Exemplary Professional Practice: Interprofessional Care to … · previous six months (June to...

Exemplary Professional Practice: Interprofessional Care

EP12 Nurses assume leadership roles in collaborative interprofessional activities to improve the quality of care.

EP12a: Provide an example, with supporting evidence, of a nurse-led (or nurse co-led) collaborative interprofessional quality improvement activity.

Introduction

According to the Institute for Healthcare Improvement (IHI):

“A substantial fraction of all hospitalizations are patients returning to the hospital soon after their previous stay. These re-hospitalizations are costly, potentially harmful, and often avoidable. Evidence suggests that the rate of avoidable re-hospitalizations can be reduced by improving core discharge planning and transition processes out of the hospital; improving transitions and care coordination at the interfaces between care settings; and enhancing coaching, education, and support for patient self-management.”

The IHI’s statement sets a goal for health care institutions to improve the care of patients being discharged. This goal is in the best interest of patients in that it prevents them from being at repeated risk of health care associated infections and allows them to maintain focus on recovery. It is also in the best interest of hospitals to avoid penalties for readmissions deemed to be preventable.

Readmissions at Massachusetts General Hospital

Many efforts have addressed the issue of hospital readmissions and have been episodically successful in population- or disease-specific initiatives, but sustained systemic change has been difficult to achieve. As a result, the goal of reducing avoidable readmissions was integrated into the 10-year Strategic Plan of the Massachusetts General Hospital (MGH)/Massachusetts General Physicians Organization (MGPO) as a strategy for improving patient outcomes and maintaining financial stability (attachment EP12.a).

Hospital readmissions are frequently cited as a contributing factor to capacity issues (i.e., not enough beds to accommodate the need for admissions). In early January 2016, the MGH Capacity Task Force was convened and led by Peter Slavin, MD, President of MGH, to address a number of issues that were creating capacity challenges (attachment EP12.b). At that time, a review of readmission data for the previous six months (June to December 2015) revealed an overall MGH readmission rate of 12.5 percent. However, the readmission rate for patients discharged from three units in the Medicine service was nearly 30 percent higher at 16 percent. These findings, in addition to the realization that prior readmission efforts had not had a lasting

or systemic impact, led Slavin to dedicate one of three key task forces to preventing readmissions. This task force was aptly named the Preventable Readmissions Task Force and was further divided into two subcommittees, one for the High Risk Population and one for the Heart Failure/Acute Myocardial Infarction Populations.

High Risk Population Subcommittee

The High Risk Population Subcommittee (attachment EP12.b) of the Preventable Readmissions Task Force is co-led by Jessica Smith Yang, RN, MS, ACNS-BC, Clinical Nurse Specialist (CNS), General Surgery Unit (Phillips House 22), Nancy Sullivan, Executive Director of Case Management, Ryan Thompson, MD, MPH, Attending Physician and Director of Quality Improvement for Medicine, and Maryellen O’Dea, MBA, Senior Process Improvement Consultant from the MGH/MGPO Center for Quality and Safety. Although Yang is the CNS on a surgical unit, her previous experience as an Attending Registered Nurse (ARN) on General Medicine Unit (Ellison 16) made her an ideal co-leader for nursing. (An ARN is a unit-based clinical nurse who, through leadership and coordination, ensures continuity from admission to discharge, by facilitating the plan of care with the nurse caring for the patient, the patient and family, and the interdisciplinary team.) O’Dea was specifically invited to join this group because of her extensive experience with process and quality improvement. The subcommittee began meeting formally in late January 2016 with an interdisciplinary team of clinical nurse case managers, physicians, pharmacists, social workers, and process improvement consultants to plan their work. The subcommittee group was charged with addressing the high rate of readmissions in the Medicine service.

Literature Review

The High Risk Population Subcommittee began their work with a review of the literature, and they found that numerous studies identified causative and preventive factors to readmissions that were consistent with those suggested in the IHI statement. The studies recommended intensive and comprehensive discharge planning for those at high risk of readmission and key interventions to reduce the likelihood of readmission such as attention to medication teaching, ensuring that follow-up appointments are scheduled prior to discharge and in close proximity to the discharge, and having a plan in place to escalate services after discharge.

The group believed that the recommendations and strategies in the literature were conducive to a quality improvement project, and they used them to guide the development of the bundle of interventions for the new Stay Connected Program (SCP) in the Medicine service and appointed members to the Stay Connected Program Operations Team (attachment EP12.b). The work plan for the development of the SCP and four slides that address key aspects of the initiative and that were part of several presentations are included in attachment EP12.c. The primary goal of the SCP initiative was to reduce the rate of readmissions of high risk medical patients to approximately the same as the overall MGH readmission rate of 12 percent.

Stay Connected Program Bundle of Interventions The SCP bundle of interventions was developed by the High Risk Population Task Force to provide pre- and post-discharge care that is comprehensive, offers alternatives to readmission, and reduces the likelihood of readmission. The bundle would be implemented on all patients on select units who were identified as being at high-risk of readmission. The interventions in the bundle are:

• Schedule post-discharge follow-up appointments

prior to discharge: o The Inpatient Administrative Coordinator

(IAC), a new position specific to the SCP, meets with the patient and family to determine best days/times, transportation needs, and other factors that would impact ability to be compliant with appointments.

o The appointments are scheduled by the IAC, ideally to occur within seven days of discharge.

• Enroll patient in “Meds to Beds” program: o The unit-based pharmacist provides

bedside medication reconciliation and counseling with the patient and family.

o Discharge medications prescriptions ordered by the medical provider are filled in the MGH Out-Patient Pharmacy and delivered to the patient/family prior to discharge.

• Activate the Skilled Nursing Facilities (SNF) Transitions of Care aspect of the bundle for patients being discharged to a SNF within the Mini SNF Collaborative (i.e., a group of SNFs routinely used by Partners facilities, including MGH):

o A Nurse Practitioner (NP) from the SNF reviews the patient’s clinical status, provides a warm handover with a SNF clinician, and communicates transition details with the patient’s Primary Care Provider (PCP).

• Request SCP Case Manager (CM) services for patient being discharged home:

o The SCP CM, also a new position specific to the SCP, provides care coordination for up to 30 days post-discharge.

• This includes assessment for unanticipated barriers to any aspect of the post-discharge plan, regular communication between all providers, and ongoing coordination of care as needed.

• Request a home visit by SCP Nurse Practitioner

(NP) for patients being discharged home: o The SCP NP, another new position specific

to the SCP, visits patient at home within 24 to 48 hours of discharge and collaborates with the discharge team, in-home services such as a visiting nurse or physical therapist, and the PCP.

o The SCP NP is available as needed for 30 days post-discharge to visit the patient in the home. It is suggested that this resource be tapped into if the patient’s needs are thought to be escalating during this time period.

Before the SCP could be used, it was necessary to identify patients at high-risk for readmission. This key first step was accomplished in a unique manner through the use of a natural language processing algorithm, developed by QPID Medical Company, which scans the electronic health record (EHR) in search of readmission risk factors, such as prior admissions, long lengths of stay, co-morbidities, and poor medication compliance. The QPID algorithm calculates a readmission risk score that identifies patients in need of increased support post-discharge. The QPID algorithm generates a list of high-risk patients that is sent to interdisciplinary care team members via email. This list is used during interdisciplinary rounds when comprehensive, individualized discharge plans are initiated for high-risk patients using the SCP bundle. Stay Connected Program Pilot Six units were targeted to pilot the SCP:

General Medicine Unit (White 9) General Medicine Unit (White 8) General Medicine Unit (White 10) General Medicine Unit (Gray 9) General Medicine Unit (Ellison 16) General Medicine Unit (Ellison 12)

As soon as the pilot units were identified, Yang began communicating with key stakeholders including the unit leadership and other groups that could provide input into the development, implementation, and success of the SCP. On June 29, 2016, she met with the Nursing Directors and Clinical Nurse Specialists/Nursing Practice Specialists of the three Phase 1 units. Yang also attended the July 22, 2016 meeting of the Attending Registered Nurses for the entire hospital and presented the plan for the SCP. Attachment EP12.d includes documents from these meetings with key stakeholders, in addition to minutes from the SCP Operations meeting where Yang shares her observations from the SCP go-live on the first pilot unit. Yang provided ongoing support on each of the pilot units at the time the SCP was initiated. This included being present for daily interdisciplinary rounds and being available to unit-based staff and team members to discuss high-risk patients and plan their discharge per the SCP bundle.

Pilot Outcomes The High Risk Population Task Force considers the program’s initial outcomes to be promising. The rate of readmissions for high-risk patients discharged from the six SCP pilot units decreased from 16 percent to 14.5 percent during the pilot period. It is estimated that 121 readmissions were prevented. Based on an average length of stay of eight days for Medicare patients, which were many of the high-risk patients, this reduction in readmissions is equivalent to 968 bed days. Additionally, of note, the QPID algorithm has identified that 30 to 35 percent of MGH Medicine patients are at high-risk of readmission.

Next Steps The SCP pilot on six Medicine units was completed in November 2016. As determined in the planning stages, once the SCP was implemented on the six pilot units, the initiative would spread to two additional units: Cardiac Medicine Unit (Ellison 10) and Cardiac Intervention Unit (Ellison 11). The implementation of the SCP bundle is currently in process on those units. Yang and colleagues then plan to refine specific aspects of the bundle based on feedback from pilot unit staff. There is also a desire to identify a mechanism to provide more detailed information about readmissions at the

unit level. Ultimately, the goal is to explore the possibility of expanding the SCP to other inpatient services or departments. Compass Award The Affordable Care Compass Award, sponsored by the Massachusetts Hospital Association, recognizes innovative and effective quality improvement projects, including those geared toward reducing readmissions. The SCP was nominated for this award in early 2017 by the MGH Center for Quality and Safety. In the April 30, 2017 edition of “From the Desktop,” a monthly newsletter written by Dr. Slavin and distributed to all staff, he announced that the SCP earned second place for this award (attachment EP12.e). Yang continues to provide leadership for this extensive quality improvement project that has had a significant impact on reducing readmissions for high-risk patients who are discharged from the Medicine service. This work is beneficial to patients in that it reduces their repeat risk of hospital acquired infections, delays in returning to baseline, and has the potential to have a positive impact on their perceived hospital experience. The work also provides a benefit to the hospital by reducing the negative financial impact related to readmission penalties for readmissions considered avoidable or preventable.

______________________________________

From: Priesand, Michael I. Sent: Thursday, June 30, 2016 8:09 AM To: Mills, Jennifer C.,R.N.; Carrigan, Kathleen D.; Macchiano, Sara A.,R.N.; Mahoney, Shannon A.,R.N.; Holmberg, Jacquelyn L.,R.N.; Tata, Lee Ann,R.N.; Collins, Jacqueline M.,R.N.; Gallivan, Theresa M., R.N.; Connolly, Debra,R.N.,MGH Case Mgmt; Kobayashi, Kimiyoshi J.,M.D.; Thompson, Ryan W.,M.D.; Smith, Jessica; Sullivan, Nancy M.,MGH Case Mgt; Cramer, Mary O.; Elfar, Annie N.; Carr, Laura Salomone; Rusinak, Donna; Sheer, Dana L.,N.P. Cc: Clear, Caitlin Ann; Marotta, Sandra; Alston, Yolanda; Sarkisianz, Tamara; Saulnier, Erica E. Subject: RE: Readmission Care Redesign Initiative

Hello all

Hope everyone is doing well today. Attached are the slides from our Readmissions meeting yesterday evening. Thank you for all of your valuable input and participation. We are really excited about this program and are looking forward to partnering with you all!

Thanks, Michael

-----Original Appointment----- From: Priesand, Michael I. Sent: Friday, June 10, 2016 3:25 PM To: Mills, Jennifer C.,R.N.; Carrigan, Kathleen D.; Macchiano, Sara A.,R.N.; Mahoney, Shannon A.,R.N.; Holmberg, Jacquelyn L.,R.N.; Tata, Lee Ann,R.N.; Collins, Jacqueline M.,R.N.; Gallivan, Theresa M., R.N.; Connolly, Debra,R.N.,MGH Case Mgmt; Kobayashi, Kimiyoshi J.,M.D.; Thompson, Ryan W.,M.D.; Smith, Jessica; Sullivan, Nancy M.,MGH Case Mgt; Cramer, Mary O.; Elfar, Annie N.; Carr, Laura Salomone; Rusinak, Donna; Sheer, Dana L.,N.P. Cc: Clear, Caitlin Ann; Marotta, Sandra; Alston, Yolanda; Sarkisianz, Tamara; Saulnier, Erica E. Subject: Readmission Care Redesign Initiative When: Wednesday, June 29, 2016 4:00 PM-5:00 PM (UTC-05:00) Eastern Time (US & Canada). Where: Thier Conference Room

Hello all

This seemed to be the best time for most people. If you are unable to attend, we can work together to figure out an alternate solution. I really appreciate everyone’s participation!

Also, I am still looking for an available conference and would appreciate the help if you know of an available space.

Thanks again! I am looking forward to working with everyone!

Examples of Yang's Meetings with Key Stakeholders

Michael Michael Priesand Senior Process Improvement Consultant Edward P. Lawrence Center for Quality & Safety MASSACHUSETTS GENERAL HOSPITAL 125 Nashua Street, Boston, MA 02114 Phone: 617-726-0535 _____________________________________________ From: Smith, Jessica Sent: Friday, June 10, 2016 3:12 PM To: Tata, Lee Ann,R.N.; Collins, Jacqueline M.,R.N.; Macchiano, Sara A.,R.N.; Mahoney, Shannon A.,R.N.; Mills, Jennifer C.,R.N.; Carrigan, Kathleen D.; Gallivan, Theresa M., R.N. Cc: Thompson, Ryan W.,M.D.; Sullivan, Nancy M.,MGH Case Mgt; Connolly, Debra,R.N.,MGH Case Mgmt; Kobayashi, Kimiyoshi J.,M.D.; Priesand, Michael I.; Holmberg, Jacquelyn L.,R.N.; Whitney, Kevin,R.N.,D.N.P. Subject: Readmission Care Redesign Initiative Dear Colleagues – Improving care transitions and reducing avoidable readmissions are core priorities for MGH clinicians, with both important clinical implications for our patients, and financial implications for the hospital and MGPO. In order to support clinicians in their efforts to improve care transitions, MGH/MGPO Readmissions Care Redesign team has been funded by Dr. Slavin to launch a robust bundle of interventions on a subset of units to target patients rated High Risk for Readmission. We are thrilled to be able to provide these additional resources to patients and staff to assist our patients at greatest need to have a successful transition out of the acute care environment and be successful at their discharge destination. Under the direction of Dr. Slavin and the Capacity Task Force, we will roll these interventions out to 8 inpatient units over the next 6 months. We are excited to inform you that your unit was chosen via random selection to be a part of our first cohort of units. Our multidisciplinary Readmissions Care Redesign core team is working diligently to ensure that our implementation plan is seamless, efficient, reliable and successful. Our project specialist Michael Priesand will be reaching out to you to set up a meeting to discuss this effort in greater detail and gather your feedback. We look forward to working with you on this important initiative. Thank you, Jessica Smith, RN (Nursing Lead, Readmissions Care Redesign) Nancy Sullivan and Debra Connolly, RN (Case Management Co-Leads, Readmissions Care Redesign) Ryan Thompson, MD (Chair and Physician Lead, Readmissions Care Redesign)

Reducing Avoidable Readmissions:Stay Connected Program

Phase 1 Unit Nursing Leadership Meeting Wednesday, June 29, 2016

Jessica Smith, RN, MSN, ACNS‐BC

1. CMS penalizes hospitals for “excess” readmissions – AMI, CHF, COPD, PNA, total joint replacement– Up to 3% reduction in all MS‐DRG payments

– MGH 2015 penalty – 0.29% ($754,000)

2. Mass Health also has a readmissions penalty– Up to 4.4% reduction in annual Mass Health payments

– MGH 2015 penalty – $108,000

3. Readmissions contribute to TME in Medicare ACO and other risk populations

4. Avoidable readmissions contribute to inpatient capacity challenges

The Case to Reduce Avoidable Readmissions

2

Innovation Units

CQS

PCORI Transitions

Partners Primary Care MGPO PCS

Care Redesign

Department-Specific Efforts

Discharge Bundle

SNF Collaborative

ED PCC

Readmit Risk Prediction

Mobile Obs Unit

Post D/C Calls

Population Health

ManagementIPASS iCMP and

PCMH

Multitude of Efforts to Reduce Readmissions

3

Capacity Task Force

4

MGH Capacity Task Force

Avoidable ED and IP Care Preventable Readmissions Delays Related to Patient Placement

Chair: David Brown, MD

PM: Bob Seger & Beth Grabowski

PI: Maryellen O’Dea & Joan Strauss

Analytics: Aaron Fishman/MIT

Members:

Tim Ferris, MD

MaryFranHughes, RN

Keith Lillemoe, MD

Ann Prestipino

Ali Raja, MD

Calvin Richardson

Jerry Rosenbaum, MD

David Storto

Chair: Michael Jaff, DO

PM: Libby Williams

PI: Sanjay Chaudhary

Analytics: Andrea Tull /MIT

Members:

Katrina Armstrong, MD

Mary Cramer

Liz Mort, MD

Brit Nicholson, MD

Nancy Sullivan

Ryan Thompson, MD

Kevin Whitney, RN

Chair: Sally Mason Boemer

PM: Allison Castagna

PI: Gianna Wilkins & Michael Priesand

Analytics: Stephen Buonopane/MIT

Members:

Peter Dunn, MD

Theresa Gallivan, RN

Jeanette Ives Erickson, RN, DNP

Tony James

Ben Orcutt

Walter O’Donnell, MD

Greg Pauly

Maureen Schnider, RN

Analytics Core: Chaired by Sally Mason Boemer and Retsef Levi with analytic support to be assigned

Project Management & Process Improvement: Chaired by Mary Cramer – PM support (ED/AD level) and PI representative assigned to each team

Non‐Acute Care: Chaired by David Storto with support to be determined as needed by teams

Understanding Readmissions Across MGH

5


Top 5 Results by Service as a % of Total Readmissions

Top 6 Results by Discharge Disposition as a % of Total Readmissions

7

1000 structured reviews, 26.9% of readmissions potentially preventable

Factors with largest difference in prevalence between preventable and non‐preventable readmissions: Inadequate treatment of medical conditions during the index admission (non‐pain)

Inadequate monitoring for medication adverse effects or nonadherence

Follow‐up appointments not scheduled sufficiently soon after discharge

Patient lack of awareness of whom to contact after discharge, or when to go (or not go)to the ED

Patient need for additional or different home services than those requested

Patients discharged too soon from the index hospitalization

Issues related to the decision to readmit the patient in the ED

Readmission Preventability – What Do We Know?

8

Achieving Success in Reducing Readmissions

9


STate Action on Avoidable Rehospitalizations (STAAR) —multi‐state, multi‐stakeholder initiative

(Institute for Healthcare Improvement, 2009‐2013)

Main conclusions from STAAR:

1. Reducing readmissions is dependent on highly functional cross continuum teams and a focus on the patient’s journey over time

2. Improving transitions in care requires co‐design oftransitional care processes among “senders and receivers”

3. Providing intensive care management services fortargeted high risk patients is critical

4. Reliable implementation of changes in pilot units orpilot populations require 18 to 24 months

Source: Rutherford, P. IHI MA STAAR Collaborative Learning Session Presentation Oct. 11, 2011

10

• High risk patients are identified via a daily email notification to inpatient careteams (Case Manager, Attending RN, Physical Therapist)

– Patients identified as “high risk” in this model are 3‐4 times more likely to be readmitted thanpatients not rated as high risk

• Care teams use the high risk patient roster to discuss/plan patient’s post‐acuteplan in multi‐disciplinary rounds

• Readmission risk score in Epic is not as predictive and NOT meant to be used for this program

11

Test Patient1111111

Test Patient121212

Readmission High Risk Indicator

Enrolled patients will receive (in addition to usual care):

1. Follow‐up appt within 7 days, scheduled before discharge by InpatientAdministrative Coordinator (IAC) with patient & family input

2. Discharge meds in hand before discharge, with med reconciliation and supplementary Rx education by unit‐based pharmacist (Meds to Beds program)

3. Enhanced transition of care to SNF, including augmented warm handoffby on‐site NP (for patients transferred to IPC‐covered SNFs)

4. NP home visit(s) post‐discharge, and/or NP‐guided home care by Partners Mobile Observation Unit NP

5. High Risk Transitions Case Manager, to provide proactive care coordination during the 30‐day post discharge period (iCMP patients will not need this)

12

Intervention – High Risk Transitions Program

Intervention – High Risk Transitions ProgramPre‐Discharge Post‐Discharge

Inpatient stay Discharge process

Skilled Nursing Facility

Home or Home w/Services•High‐risk indicator

•Clinician “opt‐in” to high risk status

•Meds to Beds

•IPC TOC NP handoff

•PMOU NP home visit•7‐day f/u appt, TCM

•Sched appt within 7 days (Inpt Admin Coord)

Identification Initiation Monitoring/Escalation

•RN warm handoff

•Electronic handoff to PCP (MGH pts)

ED Return

•Identify potential readmissions

•Alternative pathwaysto admission:Home care

Direct to SNFOutpt/home infusionSpecialty interventions

•IPC TOC NP visit (SNF)

Target Population, Estimated Impact

• High risk patients, any disposition (~35% of patients)

~300 discharges/mo, ~90 readmissions (30%)

• 22 readmissions (25%) potentially avoidable

• We hope to avoid ~8‐10 readmissions per month via

this intervention, once fully rolled out

• 8‐10 readmissions avoided = 60‐75 bed days

(LOS for readmitted patients on pilot floors is ~7.5 days)

•Daily multidisciplinary rounds

•Discharge education with teachback

•Post‐discharge calls(ARN, PCP office)

= Pilot interventions

Tentative Roll‐out Plan (units randomly selected)

• Phase 1* (mid‐July): White 9, White 10, Ellison 16

• Phase 2 (Sept‐Oct): White 8, Gray 9, Ellison 12

• Phase 3 (Dec): TBD

• Control Units: White 11, Gray 11; Ell 19/Ph20

• Measures planned for each intervention, and

overall intervention as a bundle

•High‐Risk Transitions Case Manager

13

The Norman Knight Nursing Center

for Clinical & Professional Development

R. Gino Chisari, RN, DNP

Director

INSPIRATION | INNOVATION | TRANSFORMATION

Attending Registered Nurse

Meeting Minutes

Friday, July 22, 2016

12:00 – 1:00 pm

Founders 325

Attending:

Phase I: Janet Bell, Janet Kleimola, Laura Lux, and Sally Morton

Phase II: Sarah Ballard Molway, Kelly Cruise, Jenna Hall, Donna Hoffman, Lori

Mazzarelli, Colleen McGovern, and Jennifer O’Neil

Phase III: Sharon Brackett

Phase IV:

By Phone:

Presiding

Gino Chisari

Guests: Tom Blanchard, RN, CNS and Jessica Smith, RN, CNS

Agenda Item Discussion Action

Welcome/Introduction

New/Returning ARNs

Gino called the meeting to order at 12:00 pm with 12 ARNs in

attendance.

Noted

Evidence Based Practice Tom presented the background, principles, concept and elements

of EBP and described how it is interwoven into MGH nursing

practice. He provided examples and shared resources with the

group. Although EBP has been a major component to nursing

practice at MGH, it is currently undergoing a refinement and

getting revised as a program. Tom agreed to share his slides with

the ARN group - please see attached to these minutes.

High Risk Transitions

Program

Jess Smith provided a comprehensive overview the High Risk

Transition Program designed to address readmission through a

series of interventions. They include:

1. Follow-up appt within 7 days, scheduled before discharge by

Inpatient Administrative Coordinator (IAC) with patient &

family input

2. Discharge meds in hand before discharge, with med

reconciliation and supplementary Rx education by unit-based

pharmacist (Meds to Beds program)

3. Enhanced transition of care to SNF, including augmented

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight

warm handoff by on-site NP (for patients transferred to IPC-

covered SNFs) 4. NP home visit(s) post-discharge, and/or NP-guided home care

by Partners Mobile Observation Unit NP

5. High Risk Transitions Case Manager, to provide proactive

care coordination during the 30-day post discharge period

(iCMP patients will not need this)

The project will have a rolling launch beginning in Medicine in

mid-July and eventually spreading house wide. Jess agreed to

share her slides with the ARN group – please see attached to these

minutes.

Check-in Gino adjourned the meeting at 1:10 pm after describing the next

meeting’s agenda including a discussion/demonstration on Call

Manager and locating discharged patients and a presentation by

Kevin Whitney and Marianne Ditomassi regarding discharge data.

Noted

NEXT MEETING: Tuesday, August 2 2016 at 12:00-2:00 pm in Founders 325

jeb23

Highlight

jeb23

Highlight

Reducing Avoidable Readmissions:Stay Connected Program

Attending Registered Nurse Meeting Friday, July 22, 2016

Jessica Smith, RN, MSN, ACNS‐BC

1. CMS penalizes hospitals for “excess” readmissions – AMI, CHF, COPD, PNA, total joint replacement– Up to 3% reduction in all MS‐DRG payments

– MGH 2015 penalty – 0.29% ($754,000)

2. Mass Health also has a readmissions penalty– Up to 4.4% reduction in annual Mass Health payments

– MGH 2015 penalty – $108,000




2

Innovation Units

CQS

PCORI Transitions


Care Redesign

Department-Specific Efforts

Discharge Bundle

SNF Collaborative

ED PCC

Readmit Risk Prediction

Mobile Obs Unit

Post D/C Calls

Population Health

ManagementIPASS iCMP and

PCMH


3

Capacity Task Force

4







Members:

Tim Ferris, MD

MaryFranHughes, RN

Keith Lillemoe, MD

Ann Prestipino

Ali Raja, MD

Calvin Richardson

Jerry Rosenbaum, MD

David Storto


PM: Libby Williams



Members:


Mary Cramer

Liz Mort, MD

Brit Nicholson, MD

Nancy Sullivan

Ryan Thompson, MD

Kevin Whitney, RN





Members:

Peter Dunn, MD



Tony James

Ben Orcutt


Greg Pauly




Non‐Acute Care: Chaired by David Storto with support to be determined as needed by teams


5




7


Factors with largest difference in prevalence between preventable and non‐preventable readmissions: Inadequate treatment of medical conditions during the index admission (non‐pain)


Follow‐up appointments not scheduled sufficiently soon after discharge

Patient lack of awareness of whom to contact after discharge, or when to go (or not go)to the ED





8


9


STate Action on Avoidable Rehospitalizations (STAAR) —multi‐state, multi‐stakeholder initiative

(Institute for Healthcare Improvement, 2009‐2013)



2. Improving transitions in care requires co‐design oftransitional care processes among “senders and receivers”

3. Providing intensive care management services fortargeted high risk patients is critical

4. Reliable implementation of changes in pilot units orpilot populations require 18 to 24 months


10

• High risk patients are identified via a daily email notification to inpatient careteams (Case Manager, Attending RN, Physical Therapist)

– Patients identified as “high risk” in this model are 3‐4 times more likely to be readmitted thanpatients not rated as high risk

• Care teams use the high risk patient roster to discuss/plan patient’s post‐acuteplan in multi‐disciplinary rounds


11

Test Patient1111111

Test Patient121212



1. Follow‐up appt within 7 days, scheduled before discharge by InpatientAdministrative Coordinator (IAC) with patient & family input

2. Discharge meds in hand before discharge, with med reconciliation and supplementary Rx education by unit‐based pharmacist (Meds to Beds program)

3. Enhanced transition of care to SNF, including augmented warm handoffby on‐site NP (for patients transferred to IPC‐covered SNFs)

4. NP home visit(s) post‐discharge, and/or NP‐guided home care by Partners Mobile Observation Unit NP

5. High Risk Transitions Case Manager, to provide proactive care coordination during the 30‐day post discharge period (iCMP patients will not need this)

12


Intervention – High Risk Transitions ProgramPre‐Discharge Post‐Discharge



Home or Home w/Services•High‐risk indicator

•Clinician “opt‐in” to high risk status

•Meds to Beds


•PMOU NP home visit•7‐day f/u appt, TCM



•RN warm handoff


ED Return


•Alternative pathwaysto admission:Home care

Direct to SNFOutpt/home infusionSpecialty interventions






• We hope to avoid ~8‐10 readmissions per month via


• 8‐10 readmissions avoided = 60‐75 bed days




•Post‐discharge calls(ARN, PCP office)


Tentative Roll‐out Plan (units randomly selected)

• Phase 1* (mid‐July): White 9, White 10, Ellison 16

• Phase 2 (Sept‐Oct): White 8, Gray 9, Ellison 12

• Phase 3 (Dec): TBD




•High‐Risk Transitions Case Manager

13

Readmissions Reduction Core Team Meeting

7‐26‐2016

Attendees:

Carr, Laura P Connolly, Debra, RN A Cramer, Mary P

Elfar, Annie P Henderson, Daniel, MD P Jhaveri, Vimal ,MD A

Kim, Matt P Kobayashi, Kimi, MD A O'Dea, Maryellen P

Priesand, Michael P Rusinak, Donna P Sheer, Dana P

Smith, Jess, RN P Sullivan, Nancy, RN A Thompson, Ryan, MD P

Ticona, Luis, MD P Wilkins, Gianna P Zenteno, Cecilia A

Hussain, Mehwish P Konner, Karon, LICSW P

1‐Page Documentation • J. Smith and M. Priesand drafted 1 Page summary document to share

with team. Would like operational leads of interventions to provide a

few bullet points for things to remember. Purpose of the document is to

provide assistance to staff who rotate onto the units.

Next steps • Meeting with White 10 on Wednesday 7/27 at 1PM

• Continue supporting go‐live on White 9

• Operational leads fill in 'things to remember' bullet points on 1‐page

document.

Topic: Discussion:

Upcoming Items • Unit‐based meeting with White 10 scheduled for Wednesday 7/27 at

1PM. Discussion will be focused on getting them ready for an upcoming

go‐live

• Aiming for unit‐based meeting with Ellison 16 upcoming for first week

in August.

• As we go live on more units, we will need to coordinate our resources

to support the various go‐live activities.

○ Concern over support being spread too thin.

Stay Connected Program Updates • White 9 went live on Monday, July 18th. Comments/Observations per

J. Smith who has been on the unit daily since go‐live.

○ Had been using the Treatment Team S cky Note in Epic, to

document expected date of discharge; now also using the Sticky Note to

document if patient meets readmissions high risk criteria.

○ Case Management has really championed this effort on White 9

and is a major reason it has been successful so far.

○ Quite a bit of toggling between paper Epic list and paper High

Risk list.

• Review of Inpatient Administrative Coordinator (IAC) workflow:

○ Preference is for IAC to receive requests either verbally or

through email.

• Review of SNF Transitions of Care:

○ NP cannot do physical assessment of pa ent un l creden aled

at MGH but will start attending Multi Disciplinary Rounds.

Reducing Avoidable Readmissions: High Risk Transitions Program

Wednesday, June 29st, 2016

1. CMS penalizes hospitals for “excess” readmissions – AMI, CHF, COPD, PNA, total joint replacement – Up to 3% reduction in all MS-DRG payments

– MGH 2015 penalty – 0.29% ($754,000)

2. Mass Health also has a readmissions penalty – Up to 4.4% reduction in annual Mass Health payments

– MGH 2015 penalty – $108,000




2

Innovation

Units

CQS

PCORI

Transitions


Care

Redesign

Department-

Specific

Efforts

Discharge

Bundle

SNF

Collaborative

ED PCC

Readmit Risk

Prediction

Mobile

Obs Unit

Post D/C

Calls

Population

Health

Management

IPASS iCMP and

PCMH


3

Capacity Task Force

4







Members:

Tim Ferris, MD

MaryFran Hughes, RN

Keith Lillemoe, MD

Ann Prestipino

Ali Raja, MD

Calvin Richardson

Jerry Rosenbaum, MD

David Storto


PM: Libby Williams



Members:


Mary Cramer

Liz Mort, MD

Brit Nicholson, MD

Nancy Sullivan

Ryan Thompson, MD

Kevin Whitney, RN





Members:

Peter Dunn, MD



Tony James

Ben Orcutt


Greg Pauly



Project Management & Process Improvement: Chaired by Mary Cramer – PM support (ED/AD level) and PI representative

assigned to each team

Non- Acute Care: Chaired by David Storto with support to be determined as needed by teams


5


Factors with largest difference in prevalence between preventable and non-preventable readmissions: Inadequate treatment of medical conditions during the index admission (non-pain)


Follow-up appointments not scheduled sufficiently soon after discharge

Patient lack of awareness of whom to contact after discharge, or when to go (or not go) to the ED





8


9


STate Action on Avoidable Rehospitalizations (STAAR) —multi-state, multi-stakeholder initiative

(Institute for Healthcare Improvement, 2009-2013)



2. Improving transitions in care requires co-design of transitional care processes among “senders and receivers”

3. Providing intensive care management services for targeted high risk patients is critical

4. Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months


10

• High risk patients are identified via a daily email notification to inpatient care teams (Case Manager, Attending RN, Physical Therapist) – Patients identified as “high risk” in this model are 3-4 times more likely to be readmitted than

patients not rated as high risk

• Care teams use the high risk patient roster to discuss/plan patient’s post-acute plan in multi-disciplinary rounds


11

Test Patient

1111111

Test Patient

121212



1. Follow-up appt within 7 days, scheduled before discharge by Inpatient Administrative Coordinator (IAC) with patient & family input

2. Discharge meds in hand before discharge, with med reconciliation and supplementary Rx education by unit-based pharmacist (Meds to Beds program)

3. Enhanced transition of care to SNF, including augmented warm handoff by on-site NP (for patients transferred to IPC-covered SNFs)

4. NP home visit(s) post-discharge, and/or NP-guided home care by Partners Mobile Observation Unit NP

5. High Risk Transitions Case Manager, to provide proactive care coordination during the 30-day post discharge period (iCMP patients will not need this)

12



13

Intervention – High Risk Transitions Program Pre-Discharge Post-Discharge



Home or Home w/Services •High-risk indicator

•Clinician “opt-in” to high risk status

•Meds to Beds


•PMOU NP home visit •7-day f/u appt, TCM



•RN warm handoff


ED Return


•Alternative pathways to admission: Home care

Direct to SNF Outpt/home infusion Specialty interventions






• We hope to avoid ~8-10 readmissions per month via


• 8-10 readmissions avoided = 60-75 bed days




•Post-discharge calls (ARN, PCP office)


Tentative Roll-out Plan (units randomly selected)

• Phase 1* (mid-July): White 9, White 10, Ellison 16

• Phase 2 (Sept-Oct): White 8, Gray 9, Ellison 12

• Phase 3 (Dec): TBD (likely Ellison 10, 11)




•High-Risk Transitions Case Manager

14

• Discussion, planning with floor staff (case managers, attending RNs) about workflow, process – We specifically designed this intervention to build on existing

programs so as to not be burdensome to clinicians

• Readmissions core team plans frequent check-ins, brief huddles with pilot units, collaborative learning process – How can we best work together to make this successful?

• What data or reports can we provide?

• Aiming for a go-live week of July 18th for 1 unit

15

Next Steps

The Stay Connected Program (as of 5/9/17)

PROJECT LEADERSHIP

Ryan Thompson, MD, MPH – Physician Lead Nancy Sullivan – Case Management Lead Jessica Smith Yang, MS, RN, ACNS-BC –Nursing Lead Maryellen O’Dea- Process Improvement/Center for Quality and Safety

TIMEFRAME • Initial planning for The Stay Connected Program took place in January 2016 • Kick off meetings with unit based stakeholders started in March 2016 • Staggered roll out began in June 2016, lasting until November 2016

HISTORY • The Readmission Reduction Care Re-design team, initiated in 2013, provided history for this initiative.• Institution-wide efforts to reduce 30 day readmissions have been underway with a cost neutral

approach for several years yielding no significant change in the overall hospital readmission rateand growing condition-specific CMS reimbursement penalties.

• Reducing hospital readmissions is a strategic initiative at MGH to improve patient transitions of careand address several institutional and population health concerns, including:

o Emergency department overcrowdingo Inpatient capacity challengeso The CMS financial penalties for excess readmissions for acute myocardial infarction, heart

failure, pneumonia, chronic obstructive pulmonary disease, elective total hip or total jointreplacement and coronary artery bypass graft

o The contribution to the total medical expense for the Medicare ACO and other riskpopulations.

POPULATION • 6 inpatient medical units and 2 inpatient cardiology units (medical service patient population as this population accounted for the majority of hospital readmission (approximately 57%).

• The risk score utilizes the QPID Natural Language Processing tool to scan clinical notes and look forreadmission risk factors. Patients identified as high risk by the QPID risk score are 3-4 times more likely to be readmitted and include approximately 30-35% of the patients on the medicine service at MGH.

• A high risk score is used to target patients and notify clinicians to offer these additional resources.• The QPID risk score model is approximately 80% specific and 50% sensitive

OVERARCHING GOALS

• Aim Statement 1. Reduce quarterly readmission rate for high-risk Medicine patients to under 12.0% by the end of 20172. On intervention units (care management bundle for patients at high-risk of readmission), reduce

readmission rate by 10% by mid-2017 • Four Primary Areas of Focus:1. Start with Medical Service patients2. Target the highest-risk patients 3. Leverage existing programs, evidence for what works4. Measure our interventions against a control group

GOALS of the PILOT • Reduce avoidable readmissions – avoidable readmissions contribute to inpatient capacity challenges at MGH • Improve transitions in care• Decrease CMS penalties for “excess” readmissions – AMI, CHF, COPD, pneumonia, total joint replacement

PARTICIPANTS • Multidisciplinary representatives of key stakeholder groups at MGH (Physicians, Nursing, Case Management, Pharmacy, Post Acute, Quality and Safety, Social Work, and others as deemed necessary)

MEETINGS of OVERSIGHT GROUP

Core Leadership Group – Bi-Weekly meetings Wednesdays 1pm Operations Meeting – Bi-Weekly meetings Wednesdays 1pm (alternating)

OTHER MEETINGS • Intervention unit multidisciplinary debrief – monthly • Stay Connected nurse practitioner and case management intervention meeting – monthly • Process Improvement meetings: Inpatient Administrative Coordinator (IAC) intervention, Meds to Beds

PILOT UNITS White 8, White 9, White 10, Bigelow 9, Ellison 12, Ellison 16 Ellison 10, 11 (partial implementation)

OUTCOME METRICS • Readmission Rate • Reduce avoidable bed days• Process measures for interventions – track through RedCap data base

NEXT STEPS • Refine processes for Inpatient Administrative Coordinators and Meds to Beds Program • Provide more readmission information at the unit level and increase transparency re: individual unit

readmission rates• Consider expansion to other Medicine units and other units/services

Reducing Avoidable Readmission: The MGH Stay Connected Program

Ryan Thompson, MD Jess Smith Yang, RN

Nancy Sullivan, RN

13 Oct 2016

Identification

QPID Natural Language Processingtool scans clinical notes, looks forreadmission risk factors High-risk patients ~3X more likely to be

readmitted

~25-30% of patients on Medicineidentified as high risk

Model is ~80% specific, ~50% sensitive(80% of false negatives – first MGH admission)

Readmission risk score in Epic isdifferent – Partners-wide groupactively meeting to reconcilereadmission risk models,approaches

Test Patient

1111111

Test Patient

121212

Initiation

Daily push notifications of high-riskrosters to inpatient care teams (pilotin Medicine)

Attending MD and MGH PCP notified viaseparate email

High risk status included in dischargenotification to PCPs (eHandoff)

Daily discussion/planning in multi-disciplinary rounds (Case Mgt-led)

Our Framework for Managing High Risk Patients

MGH PCP Notifications of High Risk Patients

Patients enrolled in the SCP will receive:

1. Follow-up appointment within 7 days, scheduled before discharge with patient input Builds on new “Inpatient Administrative Coordinator” role in Medicine Ideally lead to a Transitional Care Management (TCM) visit with Primary Care

2. Discharge medications in hand before discharge, with supplementary Rx educationby inpatient pharmacist Expand Meds to Beds program

3. NP home visit post-discharge, and/or NP-guided home care Advanced practice level coordination of care in the post-discharge setting “Escalation” pathway for clinic staff, home care nurses – avoid escalation to ED Limited availability until dedicated NP is hired (position posted)

4. IPC Transitions of Care (SNF discharges) – on-site NP to meet patients, provideaugmented warm handoff to SNF (available November 2016) For patients discharged to IPC SNF (MGH SNF mini-collaborative) NP notified if/when patients return to ED, collaborate with ED/SNF on readmission avoidance

5. Stay Connected Program Case Manager (available November 2016) Someone to “own” these patients and their care during the 30-day post discharge period iCMP patients will not need this

Intervention – “Stay Connected Program” (SCP)

Intervention – Stay Connected Program Pre-Discharge Post-Discharge



Home or Home w/Services •High-risk indicator

•Clinician “opt-in” to high risk status

•Meds to Beds


•SCP NP home visit•7-day f/u appt, TCM



•RN warm handoff

•Electronic handoff toPCP (MGH pts)

ED Return

•Readmission notifications (DC provider, ARN, CM, specialist)

•Alternative pathways toadmission:

Home care

Direct to SNF Outpt/home infusion Specialty interventions






• We hope to avoid ~8-10 readmissions per month via this

intervention, once fully rolled out

• 8-10 readmissions avoided = 60-75 bed days



•Discharge educationwith teach back

•Post-discharge calls (ARN, PCP office)


•Stay Connected Program Case Manager

From: Broadcast MGH Sent: Sunday, April 30, 2017 8:18 PMTo: All User MGHSubject: From the Desktop of Peter L. Slavin, MD

From the Desktop of . . .Peter L. Slavin, MD

MGH PresidentApril 2017

Mass Generally Speaking

As Nation Marks Centennial of WWI, MGH Honors those who Served at Base Hospital 6

One hundred years ago this month, the United States declared war on Germany, formally entering World War I. Andwith this decree, our nation leapt to mobilize. In Boston, the MGH activated a plan to establish a mobile hospital unit inEurope as part of the American Expeditionary Force. Led by Frederic A. Washburn, MD, MGH director and residentphysician, the hospital’s war-bound physicians underwent six weeks of military training at Fort Strong on Long Islandin Boston Harbor, while the nursing unit spent 10 days getting prepared and equipped on New York’s Ellis Island. Theinaugural MGH unit – 64 nurses, 181 doctors, six secretaries, a chaplain, a dietitian, an electrician, a carpenter and abarber – set sail from New York July 11, 1917, bound for Europe. The assignment: to set up and staff Base Hospital No.6 in Talence, France, just south of Bordeaux. Sara Parsons, RN, superintendent of the MGH Training School forNurses, was named chief nurse for Base Hospital No. 6, which was housed in Lycée Victor Louis, a school that theFrench had already transformed into a wartime hospital. The MGH took it over to relieve a shortage of medical staff inFrance. Originally intended to accommodate 500 beds, the hospital continued to expand with the growing need,reaching 3,000 beds in mid-1918. At one point, the facility housed 4,319 patients. It served mostly American troops butalso treated French units.

In its first few months of operation, Base Hospital No. 6 treated mainly illness and disease that spread among soldiers. All that changed by early 1918, when the American forces in Europe increased and fighting intensified. According tothe MGH history book Something in the Ether, by Webster Bull and Martha Bull, “Work accelerated through thesummer and fall of 1918 as the American wounded and gassed began to pile up. October was the cruelest month: therewere 4,378 admissions and 528 surgeries, as the American effort and the war itself reached their climax.” During thattime, the proportion of illness cases rose again, as a deadly influenza pandemic swept through much of the world. Overthe course of the war, Base Hospital No. 6 cared for more than 26,000 patients, with staff performing 3,600 surgeries.

More than 500 MGH doctors, nurses and others served at the Base Hospital No. 6 as well as at other hospitals and atfirst aid stations in England and France during WWI. Their recollections – preserved letters, diaries, journals andscrapbooks – provide a glimpse of wartime, from grim accounts of trainloads of wounded soldiers, to descriptions of thehorrors of conditions and disease in the battlefield trenches, to lighter moments of camaraderie and acts of kindness. Ajournal entry, for example, told of a special dinner to mark MGH’s annual Ether Day, held in Talence Oct. 16, 1918.Another clever observation came from Harold G. Tobey, MD, of the Ear, Nose and Throat Service, who wrote aboutmaking do with the tools and materials available: “Dare we confess that, as members of the Massachusetts General

Hospital – the home of the discovery of ether – we used chloroform freely to induce anaesthesia? This was due to untolddelays in obtaining orderlies to present at the time of beginning anaesthesia, and the lack of nitrous oxide. Perhaps wewere fortunate that in over two hundred anaesthesias induced in this way there was not a single accident or any cause ofuneasiness."

Perhaps most insightful is a reflection from Dr. Washburn, who penned a major MGH history volume following hisretirement as MGH general director in 1934. “The spirit of Crusaders was present with them,” he wrote of the men andwomen from the MGH who courageously volunteered to leave the comforts of home and Boston to serve their country. “Base Hospital No. 6, like many others, did what it was called up to do, and did it in a spirit of commendable devotionand sacrifice.”

The Paul S. Russell, MD Museum of Medical History and Innovation has planned a number of exhibits and programsabout the MGH and World War I. The first of a series of rotating exhibits, including documents from staff who served atBase Hospital No. 6, has been installed in the display case in the Main/Lunder Lobby. During the next two years, wewill continue to honor those who served in World War I by telling their stories and describing how medicine hasadvanced from the harsh lessons of war. In addition, later this year, we will mark the 100th anniversary of the Halifaxharbor explosion and the response from the Boston medical community to that great tragedy, and we will take a closerlook at the devastating 1918 influenza epidemic.

I want to extend my thanks to the staff of the Russell Museum, MGH Archives and Special Collections, the MGHNursing History Committee and many others who have helped create a fitting recognition of our MGH predecessorswho shepherded our hospital, our soldiers and our nation through a transformative time in history – a time that clearlyhas affected the way we care for patients today.

Mass General Highlights

MGH Community, Boston, Nation Rally to Stand Up for Science

I was thrilled to see nearly 500 MGHers, their families and friends gather together on the Bulfinch Lawn and under thetents April 22 – Earth Day – to rally together in support of science and research. In Boston, across the country andaround the world, supporters gathered for the March for Science, a public demonstration advocating for public fundingfor scientific research. Research and science are vital to the MGH, Boston and our nation, and it was truly inspiring tosee so many who took time on a cool, rainy Saturday afternoon to join in the rally at the hospital followed by the marchdown Cambridge and Tremont streets. It was also an honor to have US Congressman Stephen F. Lynch join us for ourrally and offer some inspiring words that fired up the crowd. I thank each and every one of you who were able to join usin our march in solidarity from the Bulfinch Lawn to the Boston Common, homemade signs and spirits both held high.You can get a sense of the passion and enthusiasm of the day through this video of images from the MGH rally andMarch for Science.

MGH Enters into Strategic Collaboration with New Hospital in Shanghai, China

Earlier this month I had the opportunity to join colleagues in Shanghai, China, to announce a strategic collaborationbetween the MGH and Jiahui Health Network, which is preparing to open the brand new Jiahui International Hospitallater this year. For several years the MGH has been advising Jiahui in several strategic areas, and we recently agreed toformalize that relationship as the Jiahui plans and builds its new hospital dedicated to bringing high-quality world-classpatient care to the people of their community and beyond. In addition to providing guidance in facilities, building,operations, and governance, MGH teams from Nursing and Patient Care Services and the MGH Cancer Center areadvising Jiahui in those respective areas and sharing best practices, training protocols, experience and expertise. We’reproud to work with Jiahui to develop innovative care models in China, and we value the opportunity to learn from ourChinese colleagues and apply those lessons to the ongoing work here in Boston. I want to thank Jeanette Ives Ericson,RN, DNP, FAAN, senior vice president for Patient Care and chief nurse, Greg Pauly, interim CEO of the MGPO, andtheir teams for leading these efforts and establishing what we hope will be a long, fruitful and mutually beneficialrelationship.

Two Administrative Professionals Honored with Pamela Ellis Award

Each year we honor the members of our valued administrative support staff, who each day provide vital services,assistance and oversight that enable the MGH to not only deliver the best patient care possible, but also help advance allof our missions. This year, out of 71 nominations, two outstanding staff members were selected to receive the Pamela J.Ellis Memorial Secretarial Award, which honors exceptional administrative support staff members who exhibitoutstanding qualities and performance. Congratulations to Salone Callender, patient services coordinator at MGHPrimary Care Boston, and Rony Dieuseul, patient services coordinator in the Psychiatry Department. On behalf of agrateful hospital community, I thank all administrative staff for your tremendous efforts, compassion and dedication inmaking the many programs, departments and services of the MGH run smoothly.

Hospital Recognizes Scientific Excellence at Annual Celebration

This year, for the first time, our annual Celebration of Science on April 5 was combined with the presentation of theWarren Triennial Prize to cancer immunotherapy pioneer James P. Allison, PhD, of the University of Texas MDAnderson Cancer Center. His description of the development of the first immune checkpoint inhibitor, which hassignificantly extended the survival of some melanoma patients by “removing the brakes” that suppress the immunesystem’s anticancer activity, followed fascinating presentations by Nir Hacohen, PhD, and Marcela Maus, MD, PhD,of the MGH Cancer Center; Arlene Sharpe, MD, PhD, Harvard Medical School; and Glenn Dranoff, MD, NovartisInstitutes for Biomedical Research, who outlined their own investigations in this truly promising field.

The morning’s Celebration of Science featured presentations by the winners of our top research prizes: DouglasMacArthur, PhD, of Medicine and the Center for Genomic Medicine who received the Martin Prize for ClinicalResearch; Alexander Soukas, MD, PhD, of Medicine and the Center for Genomic Medicine received the Martin Prizefor Fundamental Research; and Mario Suvà, MD, PhD, of Pathology and the Center for Cancer Research who receivedthe Howard Goodman Fellowship.

Also announced was the 2017 class of MGH Research Scholars: Galit Alter, PhD, Ragon Institute, Medicine; AndrewChan, MD, MPH, Division of Gastroenterology, Medicine; Stephen Haggarty, PhD, Center for Genomic Medicine,Neurology; David Langenau, PhD, MGH Cancer Center, Pathology; Hakho Lee, PhD, Center for Systems Biology,Radiology; Anders Näär, PhD, Center for Cancer Research, MGH Cancer Center; Richa Saxena, PhD, Center forGenomic Medicine, Anesthesia, Critical Care and Pain Medicine; and Jennifer Temel, MD, Division of Hematology-Oncology, Medicine.

Once again I’d like to thank David Louis, MD, chair of ECOR and chief of Pathology; David Fisher, MD, PhD, vicechair of ECOR and chief of Dermatology; Harry Orf, PhD, senior vice president for Research; and Maire C. Leyne,MS, MBA, ECOR director, and her team for organizing what David Louis accurately predicted would be an“extraordinary day of science.”

Boston Marathon Finish Line Marks Beginning for MGH Programs

We are truly fortunate to work among so many remarkable individuals who strive to make a positive difference in thelives of our patients both at the bedside and beyond. This month, we again witnessed that remarkable spirit andenthusiasm in the MGHers who pinned their bib numbers to their shirts, laced up their sneakers and put their long hoursand months of training to the test during the demanding 26.2 miles of the Boston Marathon. I want to take thisopportunity to extend deepest thanks to employee runners as well as the many others who so generously ran for andsupported our MGH Marathon Teams. The grit and determination of the runners and the generosity of the donorsenabled $1.3 million to be raised for various hospital programs.

Hospital’s Green Efforts Recognized with Environmental Award

The MGH will be honored at an awards gala next month with a Practice Greenhealth Partner for Change Award,

recognizing our ongoing commitment to improving environmental performance and exhibiting excellence insustainability. Practice Greenhealth is the nation’s leading health care community dedicated to transforming health careworldwide. The organization applauded the MGH’s efforts to continuously improve and expand upon programs toeliminate mercury, reduce and recycle waste and source products sustainably. Kudos to all who work to make ourhospital a more eco-friendly place.

Quality in Context

MGH’s Stay Connected Program Earns Mass Health and Hospital Association Award

The MGH’s Stay Connected Program was recently honored with a Massachusetts Health and Hospital Association(MHA) Accountable Care Compass Award for its innovative efforts to reduce avoidable readmissions among high-riskpatients. The MHA awards recognize provider excellence and innovation in the delivery of high-quality, patient-friendly, safe and efficient care.

The Stay Connected Program earned second place. The goal of the program is to improve patient care and increasehospital capacity by reducing avoidable readmissions, one of Mass General’s key strategic initiatives. The team createda bundle of interventions for patients at high risk of readmission. The program has been implemented on six generalmedicine units, and has been partially implemented on two cardiology units. The Stay Connected Program bundleincludes:

· Post-discharge appointment within seven days, scheduled prior to discharge· “Meds to beds”: medication reconciliation, counseling and delivery to bedside· High-risk case manager care coordination for up to 30 days post-discharge· Nurse practitioner home visit(s) within 24 to 48 hours of discharge and/or urgently as needed up to 30 days

post-discharge· NP-coordinated handover for patients discharged to an to IPC skilled nursing facility

The program is already having an impact. Between March and November 2016 an estimated 121 readmissions and 968bed days were avoided on the Stay Connected Program units. Additionally the program is having the desired impact onthe readmission rate, which is significantly lower on Stay Connected Program units, as seen in the graph below.

This award reflects Mass General’s ongoing efforts to provide patient-centered, high-quality care. Thanks to RyanThompson, MD, Jessica Smith Yang, RN, Nancy Sullivan, and Maryellen O’Dea for leading this initiative. Specialthanks to the multidisciplinary team – Case Management, inpatient administrative coordinators, Nursing, Pharmacy,care providers and Social Work – who have worked closely with the patients and families on this effort.

By the Numbers

March Update

The hospital ended March with a $36 million operating gain for the month, which was ahead of budget by $2.2 millionand $11.6 million better than last year. Year-to-date, the gain of $89.5 million was below projections by $10.6 millionand $3.7 million lower than the previous year, mostly because of the unfavorable pension issue. Without the pensionvariance, we would be $7.6 million ahead of budget for the year. Net patient revenue was $3.9 million below budgetbecause of unfavorable patient activity on the outpatient side, offset in part by solid inpatient activity and some one-timesettlements. Expenses were favorable to budget by $3.3 million because of lower-than-projected salary and benefitexpenses, offset by unfavorable supply expenses. Indirect research revenue of $18.8 million was ahead of budget by$1.7 million.

March, Fiscal Year 2017 Statistics

Inpatient Activity Month to Date Variance Year to Date VarianceActual vs. Budget vs. Last Yr. Actual vs. Budget vs. Last Yr.

Admissions 4,261 -42 120 24,662 -470 343Discharges 4,600 -22 56 26,462 -409 118Inpatient Surgeries 1,673 -115 -121 9,675 -723 -455Births 327 16 19 1,852 16 82Patient Days 27,513 -1,066 291 157,068 -6,892 -2,858

Length of Stay 5.98 days -0.20 days -0.01 days 5.94 days -0.16 days -0.13 days

Outpatient Activity Month to Date Variance Year to Date VarianceActual vs. Budget vs. Last Yr. Actual vs. Budget vs. Last Yr.

Outpatient Visits 80,904 -6956 -6,469 444,469 -19,357 -4,361Main Campus 41,804 -3,192 -4,264 230,098 -6,900 -587Health Centers 27,716 -3,118 -1,980 151,122 -11,070 -3,126Danvers 1,942 -56 -437 11.239 747 177

Outpatient Surgeries 2,234 -48 101 12,147 132 110Main Campus 1,570 -9 23 8,484 125 30Danvers 369 -10 96 1,933 -43 110Waltham 295 -29 -18 1,730 50 -30

Observation Cases 960 -48 136 5,691 415 560ED Visits 9.493 -603 230 52,253 -2,206 -824

Financial Position Month to Date Variance Year to Date VarianceActual vs. Budget vs. Last Yr. Actual vs. Budget vs. Last Yr.

Operating Income $36.0 million $2.2 million $11.6 million $89.5 million($10.6) million ($3.7) million

*Note: the above statistics pertain to Hospital activity only; visit volume is for Hospital billed physician visits only.

Population Health Management Report – April Update

Providing better and timelier access to services for patients and preventing avoidable increases in costs of care are bothcritical to our mission. At a high level, we track four indicators of our success in these areas. The rate of new patientspecialty visits has increased over this past quarter. Although some of the increase may be attributed to routineseasonality, our ambulatory practices are working hard to improve access, many of them through innovations such astelehealth. We are also trying to hold down the growth in costs of care for commercially insured and Medicare patientswho see MGH primary care physicians. The trend in total cost of care for both commercially insured patients andMedicare Accountable Care Organization (ACO) patients was lower than benchmarks. We are seeing both lowerEmergency Department use and lower medical inpatient admissions among our ACO population. This decrease inmedical admissions may be the result of population health management programs such as the Mobile Observation Unitand the skilled nursing facility three-day waiver program. As we strive to prevent avoidable hospital admissions, severalgroups within the institution continue to develop initiatives to provide alternatives to hospitalization when appropriate.

Description Population NetworkMeasurement

Period

Target toBeat Performance

Status

% NewOutpatient Visits

All Patients MGH Rolling 3-monthaverage as of March2017

Increaseover PriorPeriod

Increase from18.6% to 19.2%

Favorable

Change in TotalCosts of Care(Trend)

CommercialAdult

MGH Rolling 12-monthaverage as of Nov2016

6.30% 3.80% Favorable

Change in TotalCosts of Care(Trend)

MedicareACO

MGH 2016 Jan throughDec

4.5% 3.30% Favorable

InpatientAdmissions Per1000 (rate)

MedicareACO

MGH 2016 Jan throughDec

Decreasefrom PriorPeriod (CY2015)

Decrease from272.4 to256.95

Favorable

EP12 Attachment e- part 1.htm[5/21/2017 3:14:41 PM]

Two-Way Talk

Send questions, comments or ideas about this newsletter to the From the Desktop mailbox – “MGH From the Desktop”in the Partners e-mail directory. The address is [email protected].

Go Celtics!

May 4, 2017 — Caring Headlines — Page 9

Recognition/Innovation

Multi-disciplinary teams receive Compass Awards

— by Maryellen O’Dea and Jessica Smith Yang, RN

he Massachusetts Health & Hospital Association held its second annual Compass Awards, March 9, 2017, to recognize provider excellence and innovation in the delivery of safe, efficient, high-quality care. Two MGH teams, the Psychiatry Team and the Stay Connected Program, were recognized earn-ing second-place honors. The Inpatient Psychiatry Team was nomi-nated in the Providing Care to Special Populations category, demon-strating a sustained decrease in length of stay (from 11 to 9 days) over several years. The team also showed improvement in pre-noon dis-charges and admission volume.

The Stay Connected Program was nominated in the category of Reduc ing Hospital-Acquired Conditions and Re-Admissions. Imple-mented in 2016, the program is a bundle of services offered to high-risk patients on six general medicine and two cardiology units. Initial results show a decrease in re-admissions compared to a control group with a similar patient population. Special thanks to the multi-disci-plinary team, including: Case Management, Nursing, Pharmacy, Social Work, providers, and inpatient administrative coordinators.

For more information, call Maryellen O’Dea at 617-643-0201.

T

Accepting on behalf of their teams (l-r): Connie Cruz, RN; Tina Stone, RN; and Karen Rosenblum, RN, from the Psychiatry Team; and Jess Smith Yang, RN, and Maryellen

O’Dea, from the Stay Connected Program.

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight

Massachusetts General Hospital Massachusetts General Physicians Organization

Strategic Plan

January 2014

Excerpts from MGH/MGPO 2014 - 2024 Strategic Plan

MGH Strategic Imperatives and Priorities

Overview of Strategic Imperatives

This strategic plan is built around four interconnected strategic imperatives:

I. To define and deliver the highest-quality care to our patients while controlling healthcare costs. As a leading academic medical center, the MGH strives to set the standard inproviding the very best care available -- both to define what it is and to deliver it – while atthe same time, leading in efforts to contain the cost of care.

II. To sustain and enhance our academic and community missions. In order to define anddeliver the highest-quality care to our patients while controlling health care costs, the MGHmust continue to lead as an academic institution – enabling research to find bettertreatments and training the next generation of leaders – and to redouble its commitment toimproving the health of its community.

III. To strengthen our ability as an organization to deliver on the above. This ambitiousstrategic plan will be implemented during a period of tremendous change and evolution inhealthcare. Successful execution demands an organization that is well-trained, diverse,flexible and adaptable, supported by a state-of-the-art infrastructure and strong governance.

IV. To maintain our financial sustainability. None of the above will be possible unless theMGH is able to maintain its financial strength during what is expected to be a challengingperiod for healthcare providers. To that end, the strategic initiatives set out in this planserve the dual purpose of advancing MGH’s ability to achieve its mission-based goalswhile bolstering the institution’s financial health.

Strategies to Define/Deliver Highest Quality Care to Our Patients While Controlling Health Care Costs

1. Redesign the model of care from the patient perspective

MGH runs at an average daily inpatient operational occupancy rate of 92%; during peak days and hours, this rate can run above 100%. The current operating model limits patient access to inpatient care – potentially compromising clinical care, decreasing patient satisfaction and impacting employee morale. Factors impacting capacity – and thus access and service levels – include inappropriate admissions, readmissions, and inefficiencies, which lead to longer stays.

On the outpatient side, access can be a source of frustration for patients and referring physicians alike. Available data from the last ten years on sources of new patients suggests that MGH retains roughly only 1/3 of patients after their first visit, and anecdotal evidence suggest that difficulties with access, lack of clarity around availability of services and communication gaps are drivers of this trend. Referring physicians have historically reported a number of challenges

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight

jeb23

Highlight



MGH Capacity Taskforce: Work Group Structure, Membership & Staffing

Chair: David Brown, MD PM: Bob Seger & Beth Grabowski

PI: Joan Strauss Analytics: Aaron Fishman/MIT

Members: Tim Ferris, MD

MaryFran Hughes, RN Keith Lillemoe, MD

Ann Prestipino Ali Raja, MD

Jerry Rosenbaum, MD David Storto

Chair: Tim Ferris, MD PM: Elizabeth Fonseca

PI: Maryellen O’Dea Analytics: Andrea Tull /MIT

Members: Katrina Armstrong, MD

Mary Cramer Liz Mort, MD

Brit Nicholson, MD Nancy Sullivan

Ryan Thompson, MD Theresa Gallivan, RN


PM:

PI: Gianna Wilkins


Members: Peter Dunn, MD

Theresa Gallivan, RN Jeanette Ives Erickson, RN, DNP

Tony James Kimi Kobayashi, MD

Ben Orcutt Walter O’Donnell, MD

Greg Pauly Maureen Schnider, RN



Non- Acute Care: Chaired by David Storto with support to be determined as needed by teams

Rosters: MGH Capacity Task Force, High Risk Population Subcommittee and Stay Connected Operations Team

January 2016

Preventable Readmissions

High Risk Population HF/AMI Population

Tim Ferris, MD

Taskforce 2: Work Group Structure, Membership & Staffing

Chair: Ryan Thompson, MD Co-Chair: Jessica Smith Yang, RN

Co-Chair: Nancy Sullivan PM: Elizabeth Fonseca

PI: Maryellen O’Dea

Members: Laura Carr, PharmD Debra Connolly, CM Jocelyn Carter, MD

Mary Cramer Matt Kim

Kimi Kobayashi, MD Karon Konner, SW

Susan Lastinger, CM Donna Rusinak Dana Sheer, NP

Andrea Tull

Chair: Greg Lewis, MD

Co-Chair: Elizabeth Geagan

PM: Elizabeth Fonseca

PI: Maryellen O’Dea

Members: Mary Cramer

Nasrien Ibrahim, MD Jim Januzzi, MD

Retsef Levi Jacqueline Ruckel, NP Ryan Thompson, MD

Jag Singh, MD Jason Wasfy, MD Cecilia Zenteno

Taskforce 2 Leadership: Katrina Armstrong, MD, O’Neil Britton, MD, Mary Cramer, Theresa Gallivan, RN, Liz Mort, MD, Ryan Thompson, MD, Nancy Sullivan

January 2016

jeb23

Highlight

Stay Connected Program Operations Team Members

First Name Last Name Dept/AreaRhodes Berube Department of MedicineLaura Carr PharmacyJocelyn Carter, MD Department of MedicineDebra Connolly, RN Case ManagementMary Cramer Performance ImprovementElizabeth Fonseca Population Health ManagementJoanne Kaufman, RN Case ManagementMatt (Taekyu) Kim Center for Quality and SafetyKimi Kobayashi, MD Department of MedicineKaron Konner, LICSW Social WorkMaryellen O'Dea Performance ImprovementDonna Rusinak MGPOErin Scott, MD Palliative CareDana Sheer, NP-C Partners Healthcare at HomeJessica Smith Yang, RN NursingNancy Sullivan Case ManagementRyan Thompson, MD Department of MedicineLuis Ticona, MD Partners Healthcare at HomeAndrea Tull Center for Quality and SafetySusan Lastinger, RN Case Management

January 2016

Exemplary Professional Practice: Interprofessional Care to … · previous six months (June to...

Documents

Transcript of Exemplary Professional Practice: Interprofessional Care to … · previous six months (June to...