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!