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A Community-Based Approach to prevent hospital readmissions Brainerd Community Team: • • • Janelle A Community-Based Approach to prevent hospital readmissions Brainerd Community Team: • • • Janelle Shearer, BSN, MA, CPHQ, Program Manager, Stratis Health Kathryn R. Miller, RN, BS, G-L C, Director Quality and Safety, Essentia Health St. Joseph’s Medical Center Gayle Nielsen, MSN, RN Care Coordinator, Essentia Health Clinics, Central Region Marie Michlitsch, RN, Director of Nursing, Good Samaritan Society - Woodland Deanna Abramson, RN, Assisted Living Manager, Good Samaritan Society - Woodland Kayla Farr, RN, Good Samaritan Society, Home Care & Hospice January 8, 2014

A Community-Based Approach to Prevent Hospital Readmissions RARE Webinar – January 8, 2014, noon A Community-Based Approach to Prevent Hospital Readmissions RARE Webinar – January 8, 2014, noon – 1 p. m. Janelle Shearer, RN, BSN, MA Program Manager Stratis Health

Session Goals • Describe a community-based approach to improve coordination between settings of care Session Goals • Describe a community-based approach to improve coordination between settings of care • Identify how to collaborate with other organizations to improve care transitions • Identify best practices you can implement to reduce avoidable hospital readmissions

Who is Stratis Health? • Independent, nonprofit, facilitating improvement for people and communities • Who is Stratis Health? • Independent, nonprofit, facilitating improvement for people and communities • Funded by federal and state contracts, corporate and foundation grants • Medicare Quality Improvement Organization (QIO) for Minnesota • Focus areas include rural health, health information technology, patient safety, cultural competence, and long-term care

Current Medicare QIO Work 1. Beneficiary and Family Centered Care 2. Improving Individual Patient Current Medicare QIO Work 1. Beneficiary and Family Centered Care 2. Improving Individual Patient care 3. Integrating Care for Populations and Communities – Improving Care Transitions Leading to the Reduction of Readmissions • Improving Transitions of Care – community-based approach • RARE Campaign 4. Improving Health for Populations and Communities

Duluth Brainerd North Metro Duluth Brainerd North Metro

The Community Providers across the continuum of care – – – – Acute care The Community Providers across the continuum of care – – – – Acute care hospitals Clinics Home health/hospice organizations Long-term care facilities Assisted living facilities Local public health departments Patients and/or patient advocates Other community partners

Community-Based Approach • Each organization conducted root cause analysis to identify gaps in care Community-Based Approach • Each organization conducted root cause analysis to identify gaps in care related to transitions of care and readmissions • Identified community needs and resources • Identified best practice interventions to improve the gaps

The Brainerd Area Community Story The Brainerd Area Community Story

Partnering to Prevent Avoidable Readmissions Essentia Health St. Joseph’s Medical Center Kathryn R. Miller, Partnering to Prevent Avoidable Readmissions Essentia Health St. Joseph’s Medical Center Kathryn R. Miller, RN, BS, G-L C Director Quality and Safety

Essentia Health St. Joseph’s • Type of provider-Acute care 162 bed full service JCAHO Essentia Health St. Joseph’s • Type of provider-Acute care 162 bed full service JCAHO accredited hospital (exceptions: Cardiac and Neuro surgery) with on site Cath Lab • Central Minnesota-Brainerd Lakes area • Staff composition RN and CNA teams • ICU, Telemetry, Medical, Surgical, Mental Health and Chemical Dependency Units • EH is one of the first two organizations in the country (Essentia and Health. Partners) to attain highest level of recognition as an Accountable Care Organization (ACO) by NCQA

Issue/Problem • Needed to look at those diagnoses that had high readmission rates, particularly Issue/Problem • Needed to look at those diagnoses that had high readmission rates, particularly the Heart Failure population

Main Areas of Focus • Developed an Interdisciplinary team that met monthly • Initiated Main Areas of Focus • Developed an Interdisciplinary team that met monthly • Initiated f/u telephone calls in 24 -48 hours • Developed a system for all d/c patients to be seen by PCP within 5 days of discharge

Development of Transitions Subgroup • Intensive effort to work in a small group setting Development of Transitions Subgroup • Intensive effort to work in a small group setting with key community members (nursing homes, home care, etc. ) • Identified barriers to a smooth transition: – i. e. Lack of; incomplete documentation (MAR) SOLUTIONS: • Worked with our IT department to allow the nursing homes view only access to our EMR (Electronic Medical Record-Epic) • Educated hospitalists on tying diagnosis with medication ordered on discharge

Results • We have begun to see a downward trend in our readmission rates Results • We have begun to see a downward trend in our readmission rates for Heart Failure, COPD and Pneumonia patient populations • Work still needs to be done on: • 1) Pharmacist reviewing medications with all patients at the time of discharge • 2) Continued work on formation of a Palliative Care Team to address end of life/quality of life issues with patients and their families

Contact Information Kathy Miller RN, BS, G-L C Director Quality and Safety Essentia Health Contact Information Kathy Miller RN, BS, G-L C Director Quality and Safety Essentia Health Central Region St. Joseph’s Medical Center 523 North Third Street Brainerd, MN. 56401 Email: kathryn. [email protected] org (218) 828 -7435

Good Samaritan Society Bethany, Pine River and Woodland Marie Michlitsch, RN Good Samaritan Society Bethany, Pine River and Woodland Marie Michlitsch, RN

Good Samaritan Communities of Brainerd and Pine River • Woodland has 41 Care Center Good Samaritan Communities of Brainerd and Pine River • Woodland has 41 Care Center residents. Roughly 25% are on a short term stay for rehab. • Bethany has 124 residents. There is a subacute unit with capacity for 40 resident’s on this campus. Roughly 25% of the campus is short term subacute residents. • Whispering Pines in Pine River has 56 residents with roughly 20% residents on a short term stay.

Issue/Problem • Noted increase in hospital readmissions within 100 days. • Highest rate of Issue/Problem • Noted increase in hospital readmissions within 100 days. • Highest rate of readmission noted to be 6%. • Increased cost with the readmissions to the hospital. • Increased resident and family stress and depression with readmissions to the hospital.

Success Strategy 1 • Noted problem with diagnosis listed on discharge orders. • Staff Success Strategy 1 • Noted problem with diagnosis listed on discharge orders. • Staff unaware of off label use of medications unable to properly educate residents on medication use. • Worked with the hospital on obtaining diagnosis for medications. • Barriers noted with working with computerized charting systems.

Success Strategy 1 • Hospital worked on obtaining access to their computer system for Success Strategy 1 • Hospital worked on obtaining access to their computer system for Care Center Staff. • Care Center staff will have ability to review records from the hospital to ensure quality of continuum of care for the residents. - This is a work in progress and all staff are thrilled to have the ability to review residents records to ensure quality care.

Tools • Physicians Orders for Life Sustaining Treatment. – Five staff trained as Advanced Tools • Physicians Orders for Life Sustaining Treatment. – Five staff trained as Advanced Care Planning Facilitators. • INTERACT tools utilized for nursing staff included the following: – Care paths for resident condition changes. – Acute change in condition file cards available to all nurses. – Stop and Watch forms utilized for early detection of changes in condition. – SBAR - Situation Background Assessment or Appearance Request forms utilized in Point Click Care. – Designated staff audits all hospital admissions and Emergency Room visits to determine if potentially preventable. Education occurs as needed if determined potentially preventable. – INTERACT website: http: //interact 2. net/

Care Paths • • • CHF UTI Pneumonia AMSC Fever Dehydration 23 Care Paths • • • CHF UTI Pneumonia AMSC Fever Dehydration 23

Change in Condition: When to report to the MD/NP/PA Immediate Notification: Any symptom, sign Change in Condition: When to report to the MD/NP/PA Immediate Notification: Any symptom, sign or apparent discomfort that is: 1. Sudden in onset 2. A marked change (i. e. more severe) in relation to usual symptoms and signs 3. Unrelieved by measures already prescribed This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 8 SOW-GA-NH-08 -37 Sources: AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. Mc. Graw-Hill, 1996 When to report to the MD/NP/PA Change in Condition: © 2010. Florida Atlantic University 24

Vital Signs (Report Why Vital Signs Were Taken) Vital Sign Blood Pressure Pulse Respiratory Vital Signs (Report Why Vital Signs Were Taken) Vital Sign Blood Pressure Pulse Respiratory Rate Weight Loss Report Immediately • Systolic BP > 210 mm. Hg, < 90 mm. Hg • Diastolic BP >115 mm. Hg • Resting pulse > 130 bpm, < 55 bpm, or >110 bpm and patient has dyspnea or palpitations • Respirations > 28, < 10/minute • Oral (electric thermometer) temperature > 101 F Report on Next Work Day • Diastolic BP routinely > 90 mm. Hg • Resting pulse >120 bpm on repeat exam • New Onset of anorexia with or without weight loss • 5% or more within 30 days • 10% or more within 6 months © 2010. Florida Atlantic University 25

EARLY WARNING TOOL “Stop and Watch” If you have identified an important change while EARLY WARNING TOOL “Stop and Watch” If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Name of Resident _______________ Seems different than usual Talks or communicates less than usual Overall needs more help than usual Participated in activities less than usual Ate less than usual (Not because of dislike of food) N Drank less than usual Weight change Agitated or nervous more than usual Tired, weak, confused, or drowsy Change in skin color or condition Help with walking, transferring, toileting more than usual Staff_________________________ Reported to ______________________ Date _____ / ____ Time ________ © 2010. Florida Atlantic University Adapted from Boockvar et al. , J Am Geriatr Soc 48: 1086 (2000) 26

SBAR Structured and standardized communication format between health care workers. S=Situation (a concise statement SBAR Structured and standardized communication format between health care workers. S=Situation (a concise statement of the problem) B=Background (pertinent and brief information related to the situation) A=Assessment (analysis and considerations of options — what you found/think) R=Recommendation (action requested/recommended — what you want) 27

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Results • Noted decline in preventable hospital readmissions. • Noted increase in changes in Results • Noted decline in preventable hospital readmissions. • Noted increase in changes in orders prior to admissions to the hospital in attempt to prevent hospital admission.

Contact Information Marie Michlitsch RN Director of Nursing Good Samaritan Society Woodland 100 Buffalo Contact Information Marie Michlitsch RN Director of Nursing Good Samaritan Society Woodland 100 Buffalo Hills Lane Brainerd, MN 56401 [email protected] com (218)855 -6601

Good Samaritan Society Assisted Living Bethany, Pine River, Woodland Deanna Abramson Assisted Living RN Good Samaritan Society Assisted Living Bethany, Pine River, Woodland Deanna Abramson Assisted Living RN Manager Woodland Campus

Bethany and Pine River Campuses Bethany • In Brainerd • 37 Senior Living Apartments Bethany and Pine River Campuses Bethany • In Brainerd • 37 Senior Living Apartments • 20 -25 residents on A/L services • • Pine River In Pine River 36 Senior Living Apartments Recently added A/L services 1 Cottage Style House with 16 higher level A/L

Good Samaritan Society Woodland Senior Living Apartments & Samaritan Houses • Good Samaritan Society Good Samaritan Society Woodland Senior Living Apartments & Samaritan Houses • Good Samaritan Society Woodland Campus in Brainerd MN • Senior Housing- Apartments with Assisted Living and Cottage Style Units for Higher Level Assisted Living & Memory Care • Apartments- average 70 A/L residents (128 total Apartments), 16 beds A/L in Cottage Style, & 32 beds Memory Care • Universal Workers (NARs) 5 RNs & 3 LPNs

Issues/ Challenges • Admitting Residents with higher level of care needs • Limited amount Issues/ Challenges • Admitting Residents with higher level of care needs • Limited amount of Licensed Staff in our buildings to assess and monitor the resident’s health issues. • Many times A/L staff not making the decisions for residents going to ED (residents / families) • Hospital staff & Physicians unaware of the limitations the Assisted Living settings in meeting resident’s health/ care needs

Goal or Aim • We want to give our Assisted Living residents the best Goal or Aim • We want to give our Assisted Living residents the best nursing care that we can possible • To decrease the ED visits and the hospitalizations for our residents. • If possible we want to catch as many symptoms as necessary to alleviate the stress and discomfort of sending the resident into ED. • Build communication and trust with local providers to give the residents a smooth transition when hospitalized and/or transferred back to home.

Stop & Watch Forms Catch changes in condition early Empower our staff to bring Stop & Watch Forms Catch changes in condition early Empower our staff to bring up issues to Nursing Staff All staff/All departments are educated. Easy access to forms Get away from writing notes on all types of pieces of paper Education during our annual staff training Staff needs follow up & feedback At this point we haven’t seen too many utilized- oncoming reinforcement • Challenge when have some residents who refuse to be seen by their Physician • •

Pilot to develop and begin tracking Assisted Living Resident’s hospitalizations & re-hospitalization • Look Pilot to develop and begin tracking Assisted Living Resident’s hospitalizations & re-hospitalization • Look for trends and to look for ways to decrease some of our ED visits and hospitalizations; • Be part of our QI/QA process that will be required with our new Comprehensive License • Using a tracking form and a Data sheet & QI form • Need to get all staff to see importance of tracking & ways for reduction. • Have data to show results • Can be used for Marketing reasons, that if your facility can show the data that they have fewer ED visits the hospital and other would recommend your facility to the potential residents

Deanna Abramson Good Samaritan Society Woodland RN Assisted Living dabramso@good-sam. com 218 -855 -6632 Deanna Abramson Good Samaritan Society Woodland RN Assisted Living [email protected] com 218 -855 -6632

Essentia Health Clinics Central Region Gayle Nielsen, MSN, RN Care Coordinator Essentia Health Clinics Central Region Gayle Nielsen, MSN, RN Care Coordinator

St. Joseph’s-Essentia Clinics Baxter, Brainerd, Crosslake, Hackensack, Pequot Lakes, Pierz, Pillager, Pine River St. Joseph’s-Essentia Clinics Baxter, Brainerd, Crosslake, Hackensack, Pequot Lakes, Pierz, Pillager, Pine River

Appointments • In-patient and ED Ward Clerks are now able to make visit appointments Appointments • In-patient and ED Ward Clerks are now able to make visit appointments – Within 5 days for high-risk readmissions • Reserved anywhere from 0 to 4 slots daily for Same Day Visits. – Released 5 p. m. the evening before or 8 a. m. day of • Reserved 0 -2 slots a week for Hospital Follow-up visits – Released 24 hours before

Baxter Clinic/Long Term Care • Long term care leadership came to a Baxter Clinic Baxter Clinic/Long Term Care • Long term care leadership came to a Baxter Clinic Department meeting for faceto-face discussion • Doctors and nurses from the clinic attend • Medication lists • Orders

Care Coordination Program Goal: Triple Aim: Improve Quality Improve Patient Satisfaction Reduce Cost Care Coordination Program Goal: Triple Aim: Improve Quality Improve Patient Satisfaction Reduce Cost

Role of the RN Care Coordinator Program Goal #1 Improve Quality • Regular contact, Role of the RN Care Coordinator Program Goal #1 Improve Quality • Regular contact, with one individual • Pre-visit calls to “package the visit” for PCP Updates from specialists visits Changes in function/ clinical condition Patient’s agenda • Self management support, patient education • Management of care transitions – post discharge, ER visits, other events

Role of the RN Care Coordinator Program Goal #2 Patient Satisfaction – Develop Care Role of the RN Care Coordinator Program Goal #2 Patient Satisfaction – Develop Care Plan with patient and family • One stop summary of all problems, meds, instructions, plans • Identify patient’s personal goals and match them with the medical plan – One trusted person to call when urgent matters arise – Advocate and system navigator

Role of the RN Care Coordinator Program Goal #3 Reduce the total cost of Role of the RN Care Coordinator Program Goal #3 Reduce the total cost of care – Prevent hospitalizations • Improve patient and family understanding of the plan • Attentive follow-up • Arrange appropriate home support – Prevent unnecessary ER Use • Create a “Primary Care Home” • Emergency plan of care – what to do when…

Referral Criteria (At Least 1 of the identified) • Regular Care with 3 or Referral Criteria (At Least 1 of the identified) • Regular Care with 3 or more sub specialists for significant medical conditions • >3 Hospital readmissions in 6 months • Greater than 3 ER visits within 6 months • Greater than 4 points noted on Risk Stratification Tool • Threats to self care ability identified by RNCC (inadequate support, financial barriers, impaired medical literacy, language barrier) • 2 or more chronic conditions identified on problem list (outside of quality targets).

General Information about our Program • • Two RN Care Coordinators Eight Clinics 33 General Information about our Program • • Two RN Care Coordinators Eight Clinics 33 Practitioners Total Number Patients Enrolled: 102 62 Female, 40 Male 73% of patients are Medicare 22% Medical Assistance ACO-BCBS and Medica

Readmission Data July 1 - August 1, 2013 • • • 35 discharges involving Readmission Data July 1 - August 1, 2013 • • • 35 discharges involving 31 patients One Care Coordination Patients 9 readmissions involving 5 patients None of them were Care Coordination Patients Three patients had two readmissions each-one of them is deceased and one on hospice

13 Care Coordination Patients Six months before enrollment • 13 ED visits • 13 13 Care Coordination Patients Six months before enrollment • 13 ED visits • 13 Hospital Admissions Six months after enrollment • 4 ED visits • 8 Hospital Admission • 69% reduction in ED visits • 61% reduction in Hospital Admissions

Contact Information Gayle Nielsen, MSN, RN Coordinator Essentia Clinics Email: gayle. nielsen@essentiahealth. org 218 Contact Information Gayle Nielsen, MSN, RN Coordinator Essentia Clinics Email: gayle. [email protected] org 218 -454 -5967

Good Samaritan Society Home Care & Hospice Kayla Farr, RN Director Good Samaritan Society Home Care & Hospice Kayla Farr, RN Director

Good Samaritan • Home Care • Hospice • Avg daily census • HC- 72 Good Samaritan • Home Care • Hospice • Avg daily census • HC- 72 • Hos-14

Location • Located in Nisswa, MN • Coverage area within 45 miles from the Location • Located in Nisswa, MN • Coverage area within 45 miles from the office, remote locations we utilize telemedicine. • We have nursing divided for both service lines.

Concerns • Return hospitalizations • Notification from our home care patients of going into Concerns • Return hospitalizations • Notification from our home care patients of going into the hospital • “Repeat offenders” • Tracking of telehealth patients who go into the hospital.

Goal • Reduction of our hospitalization rate • Collaboration effort between providers • Increase Goal • Reduction of our hospitalization rate • Collaboration effort between providers • Increase disease management for our patients.

Success Story • Identification of our hospitalizations – Who/Why – Stratis Health – Acute Success Story • Identification of our hospitalizations – Who/Why – Stratis Health – Acute Care Transfer Log (INTERACT tool) modified. – Increase team awareness: • Hospital • Home Care • Hospice

Challenges • Acknowledgment of issues that need to be addressed. • How to stay Challenges • Acknowledgment of issues that need to be addressed. • How to stay focused on the collaboration for the “patient” versus feelings of “pointing fingers”. • Getting team members to “attend” to a after hours call.

Contact Information Kayla Farr, Director Good Samaritan Society Home Care & Hospice kfarr@good-sam. com Contact Information Kayla Farr, Director Good Samaritan Society Home Care & Hospice [email protected] com 218 -963 -9452

Q&A Q&A

Contact Janelle Shearer, MA, BSN, RN 952 -853 -8553 or 877 -787 -2847 jshearer@stratishealth. Contact Janelle Shearer, MA, BSN, RN 952 -853 -8553 or 877 -787 -2847 [email protected]alth. org

Stratis Health is a nonprofit organization that leads collaboration and innovation in health care Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities. Prepared by Stratis Health, the Medicare Quality Improvement Organization for Minnesota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U. S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10 SOW-MN-C 8 -14 -42 010214

Upcoming RARE Events…. Stay tuned for the next RARE Webinar… Team Care for the Upcoming RARE Events…. Stay tuned for the next RARE Webinar… Team Care for the Chronic Disease Patients: Using lay “Care Guides” February 21, 2014 (1 -2 p. m. )

Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Future webinars… To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact Kathy Cummings, [email protected] org