Confidential to Stanford Hospital and Clinics

A Nurse-Led Multidisciplinary Team Approach to Improving Heart

Failure Patient Transitions and Reducing

Readmissions

Christine Thompson, MS RN CNS CCRN CHFNCharlene Kell, EMBA RN BSN CCRN

Research Days - South San Francisco 22 October 2014

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Reducing avoidable readmissions of heart failure patients on the national agenda• Heart failure (HF) currently affects 6.5 million adults in the US• Prevalence of HF projected to increase by 25% by 2030• Hospitalizations are responsible for the majority of $39 billion spent

annually for HF care• The Centers for Medicare & Medicaid Services (CMS) has mandated

reporting of hospital-level 30-day readmission rates for HF, acute myocardial infarction, PNA (now inclusive of other diagnoses)

• CMS penalties initiated Oct 2012

Journal of the American College of Cardiology Vol. 60, No. 7, 2012© 2012 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.03.066

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Acknowledgement

• Two year grant focused on reducing HF readmissions (2012-2014)

• Triad leadership structure– MD, Administrator,

CNS• Partnership with local

clinic (PAMF)

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Primary HF Patient Readmissions – where we were . . .

Baseline Data – CY 2011

475

93

148

3313

0

50

100

150

200

250

300

350

400

450

500

DischargedPatients

30- DayReadmissions

90-DayReadmissions

90-Day ERUtliization

90-DayObservation Stay

Primary HF Patients

# Patients (2011)

Goals: • Reduce 30-day readmissions by 30%• Reduce 90-day • readmissions by 15%

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Using Clinical Effectiveness framework to ensure sustainable outcomes…

Physicians Nurses Pharmacists Dieticians RespiratoryTherapists

Social Workers

Case Managers

Our patientswill be supportedby…

…a multidisciplinarycare team…

PatientAdvisors

PerformanceExcellence

ClinicalInformatics HIMS Coding Clinical

Bus AnalyticsAging Adult

Services Quality…whose work isshaped by a cross-functional SHC team…

…and supported by theCardiovascular Data Mart thatprovides the “singlesource of truth” data

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Heart Failure Interventions: A LEAN-based Approach

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Redesign of HF Patient Transitions of Care: Interventions

• HF CNS Consult Order• Risk assessment and flagging high-risk patient in EPIC• Medication reconciliation processes

redesigned, including MD workflows; enhanced medication education

• Enhanced patient/caregiver education using teach back

• Follow up appointments made prior to discharge

• Post-discharge phone follow up with template integration into EHR

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Care Transitions: Community Stakeholder Meetings to Develop Standards for Skilled Nursing Facilities and Home Health

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Readmission Metrics from Electronic Health Record to HF Dashboard

Current filter selections displayed here

Individual or multiple rules can be selected to filter the patient cohort

Current State displays 30 days readmit rate, 90 days readmit rate, and Balance measures for last 30

and 90 days

Actual discharge and readmit counts for the rates are displayed below the gauge

Filter dashboard

view by unit, age

etc.

Readmission Trending Chart

compares last 30 and 90 days rate

to previous months, quarters

or year

Trending Chart toggles between readmission rate and patient readmit count

The Bar Charts compare the Index Admission Length Of Stay to Readmit Length Of Stay and the Days to Readmit

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Collaboration: Promoting Nurse as Educator

– Two hour workshops on health literacy and teach back for staff on three key patient care units

– Creation of video• Nursing Education website• Stanford YouTube

– Incorporation of teach back into unit orientation

– Spread to multidisciplines, inpatient & outpatient

– Documentation in EMR & tracked on Dashboard

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Teach Back on the HF Dashboard

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Collaboration: Medication Safety

• Improved Medication Reconciliation processes on Admission and Discharge

• An accurate, understandable medication list at discharge

• Pharm Techs in ED to assist with creating current med list

• New Transitions of Care Pharmacist role implemented, 7 days/week for HF & complex Medicine patients

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Redesign of HF Educational Materials

• Multidisciplinary; patient reviewed

• Updated & synchronized inpatient/outpatient materials

• Multilingual• Hardcopy materials & SHC

website

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Communication

• Monthly “What’s New in Heart Failure Care” newsletter e-mailed to staff

• Monthly multidisciplinary Heart Failure Operations Team meetings with community partners

• Weekly Heart Failure Clinical Effectiveness Council meetings (HF CEC)

• Use of HF Dashboard for “Active Daily Management” on patient care units

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Collaboration: Community Outreach

• Aging Adult Services partnership home visits– Home monitoring pilot

• Patient Partners (P2) with Stanford School of Medicine (in-home health coaching)

• Skilled Nursing Staff education on HF patient assessment, care, and patient family education

• Quarterly roundtables with SNFs and Home Health providers

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Patient Engagement in our Heart Failure Program

• Two committed volunteers for our Heart Failure Program serving 2 ½ years --- themselves HF patients

• Invaluable contributions to our HF Readmissions Reduction work• Review/critique the HF patient education tools• Attend monthly multidisciplinary HF Operations Team meetings• Participated in Rapid Process Improvement Workshop (RPIW)

using LEAN methodology for Medication Reconciliation• Participated in Value Stream Mapping for Heart Failure Patient

Care from point of entry into our system to transition home

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Empathy Mapping: Overview

• Interview completed by a trained hospital volunteer using open-ended questions

– SAY: What are some quotes and defining words the patient said?– DO: What actions and behaviors did you notice?– THINK: What might the patient be thinking?

What does this tell you about his or her beliefs?– FEEL: What emotions might the patient be feeling?

• Empathy mapping allows us to synthesize observations and draw out unexpected insights

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How can Empathy Mapping help?

• Identify prevalence of contributing factors or barriers to successful self-management for health, particularly in high-risk patients

• Insights on the patient’s experience of care processes and perception of communication

• Promotes patient reflection; feeling heard• Opportunity to address patient-specific issues• Evaluate aggregate data for themes and trends that can

inform re-design of processes of care to better meet physical and emotional needs

• Design and refinement of a healing environment of care

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SHC Primary HF Readmissions: April 2013 – March 2014 (Baseline CY 2011: 20% 30-day; 30% 90-day Readmit Rates)

0%

5%

10%

15%

20%

25%

30%

35%

30- DayReadmissions

90-DayReadmissions

90-Day ERUtlization

90-Day OBS Stay

20%

31%

7%

3%

10%

26%

10%

5%

Pre Intervention

Post Intervention

HF Readmissions Pre- and Post-implementation

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Reducing Avoidable Readmissions Heart Failure: Moore Cohort Baseline to Project Implementation Statistically Significant Reduction

Baseline Post Interventions start date to YTD (30 day d/c data availability)

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Lessons Learned

• Designing & implementing a patient-centered program for HF care that improves outcomes and reduces readmissions is a cross-functional team effort, spanning the care continuum – not a project but a culture change

• Active collaboration with community partners essential• Leveraging the EMR facilitates improved communication to and

consistent care practices• “Keep the patient at the center”: patient engagement and

participation is critical to success • Creating analytic tools that provide accessible, real-time metrics

to frontline staff & managers reinforces the effectiveness of nurse-sensitive interventions (e.g. use of teach back, post-discharge follow up calls)

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Future Directions

• Spread of HF readmissions reduction standards across other secondary HF populations to improve patient care transitions

• Continue to review/refine current patient care interventions and add new interventions after pilot-testing

• Collaborate with non-specialty providers (e.g. Primary Care, General Medicine) on Best Practices for HF management

• Strengthen community partnerships and create evidence-based community standard

• Continue to develop & analyze our own prospective risk assessment tool utilizing data elements in the EMR

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Resources

• Coleman EA, Min SJ, Chomiak A & Kramer AM. Post hospital care transitions: patterns, complications, and risk identification. Health Services Research.2004.39(5):1449-1465.

• Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; 2008. Available at www.IHI.org.

• Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2012.Available at www.IHI.org.

• Christine Thompson: chrthompson@stanfordhealthcare.org • Charlene Kell: ckell@stanfordhealthcare.org