DataVision

Sepsis - Mortality

Heart Failure – Readmissions [Nurse Transition Coach Model]

Presented by: Elizabeth Fonseca, RHIA MCSM

Presenter Name Presenter Title

• 427 licensed beds

• Average daily census = 200 inpatients

• 500+ physicians on staff

• 2700 employees

• Teaching hospital – GME program

• Suburban location 10 miles SW of downtown Chicago

• Acute, transitional, behavioral, and home healthcare services

• 1 of 4 Tenet hospitals within the Chicago Market

Sepsis Quality Project Overview

• Sepsis is leading cause of inpatient mortality in acute care hospitals in the U.S.

• Sepsis is a time-sensitive diagnosis; sepsis resuscitation bundle was

developed and implemented in the ED.

• Sepsis steering committee reviewed literature, performed gap analysis, and

created a “Sepsis Alert” process.

• Simple one-page order set created / Focus Study in Midas+.

• PDSA techniques were used to foster timely protocol and implementation

process improvements.

• DataVision sepsis mortality outcomes studied and reviewed – Pre- and post-implementation mortality outcomes reviewed [Baseline phase versus Sepsis

Protocol Implementation Phase]

– Benchmark reviews

Sepsis

ED

Protocol

Sepsis Focus Study/Data Collection

Sepsis – Data Definitions

DataVision & Statit Scorecard

DataVision and Statit Links

DataVision and Benchmarks

Statit and Pre- / Post-Comparison

Sepsis

Outcomes

Statit

Heart Failure Readmissions

Nurse Transitional Coach Model

Reducing Readmissions

• Upon admission we establish a mutually responsible relationship with patient and family; patient-centered and specific

• Assess the patient’s understanding, goals, and needs (transportation, caregivers, money for medications …)

• Individualize each patient’s care and liberate resources needed

There is no single answer for our patients. They are all different, with their own story and circumstance, their own vision of quality of life.

The transition coach is their teammate, coach, facilitator, organizer, planner, teacher, and partner, always available to help with even their most

fundamental need of respect, trust, and consistency. The transition coach is the voice that is always available for inpatient and outpatient.

Nurse Transition Coach Model,

A Patient-centered Approach

Nurse Transition Coach Model

• Grounded in Jean Watson’s theory of human caring emphasizing rapport and trust building with patients and their families

• Establish a care continuum hand-off with bidirectional communication to ensure shared accountability for collaborative decision making

– Multidisciplinary rounds

– Patient/caregiver follow-up within 48 hours of discharge and weekly for 30 days

– Hand-off to complex care managers after 30 days

– Homecare case manager weekly report

– SNF or subacute weekly report

• Process improvement

– Bedside postreadmission meeting with transition coach, CNO, CMO, case management

– Readmission Review Weekly Meeting and root cause analysis of all readmissions

– Monthly Readmit Care Meeting with community care, home care, social work, case management, quality, transition coaches

Nurse Transition Coach Model

• Receives a starter pack of discharge medications regardless of ability to pay

• Discharged with a follow-up appointment within 72 hours

• Given access to affordable transportation for physician visits (that is, $2 a ride)

• Referred to homecare and seen with 24–48 hours of discharge with recommended visit frequencies

• Bedside report/debriefing for each readmission at 8 a.m. with the Readmit Care Team

• Primary care physician intervenes at readmission to treat and discharge in observation status

ED Readmission Alerts

• ED alert sent to identified healthcare team members that former core

measure patient (within 30 days) has presented in the ED.

• Healthcare team evaluates and treats patient by using information from

previous (index) admission.

• When clinically appropriate; readmission may be avoided.

• All trigger alerts are stored in Midas+ for further clinical evaluation and

performance improvement.

Midas+ Alert Setup

DataVision – Data Definition

Year

HOSPITAL: A

Num Den Percent

2011 50 291 17.18%

2012 31 256 12.11%

2013 12 149 8.05%

Year

HOSPITAL: B

Num Den Percent

2011 46 182 25.27%

2012 24 188 12.77%

2013 10 106 9.43%

Year

HOSPITAL: C

Num Den Percent

2011 20 104 19.23%

2012 33 123 26.83%

2013 8 65 12.31%

Year

HOSPITAL: D

Num Den Percent

2011 26 133 19.55%

2012 22 141 15.60%

2013 11 67 16.42%

Year

CUMMULATIVE

Num Den Percent

2011 142 710 20.00%

2012 110 708 15.54%

2013 41 387 10.59%

DV:Supporting Details

Readmission Reduction Num Den Percent

2009 100 528 0.189394

2010 69 425 0.162353

2011 142 710 0.20

2012 110 708 0.155367

2013 41 387 0.105943

Difference between 2011 and 2013 0.094057

*Difference between 2011 and 2013 / 2011 x 100 47.02842

*Cumulative year 2011: percent: .20 and subtract from the Cumulative year 2013 percent .1059

*Reduction: 0.9 between 2011 and 2013

*Reduction calculation: (2011) .20 x 0.9 = .4795 x 100 = 47.95% reduction

DataVision:Comparative Outcomes

SUCCESS

Questions?