Transcript Insert Session Title

Bethany Model of Care
Sister Jacquelyn McCarthy, CSJ, RN
CEO/Administrator
Bethany Health Care Center
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Faculty Disclosures
Sister Jacquelyn has disclosed that she has
no relevant financial relationships.
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Learning Objectives
By the end of the session, participants will be able to:
• Understand the importance of daily collaboration of interdisciplinary
nursing and support teams who provide timely intervention and
implementation of medical care.
• Understand the importance of adherence to institution organizational
improvement plans.
• Understand that providing a comprehensive array of in-house
medical services and an in-house education program tailored to
enhance the delivery of quality care requires a willingness of the
staff to change from the traditional way of caring for our residents to
a resident-oriented approach.
• Understand the impact of low employee turnover on care given to
residents.
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Facility Demographics
• Bethany Health Care Center
• Framingham, Massachusetts
• Total # of Beds = 101
• A Non-profit Facility Sponsored by the
Sisters of St. Joseph of Boston
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Bethany Model of Care Program
• Initiated formal study beginning January, 2003 – program was in place to
a degree prior to this date.
• We wanted to have a “treat in place” modality of care.
• We believe we could reduce the number of unnecessary admissions to
the acute care setting.
• We had historically followed this mode of care, but had not studied
outcomes.
• Our objective was to verify that “treat in place” philosophy could be an
option for residents who reside in long term care facilities and have
positive outcomes.
• Efficacy - the degree to which a test, procedure or service meets the
individual’s needs, desired or projected outcome(s).
• Appropriateness - the degree to which care and services are relevant to
the individual’s needs, given the current state of knowledge.
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Bethany Model of Care Program (Continued)
• Availability - the degree to which appropriate care and services are
available to meet the individual’s needs.
• Timeliness - the degree to which the care and services provided to the
individual are at the most beneficial or necessary time.
• Effectiveness - the degree to which care and services are provided in the
correct manner, given the current state of knowledge, to achieve the
desired or projected outcome.
• Continuity - the degree to which the individual’s care and services are
coordinated among practitioners, among organizations and over time.
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Project Timeline
Study was conducted over 5 years 2003 – 2007
Planning and Research
Data compiled included:
1. Age of Residents – Currently Bethany residents 85 years old and
over is 73%. Compared to Massachusetts state average of 45% and
national average of 41%.
2. Number of hospitalizations: 29 in 2003 to 8 in 2007
3. Number of infections:
129 in 2003 to 74 in 2007
4. Number of deaths:
33 in 2003 to 21 in 2007
5. Average number of medications residents receive:
40% - 9 medications or less
6. Positive contributing factors:
a. Low turnover of direct caregivers
RNs:
31% in 2003 - 9% in 2007
LPNs:
7% in 2003 - 0% in 2007
CNAs:
15% in 2003 – 21% in 2007
b. Care hours provided 3.5 to 3.8 hours per resident; Massachusetts
standard is 2.6.
7. Reviewed Contracted Vendor use looked for ways to improve inhouse service to residents.
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Project Timeline (Continued)
Issues encountered:
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How do we bring as many services to the facility as possible so
that residents do not have to leave the building.
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Added Mobile Barium Swallow Capability.
Added Psychiatrist to Bethany Staff.
Added INR Testing On Site.
This is an on-going study monitored by our QI team that meet
monthly.
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QI Planning & Implementation
•
Committee Members meet monthly:
CEO/Administrator
Pharmacy
Assistant Directors of Nursing
Lab
Director of Nursing
X-Ray
Medical Director
Rehabilitation
Department Heads
Human Resources
Nurse Managers
Pastoral Care
Social Services
• Interdisciplinary members meet daily.
Meetings: Results communicated to Staff at QI meeting
• Collaboration with committee to look at best practice.
• Identify high risk issues such as falls, weight loss, infections, change of
condition promptly at daily interdisciplinary meetings.
• Continue to monitor to see if factors changed and effect on resident care.
Plan Review
• Staff
• Quality Assurance Committee
In addition:
• Each month the information regarding fall, weight loss, infections is
communicated to Staff.
• Each day information regarding changes in condition is shared with Nursing
Staff, Social Service and Administration.
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Issues Found/Communicated
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Residents preferred to be treated in their own home at Bethany.
Families/Health Care Proxies are in agreement with resident’s
preference to be treated at our facility.
Longevity of staff builds relationships with residents. Consistent
care assignments of CNAs; Medical Director at Bethany more
than 20 years; NP more than 5 years; DON 19 years; ADON 15
years; Administrator 12 years.
Quick assessment of health issue and intervention reduced need
for hospitalization. Staff recognizes subtle changes in resident’s
condition allowing for quick assessment of health issues.
Five days per week visit by facility Physician and Nurse
Practitioners. 24 hour availability of Primary Medical Director and
Nurse Practitioners allows for immediate intervention and
implementation of care to reduce need for hospitalization.
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Tools Used to Affect Change
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Tools used
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In the beginning
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Committed Medical Director whose philosophy is to treat in place when at all
possible and who practices evidenced-based medicine.
Five day per week visits by on-site Primary Nurse Practitioners. Five days per
week visits to the facility by Medical Director to those who are experiencing health
decline.
As time progressed
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Round table discussions with contracted psychiatrist to discuss behavior
modification.
On-going training of nurses on physical assessment of residents by Education
Coordinator, NPs, Pharmacy, Rehabilitation, and Audiologist.
Monitoring of turnover rate of staff at facility and compare with State average.
On-site monitoring of necessary hospitalization and number of MLOA days.
Proactive fall reduction program to reduce unnecessary hospitalizations.
– Rehab rounds weekly.
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Daily discussion of falls and high risk residents with interdisciplinary team.
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Walking club.
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Daily exercise classes.
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Daily activities on each unit to keep residents engaged.
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Tools Used to Affect Change (Continued)
•
Tools used
– As time progressed (continued)
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Monitoring of meal consumption. Adequate nutrition reduces skin
breakdown and reduces admissions for those who are diabetic.
– Watch your weight group (for residents who are trying to lose
weight)
– Food group meetings (for all residents to discuss menu
choices and favorite foods)
– Monthly weight management meetings.
– Weight changes discussed at weekly interdisciplinary meeting.
Prevention of infections through vaccinations of staff and
residents, education of staff and residents.
Tools created
–
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Use of on-site Barium Swallow
INR testing in-house
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Facility Expenses
• No additional costs were incurred because planning and
execution were done during normal work hours. However, the
cost of on-call psychiatrist was $1500 per month and use of
coagucheck was $156.25 per month.
Supplies for the
coagucheck were about $250 per month. Facility receives
reimbursement of about $5.95 per INR. Average number of INR
tests done: 105 per month.
• The BMCP "treat in place" modality of care has resulted in cost
savings associated with decreased hospitalizations, testing,
medication costs and transportation services.
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Outcomes
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Reduction in hospitalization and infection:
– 29 residents hospitalized in 2003; 7 residents hospitalized in 2007.
– Decreased days in hospital: 102 in 2003 to 34 in 2007.
– Reduction in infections from 129 in 2003 to 74 in 2007, with the most notable
reduction in urinary track infections: 53 in 2003 to 26 in 2007.
– A fall reduction program that included weekly rehab rounds that reduced the
number of hospitalizations.
– Average number of medications prescribed decreased.
– 40% of Bethany residents take fewer that 9 medications.
– Deficiency free DPH survey rating 11 consecutive years.
– One of 33 homes in the United States to receive a 5-Star rating from the Federal
Government.
– 100% referral recommendation from residents and families who responded to a
Massachusetts Department of Public Health Survey.
– Reduction in turnover rate of employees:
2003
2007
• RN
31%
7%
• LPN
7%
0%
• NA
15%
21%
– Reduced recruitment and training costs.
– Consistent resident care assignments have brought benefit to residents who
have their issues addressed quickly and staff who have strong relationships with
residents.
– Staff satisfaction with job improved.
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Closing Thoughts
This model of care can be easily replicated.
Essential Elements Needed:
1.
2.
3.
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5.
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Dedicated Medical Director.
Nursing Department with strong assessment and collaborative skills.
Quality Improvement Program that meets regularly and resolves
issues across departments.
Salary and benefit package that will keep turnover rate low.
Common understanding and acceptance among employees and
families that “treating in place” can prevent hospital acquired
conditions.
“Treating in place” can and does improve quality of life!
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