“Kitchen Table – The Source of Truth” Karen Adams, RN, BSN Geisinger Home Care and Hospice and...

“Kitchen Table – The Source of Truth”

Karen Adams, RN, BSNGeisinger Home Care and Hospice

andJanet Comrey, MHSA, RN

Sr Consultant, Population HealthGeisinger Health System

May 17, 2012

“What is needed is a shift from a focus on providing excellent care just within the walls of various clinical settings to understanding and attending to the experiences of patients over time, across settings”

Birk,Susan : Reducing Hospital Readmissions, Healthcare Executive. Mar/April 2012

Copyright Geisinger Health System 2012Confidential and ProprietaryNot for use or distribution without permission

Every morning Henry wakes up, sits down with his cup of coffee, bowl of oatmeal, and checks out the latest gossip in the day’s newspaper. Alongside his bowl he lines up his morning drill of medications; one pill for his heart, another for his cholesterol, one funny shaped one he can’t remember why he’s taking, a big vitamin his daughter said he should take, and his daily aspirin for his aching knees. Come dinner time he lines up his next round, asking himself, “Did I take that one already?” or “Was I supposed to take that one with food?” or “Did the doctor tell me to wait until bedtime to take that one?” This is the battle Henry faces each day. Chances are he’s taking at least one or more of his medications inappropriately and runs the risk of experiencing a number of negative side effects…..

Aging & Disability resource Center, WI. (2011)

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www.adrc-cw.com


Why be concerned about Transitions of Care?

Readmissions increasingly represent quality indicator

One in five seniors are readmitted within 30 days

Up to three-quarters may be preventable

$15 billion to Medicare program

“The Billion Dollar U-turn”

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Jencks, Williams & Coleman, NEJM 2009MedPAC, 2007Taylor, H &HN 2008


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Recent Publications :

Dartmouth Atlas: “…there was relatively little change in 30-day readmission rates from 2004 to 2009, regardless of the cause of the initial hospitalization.”

JAMA: “Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly.”

Annals of Internal Medicine: “No single intervention implemented alone was regularly associated with reduced risk for 30-day re-hospitalization.”

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www.dartmouthatlas.org, Released September 28, 2011.JAMA. 2011;306(15):1688-1698. Released October 19, 2011.Ann Intern Med. 2011;155:520-528. Released October 18, 2011.


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Quality Advisor™ Inpatient data All-cause readmission 30 day- last 12 mos

(Premier, inc.)

We should be able to impact

Where is largest opportunity?


Thirty Day Readmission Rate* by Discharge Disposition CY11 to Any Provider

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* All Cause Readmissions to same facility excluding Psych, Rehab, and Deaths from the denominator

76% of patients were either discharged to home or to home with home health


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Readmissions

DRIVERS KEY TACTICSGOAL

Screening

Care Mgmt: Inpatient/ Outpatient

Team Communi-

cations (IDTs)

Patient Education/ Med

Rec

Drivers of Reducing Readmissions

Post-Transition Care

Early identification of readmission riskTarget interventions based on risk level

Early DC needs assessment of high risk ptsDC Planning – choose best next care setting

Seamless transition between IP & OP Care Mgt

Proactive Outreach programs

Multi-disciplinary care coordination

Social issues addressed (non-compliance, ability to buy meds, advanced directives)

Patient Activation and Engagement

Comprehensive Transition PlanningTeach-Back methodology

Post-DC Follow-up appt for EVERY patientInstant communication of Transition Record to post-DC providers/agencies

IP Pharmacist consult on high risk pts/meds

MH with tele-monitoring, follow up phone calls, SNF management

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Major Initiatives from January 2008 to the Present:• Risk Screening• Interdisciplinary Team Rounds (IDTs)• Care Management Assessment/Workflow• Proactive Outreach

• Kitchen Table• Discharge Bundle• ProvenHealth Transitions

GHS Transitions Processes


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Readmission Risk Screening


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Based on the premise that:– Resources are finite– One cannot bring all resources to bear on each patient– Highlighting “High Risk” patients raises awareness within the health

care team– Interventions focused on patients at highest risk for readmission

Readmission Risk Screening


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Comprehensive care management assessment regardless of perceived “discharge needs”

Transition care activation (one or more)– Outpatient care management referral– Pharmacist review of high risk medications– Post discharge home care visit

Order primary care provider and/or specialist follow-up appointment prior to discharge with reminders to admitting physicians

Readmission Risk Screening – High Risk Targets


Scoring guidelines:0 – 2 Low Risk3 – 7 Medium Risk8 – 22 High Risk

TOC Readmission Risk Screening Tool

“YES” = point value designated for question

“NO” = 0 points

The weight given to each question in this tool is based on that response’s influence on the overall likelihood of patient’s readmission within 30 days

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narcotics


Screening

QuestionPotential

ScoreOdds Ratio

P-value

Age 65 or Greater? 1 1.24 <0.0001

Admitted from SNF or Requires Paid or Family Care 1 1.49 <0.0001

Currently has CHF, COPD, ARF, CRI, or is on dialysis 2 1.71 <0.0001

Takes more than 5 Prescription Medications 1 1.93 <0.0001

Takes Digoxin, Insulin, Anticoagulants, Narcotics or ASA /Plavix

1 1.58 <0.0001

History of Wound Infection or Poor Healing Wound 1 1.62 <0.0001

History of Pulmonary Embolism or DVT 1 1.31 <0.0001

Uses Cane, Walker, Wheelchair or Person to get Around 1 1.46 <0.0001

Will be alone after discharge or unable to attain assistance 2 1.09 0.0787

Hospital Admit in Past 12 Months 5 2.19 <0.0001

On Disability 2 1.39 <0.0001

Patient Considers own Health 2 1.21 <0.0001 | 16


Screening

All patients screened

Nursing driven – ED and floor

Surgical pre-admission screening

Resource management| 17| 17| 17

37,735 patientsTwo hospitalsNegative predictive value = 90.8%


Readmission Rates by Screening ScoreFeb 11 – Jan 12

Includes: GMC GWVAGP4 IP BP6 IP GP2 IP CSU IP MS4W IP MS5E IP MS6E IP AGP5 IP BP7 IP HFAM 7 IP MS3 IP MS5 IP MS6 IP PCU IP BP5 IP BP8 IP HFAM 8 IP


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Care Management Assessment/Workflow and Proactive Outreach


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A full Care Management Assessment is completed for:– Patients with a high risk of readmission based on TOC readmission risk screen

results– Patients with any discharge planning needs that are to be arranged by Inpatient Care

Management staff– Appropriate Patients who can be referred to :

• SNFists• OP Case Management/Medical Home

• Kitchen Table program - one medication management home visit post-discharge for select population

An abbreviated screening is completed for:– Patients with a low risk of readmission based on TOC readmission risk screen results– Patients with no discharge planning needs including:

• Patients who will be discharged to home with no services that would be arranged by Care Management staff

• Patients at the end of life who are expected to expire prior to discharge

Review of Readmissions that occur for preventable issues

Care Management/Outreach


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Kitchen Table

Medication non-adherence drives 10 to 25 percent of hospital and nursing home readmissions (WHO, 2010)

Patients being discharged from the hospital who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow-up appointments, are 30 percent less likely to be readmitted or visit the emergency department than patients who lack this information (AHRQ, 2011)


GHS Home Medication Management Referral Program – The Kitchen Table Program®

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Home Care RN visit for secondary medication reconciliation and patient education post-DC – HHC RN coordinates w/ IP Pharmacist for questions/issue resolution

Eligibility:Pt screened as HIGH risk for readmission on TOC toolPt discharged to home setting with home health needPt not actively enrolled with ProvenHealth NavigatorPt lives in GHC service area & agrees to home care visit


Patient ReferralHome Care Nurse Pharmacist Doctor

Access EMR D/C Medication List

Collect Actual Medication List

Is there aDiscrepancy?

Nurse calls Pharmacist

Update Plan of Treatment

Educate Patient

Distribute Plan of Treatmentto PCP / Hospitalist

Fax Listto Pharmacist

EPIC Messageto Nurse

Check forInteraction

Verbal Orderto Nurse

Update EMR

DoctorRecommendation

to Pharmacist

Doctor Signs and Returns

Yes

No

YesNo Consult

Hospitalist

No

Yes

No

Yes

PotentialHarm?

Can PharmacistResolve?

PotentialHarm?

Home Care Medication Management Model


The Kitchen Table Program® Results

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Internal Data, FY 2011 pilot

Kitchen Table

• 110 total enrollees


About Cost of Readmissions at GHS

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• We estimate the average cost for a Readmission at Geisinger as $8,970 with an average length of stay of 5.7 days during those readmissions•Assuming a readmission rate of 18.0% for the high risk population, we would have expected about 20 patients of the enrolled population (110) to be readmitted.•Knowing only 12 Kitchen Table enrollees were actually readmitted, we assume 8 admissions were prevented.

• Assuming a cost of $100 per enrollee, providing Kitchen Table consultation for 110 enrollees equates to $11,000.

•Assuming prevention of readmission for 8 enrollees, using the above calculated costs, we potentially have saved the system $60,760.00 and 46 bed days.

•How many more within the total population could we have prevented??


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ProvenHealth Transitions


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Geisinger’s ProvenHealth Transitions

12-point Bundle(Proposal)


Summary

Systemic approach to transitions

Screening to effectively deploy resources

Engage health care team and patients/families

Plan post-acute follow-up

Deliver accurate information in timely manner

Engage patient longitudinally post-discharge| 28


Questions?

Karen Adams, RN, BSN

Geisinger Home Care and Hospice

[email protected]

Janet L Comrey, MHSA, RN

Sr. Consultant, Pop. Health

[email protected]


“Kitchen Table – The Source of Truth” Karen Adams, RN, BSN Geisinger Home Care and Hospice and...

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