Transcript Document

IMPLEMENTING A HOSPITALIZATION MONITORING
SYSTEM IN MULTIPLE NURSING FACILITIES: A TWOYEAR QI PROJECT ACROSS A CCRC CORPORATION
Peter Jaggard MD CMD
Mary Ann Anichini, GNP-BC
et. al.
Presbyterian Homes
Evanston, Illinois
Speaker Disclosures:
Dr. Jaggard is an employee of Presbyterian Homes. He
has no other relevant financial disclosures.
Learning Objectives:
By the end of the session, participants will be able to:
• Objective 1: Describe reasons why hospitalization, rehospitalization,
and preventable hospitalization rates are important for nursing
facilities to track
• Objective 2: Describe tools and interventions which may be helpful in
understanding and reducing unnecessary hospitalizations from NFs
• Objective 3: Discuss possible factors affecting a facility’s rate of
hospitalization and re-hospitalization
Background: Why Hospitalizations and
Rehospitalizations from Nursing Facilities Matter
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Reveals some aspects of Quality of Care at NF
Refocuses Nursing Education onto “Change of Condition”
Resident Satisfaction
Regulatory: OIG Work Plan for 2011 - 2012
Readmission Penalties for Hospitals began October 2012
Recognizing and realigning with partners for collaboration
between acute and subacute care (e.g., Lehigh Valley
Health Network - JAMDA 13(2012) 811-816, Prioritizing Partners
Across the Continuum)
• Reducing Costs: $12-44 billion/year spent on
preventable hospitalizations?
Presbyterian Homes (IL): Overview
• Multi-campus CCRC corporation in suburban Chicagoland, with NFs
at its 3 major campuses approximately 13 – 17 – 20 miles apart.
• Facility A: Located on “Flagship” campus. NF ADC 174. Four core
physicians care for >80% of patients; three are on-site multiple days
per week. Full-time APN. 5 Star Facility.
• Facility B: 25-30 years old. NF ADC 92. Acquired approximately 15
years ago. Employed medical director devotes half-time at CCRC
campuses A and B. No APN. 5 Star Facility.
• Facility C: Built 14 years ago. NF ADC 58. Maturing CCRC. Parttime APN. 2 local MDs provide weekly rounding for subacute care;
medical director on-site one day a week. APN 3 days per week. 4
Star Facility.
Presbyterian Homes CQI Project: Getting Started
Pilot Project (CQI Cycle 1)
• Conceived in response to OIG focus on hospitalizations.
• Opportunity for comparative QI across campuses.
• Literature search revealed work of INTERACT research
and INTERACT Tools (Ouslander, Lamb et.al. http://interact2.net)
• 3-Month Pilot project at Facility A: Results
Hospitalization Rate 1.47/1000 pt-days (Sept-Nov 2010).
36% rated as preventable, using INTERACT QI Tool.
Preventables were disproportionately patients with an
outside physician; communication with outside MDs
found to be a factor in preventable hospitalizations.
CQI Cycle 2 Methods and Interventions:
Creating and Sustaining Momentum
• Hospitalization data collected at all NFs, Oct ’10– Sep ’12
KEYS TO KEEPING FOCUS ON ISSUE
• Monthly reporting of data at each facility QI (train staff
how to collect and report data; expect data reporting)
• Quarterly reporting of data at corporate QI and/or
compliance meetings (share successes and challenges)
• Development of corporate clinical dashboard for data
(develop a consistent standard for reporting data)
STAFF EDUCATION ACROSS THE CAMPUSES
• INTERACT Webinar training all 3 NFs, April-Aug. 2011
CQI Cycle 2 Facility-A Specific Interventions
Facility A
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Improved communication with outside physicians – APN task
INTERACT Transfer Log
INTERACT QI Tool by nurse clinician to assess avoidable hosps.
Developed log for tabulating QI Tool findings
Identified pneumonia as the most frequent diagnosis in preventable
hospitalizations in Year 1
• Targeted pneumonia as a topic for staff education to recognize onset
of early symptoms
• Used AMDA reference cards (Early Management of Clinical
Conditions) to increase nursing assessment skills
• Touch screen of Vision EMR found to be more useful than INTERACT
“Stop and Watch” tool for CNAs
Facility A Results
Facility A: Hospitalizations/1000 resident days
Hospitalizations / 1000 resident days
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Facility A Results
Hospitalization Rate – Year 1: 2.07
Year 2: 2.35
30-day Rehosp Rate – Year 1: 9.9% Year 2: 13.4%
Preventable Hosp. Rates:
Sept-Nov 2010
36% (8/22)
May-August 2011
12.8% (5/39)
Oct-Dec
2012
2.1% (1/48)
Facility B- Specific Interventions
Facility B
• Began a weekly hospitalization IDT review meeting in
May 2011, after first 7 months of data revealed high rates
of hospitalization and readmission.
• Meetings include administrator, DON, nursing leadership
from each unit, and the medical director
• DON: Meetings have helped change the nursing mindset
from immediately calling the doctor for a hospital transfer,
to a more analytic assessment of change of condition
• DON: INTERACT training helped change the nursing
culture; gave a new and clear set of expectations
• DON: Collaboration with hospital on CHF protocol helped
Facility B Results
Facility B: Hospitalizations/ 1000 Resident Days
(vertical line, May 2012 indicates start of hospitalization review committee)
8
Hospitalizations/ 1000 resident days
7
6
5
4
3
2
1
0
Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sept.
2010 2010 2010 2010 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012
Facility B Results
Hospitalization Rate – Year 1: 5.15
Year 2: 3.24
30-day Rehosp Rate – Year 1: 34% Year 2: 16.5%
COMMENT: Facility B showed dramatic improvement from Year 1 to
Year 2 in both hospitalization and rehospitalization rates, with the trend
line reversal corresponding temporally with the INTERACT webinar
series starting April 2011 and initiation of the IDT hospitalization review
meeting in May 2011.
Facility C Results
Facility C: Hospitalizations / 1000 resident days
Hospitalizations/1000 resident days
9
8
7
6
5
4
3
2
1
0
Facility C Results
Hospitalization Rate – Year 1: 3.95
Year 2: 4.70
30-day Rehosp Rate – Year 1: 12.7% Year 2: 16.9%
COMMENT:
• Significant leadership turnover (DON) throughout Year 2 hindered the
introduction and limited the sustainability of interventions
• Spike in hospitalizations correlated with a 2-3 week Norovirus
outbreak
Summary and Discussion
• Measuring and reviewing hospitalizations from a NF can identify
systemic factors to be targeted for quality improvement.
• Interventions such as sustained interdisciplinary hospitalization
reviews and engagement with INTERACT training and tools are
associated with some improved measures in this CQI project.
• Hospitalization rates are likely due to a complex interplay of many
factors, including but not limited to case mix, local referring hospital
readmission rates, degree and frequency of physician presence in the
NF, and nursing skill in assessing a resident’s change of condition.
• Medical directors and attending physicians can make a difference by
promoting high-quality subacute care and assisting the nursing staff in
improving response to clinical change of condition in the NF.