 70

• 63% patients have CHESS >2

• 72% patients have MAPLe >3

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0

5

10

15

20

25

30

<50 51-60 61-70 71-80 81-90 91-100 >100

Patients Readmitted to Hospital by Age (N=81)

Key Learnings

• Bridging the patient to home is an effective strategy to reduce hospital readmission rate

• Programme supports integration of patient care across sectors (hospital / home care / primary care)

• Hospital engagement is required at the front line, middle and upper management levels

• Identification / hospital screening for risk is important: need appropriate hospital risk screening process

• Local test of change showed all medical patients at risk of readmission using LACE screening tool. Hospitals across the LHIN will implement a Bundled Transitions Project using teach back techniques to further screen patients

• Timely transfer of accurate information such as medication lists and in-hospital record of care is important

• Medication lists, in-hospital record of care.

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Key Learnings

• Focus on specific populations will focus efforts and help reduce hospital readmission (e.g. HF)

• About half of all patients have diagnosis of COPD or HF.

• Many patients have multiple diagnoses and multiple physicians involved – who is ‘in charge’?

• Patients often become disconnected from their primary care physicians: making the connection is important but can be challenging (physicians away, may not know the patients well). Number of orphaned patients is small

• Medication management is a key strategy

• Data collection across sectors is important to determine impact of programme on readmission rate

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Outstanding care – every person, every day