Collaborating with Community Nursing Homes to Improve
Transitions and CarePatrick Schultz, MS, RN, ACNS-BC
Director of Quality and Patient SafetySanford Medical Center Fargo, ND
Roadmap
• Who We Are• What Drove Us• What We Did• Where We’re At• Where We’re Going
Who We Are
Serving 2.3 million people 27,000 employees including 1,400 physicians 43 hospitals 45 long-term care facilities 243 clinic sites 92,000 health plan members in four states $3.2 billion in annual net operating revenue
Sanford Health
Barney
What Drove Us
Drivers
• Readmission Reduction Program– Began October 1, 2012
• Professional Practice Review (Peer)• Medicare Spending per Beneficiary• Sepsis Measure
Readmission Reduction ProgramFFY 2017 Readmission Reduction Program
Diagnoses Discharge Dates Payment ImpactAMIHFPNCOPDTHA/TKAIsolated CABG
July 1, 2012 through June 30, 2015
3%
Professional Practice ReviewCaregivers of HF Patients Can Have Unrealistic Hopes for Prognosis –Steve Stiles, September 28, 2015
More often than not, family members caring for loved ones with advanced heart failure don't understand how serious the disease is, have unrealistic expectations about the patient's chances for survival, and even may be looking forward to recovery, suggests a study based on interviews of 80 such caregivers.
http://www.medscape.com/viewarticle/851630
Medicare Spending per Beneficiary
• Value Based Purchasing– Began October 2012– An MSPB Episode includes all claims between 3
days prior to index admission to 30 days after the hospital discharge
Sepsis
• Sepsis as an Inpatient Quality Reporting measure– 10/01/15 – 06/30/16 Discharges
Proposed Measure
Dry Run/
Voluntary
Pay for Reporting/
Penalty for not
Reporting
Public Reporting
Pay for Performance
Focus
•
What We Did
One Care for Seniors
• Started 09/2011• Purposes– Improve transitions from hospital to nursing homes– Reduce readmissions from nursing homes to hospital
Call for Partners
• Bethany—288 Skilled Nursing beds• Eventide—260 Skilled Nursing beds• Elim—136 Skilled Nursing beds
One Care for Seniors
• New leadership 1/2013• Expanded work– Advance Care Planning– Heart Failure, Sepsis, Renal Failure
Challenges
• How to measure readmission? • How to measure advance care plan use?• How to know transitions went well?
Overcoming Challenges
• How to measure readmission?– First try: Hired PhD part time to collect data – Next: Epic report with discharge destination
triggers when a patient returns to Sanford within 30 days (dependent on proper entry)
Overcoming Challenges
• How to measure advance care plan use? – Epic report includes presence or absence of
Advance Care Directive
Overcoming Challenges
• How to know transitions went well?– Monthly meetings 0700– HF mismatches– ACPs not entered– NP issues– Xrays done in the nursing homes– Connection with Director of Quality
Overcoming Challenges
• Added a Partner—QIO – CMS Data Reports
Home
Interventions
• One call back phone number for questions• EpicCare Link• Interventions to Reduce Acute Care Transfers
(INTERACT) tools https://interact2.net/index.aspx
• Increased Nursing Home capabilities
EpicCare Link: Access to EMR
• EpicCare Link is Epic’s web-based application for connecting organizations to their community affiliates.
INTERACT: Care Paths
INTERACT: Care Paths
INTERACT: QI Tool
INTERACT: Advance Care Planning
INTERACT: Communication
INTERACT: NH Capabilities
Traveling Dentist
Heart Failure Actions
• Education– CNS and NP sessions for partners– Expanded to 5 teleconference sites which reached
87 rural nursing home workers– Weigh daily (dehydration a problem also)– IV diuretics and IV fluids
Risk?
Sepsis Actions
• Education– CNS presentation to combined group – UTI antibiotic stewardship program (symptomatic
with UC+)– Emphasis on INTERACT Care Paths– Discussion with providers regarding trusting Xray
Advance Care Planning Actions
• ACP education for all Nursing Homes• Increased number of facilitators• Created HF referral for ACP for all NYHF Class
III & IV• Added NYHF Class to order sets
Where We’re At
Heart Failure Data
• Private data
Sepsis Data
• Private data
Acute Renal Failure Data
• Private data
Advance Care Planning Data
• Private data
Mellow
Where We’re Going
SIM-ND
SIM-NDTraining for Nurses and Unlicensed Personnel
• Geriatric MI in LTC “There is an elephant on my chest” - • Geriatric CVA in LTC “What about the droop”? • Geriatric DVT/PE in LTC “My leg hurts” • Geriatric GI Bleed “It won’t stop” • Geriatric HF in LTC “Why are my ankles so fat?” • Geriatric Progressive from Admit to Fall in LTC “I need the bathroom” • Geriatric UTI in LTC “What day is it again?”
Telemedicine
• Partners have all put telemedicine into their budgets
• Challenge: CMS payment only for a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract
Next Steps
• ACP for COPD• State of ND following WI and MN lead• HF education and expectations to RN Health
Coaches and Provider Panel Specialists in our clinics
• Palliative care clinic (may change name)
No Readmission/ACP in place!