Cross Continuum Team Work

in theER

TEAM

• ELIZABETH SAYKIN,RN,LSW,CCM• LAURA O’CONNOR, LSW• ER PHYSICIANS• ER NURSES• SECRETARY• Diane DeMatteo,RN,BSN,CCM Holyoke Health Center• Cary Hardwick, NP CCM ,Holyoke Health Center• Cherelyn Roberts,RN,BSN, STAAR Manager• Home Health Care Agencies• LTC and STR facilities• PCPs

The Population we serve

HMC serves a population of:• 30% of 25 and older population have not

graduated from high school• 57.7% of Hispanic , 25 and older have not

graduated from high school• 41.9% of less <18 are below 100%

poverty level• 56% of Hispanic <18 are below 100%

poverty level

Our Hospital

• HMC is the largest provider of inpatient and outpatient healthcare services to the poorest community in Mass.

• The Robert Wood Foundation research concludes that poor health is closely related to poverty.

• 100% of adult patients admitted to the hospital from Holyoke Health Center are cared for by a hospitalist

Bed Capacity

• ER sees roughly up to 140 patients per day• Stroke Center• 22 ER bed capacity plus 4 Fast Track• Trauma room• ICU – 11beds• Tele- 30 beds• MedSurg- 55 ( capacity to add 30 beds if

overflow floor opened)• Psych- 17 beds• Maternity - 12

According to :

• Agency for Healthcare Research and Quality

• Centers for Disease Control and Prevention

• American College of Emergency Physicians

The numbersNationally

• More than 9 in 10 ED visits in 2008 were related to acute conditions and half also involved chronic conditions.

• ED visits increased by nearly 22 million or 23% , faster than the U.S. population, between 1997 and 2007.

U-Turn

• “With new healthcare reform laws, and smarter ways of thinking about optimal medicine, the ED is being asked to pave a much different path, a U-turn lane for patients who can be more effectively –and less expensively- cared for at home or another setting.”

• Source: Cheryl Clark, Senior Editor of Health Leaders Media.May,2011

Quick Facts

• Readmisson Rate holding steady at under 14% for all cause but observation rate climbing

• Patients were being readmitted in less than 7 days of discharge

• Patients who had “refused” rehab or services were now in the ER and getting readmitted

Rates

• Our readmission rate since CHF Program went from

• Oct 2010 15% to Oct 2011 ,11.3%

• Nov 2010 16% to Nov 2011 ,11.7%

• Dec 2010 14% to Dec 2011, 13%

• We were holding steady at less than 14% , our goal.

Readmissons

Our CHF patients were not being readmitted, SO who were?

1. Observation patients , especially on weekends

2.Readmits who had left in less than 7 days

3. Patients who had refused services or rehab

All Cause Readmissions• August and Sept CHF Program Education Started

• January ’12 LEAN Event/ CTT in ER March ’12 CTT cut to 4 hours per day

LEAN EVENT

Main focus was to look at the Admission through discharge process.

Items adressed:

• Multidisciplinary rounds

• Observations vs Admissions criteria

• Med reconciliation

• Patient Navigator

Obs vs Admit Criteria

• Hospitalist reported not having enough information on the criteria for obs vs admit

• ER physician reports not enough information on criteria

• Both physicians state, they needed “help with decisions to admit or observe”

Observations

12/11

Team started in ER

3/12

Team hours cut down to 4 hours per day M-F

Patient Navigator

• Need SOMEBODY to connect the dots!

• Patient is not kept up to date on their daily tests and results and plan

Left us with the question • WHO IS DRIVING

THE BUS?

STAAR PROGRAM

• LEAN Event

Aligned with STAAR

Initiatives, which aligns with the Patient-Centered Medical Home Initiative

Observations we Made

When a STAAR initiative was implemented or removed , it had an impact:

• Aug/Sept 2011 CHF Program education began• Jan/2012 , LEAN Event, ER education began• March 2012, the RN from the CTT decreased hours to

only 4 per day• Made very clear that the ER was left out of the loop • ER staff at the LEAN event not aware of the work we

had started on the inpatient floors• Many of the topics discussed at the LEAN EVENT had

STAAR Alignment

SILOS

• Found we were still working in SILOS

• The LEAN event brought some key people together from Quality, STAAR, Frontline Staff, Docs, Ancillary depts who all had the same hope ( to provide the most efficient patient centered care)

• The Main Gateway to our hospital was not Informed!

AHA!

• We had totally missed an opportunity to impact readmissions in the ER!

Decision made to Visit the ER

• Educated staff on Teach Back, Health Literacy

• Educated ER staff on educational materials we were sending patients home with

• Partnered with ER staff to identify high risk patients who they already knew

Plan, Dec 2011

• To decrease the amount of avoidable all cause readmissions within 30 days of last discharge by assigning a “transition team” in the ER who can be consulted by ER physicians and hospitalists to assist with “treat and release” to an appropriate setting when acute care is not necessary. This team will also advise on admission and observation status

Who and What?

• Transition Coordinator( Betsy) will team up with Social Work ( Laura)

• CTC will identify any ER patient who may be a readmission and communicate with the ER physician on appropriateness of disposition

• CTC will communicate with PCPs, VNA , specifically the Health Center when the patient arrives to collaborate on a possible discharge plan or to discover issues that may impact the possible readmission

Transition

• CTT will assist with communication between the ER physician and hospitalist

• CTT will provide information of services provided in other levels of care to the physicians if acute care is not required

• If the patient is discharged to VNA ,LTC or STR or with a follow-up appt, CTT will insure the “warm handover” is done

Enhanced Communication

• CTT accepts calls from VNA’s

• LTC, STR and most often, the Holyoke health Center prior to a patient arriving.

• Important information is shared

• Treatment plan is discussed

• Clinical picture reviewed & communicated

( Betsy and Laura)

Evaluation

A log will be kept to track all the possible readmissions, how many were readmitted and how many treated and released

Relationships

families

CommunityServices,

Shelters,etc

ASAP

Community Pharmacist

PCP

LTC ,STR

VNA

HealthCenter

ER

Home Health Scenario

• VNA calls CTC in ER to alert of patient returning• Warm handover done from VNA with reason for

visit and current med list is faxed.• CTC delivers info to ER physician• CTC follows patient clinically until ready for

either admission or discharge• Services available discussed with ER physician

Disposition

• If patient returning to home, warm handover done to VNA including treatment plan and any med changes.

• If indicated a call will also be made to the PCP

Our Partner

“Engaging the Pioneer Valley” - March 23, 2009

Our Mission at the Holyoke Health Center is to improve the health of our patients by providing quality health care and supporting comprehensive

community-based programs to create a healthy community.

Preventive andacute careChronic care managementPublic Health Focus

100% of our medical assistants, front desk staff, and switchboard are bilingual/bicultural

92% of patients have incomes below 200% of Federal Poverty Level

90% are Latino/Puerto Rican from downtown Holyoke community

2nd highest overall mortality rate

9th highest mortality rate from heart disease

3rd highest rate of HIV infection

4th highest for rates of preventable hospitalization for asthma, angina & bacterial pneumonia

Highest rate alcohol & drug related deaths

5th highest rates of suicide

2nd highest rate of teen births

3rd in rates of Gonorrhea & Chlamydia

Highest rate of publicly funded prenatal care

Meeting Our Mission

• As part of the Patient-Centered Medical Home Initiative, HHC has hired 3 new Clinical Care Managers (CCM) , experienced RNs or NPs, who are working with specific providers’ patients especially those who frequently present to the ER and /or are Hospitalized.

• The CCMs offer each medical team, in-depth support for the high-risk and complex patients. This includes f/u care for ER and Hospitalized individuals within 48hrs of discharges.

Shared Information

HMC shares access with HHC to their Meditech system, where real time clinical information can be accessed, by our PCP, CCMs and nurses. This information includes:

• Names of our Patients presenting to the ER• Names of In-patient admissions• Lab work• Images• Consultation reports• Discharge planning

Collaboration with HMC

As a result of this shared information, HHC PCP and CCMs have been able to :

• Call ahead to announce a patient presenting to the ER

• Allow physician-to-physician conversations• Call in Pt’s home med lists• Anticipate patient’s needs upon disch• Collaborate with the case managers and

the CTT for disch planning and f/u care.

ER Discharge Collaboration

• HHC receives daily ER report for each (indentified) HHC Pt seen at HMC

• HHC CCMs review reports, then make F/U contact with each Pt within 48 hrs

* Telephone Call by CCM to assess needs

* Did-You-Know letter

ER Follow-Up Visit

• Review of d/c Plan

• Medication Reconciliation

• General Assessment with focus on the presenting problem

• Assess need for community services, etc.

Some Data from Our Test

January 2012– 23 possible readmits;– 9 were treated and assigned to another level of care.

( 7am-3pm)February 2012

- 48 possible readmits ; 21 were treated and released ( 7am-3pm)

March 2012- (CTC cut down to 4 hours p/day instead of 8)

37 possibles; 15 were treated and released (7am-11am)

Future Goals

• Automatic notification 24/7 to a Transition Team anytime a readmission comes in

• Improve communication to all PCPs, similar to the HHC• Spread the process of “calling ahead” to SNFs and LTCs • Decrease the use of inappropriate observation status• Decrease the readmission rate to <10% for all cause• Establish Palliative Care & Hospice process from the ER

BARRIERS

• Health Literacy continues to be a barrier

• Patients not knowing their MDs and their home meds

• Inconsistent communication between hospital providers (MDs, RNs) and PCPs

• Limited electronic registers and tools for communication

Not So Good Stories

Success Stories