Transcript Slide 1

Cross Continuum
Team Work
in the
ER
TEAM
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ELIZABETH SAYKIN,RN,LSW,CCM
LAURA O’CONNOR, LSW
ER PHYSICIANS
ER NURSES
SECRETARY
Diane DeMatteo,RN,BSN,CCM Holyoke Health Center
Cary Hardwick, NP CCM ,Holyoke Health Center
Cherelyn Roberts,RN,BSN, STAAR Manager
Home Health Care Agencies
LTC and STR facilities
PCPs
The Population we serve
HMC serves a population of:
• 30% of 25 and older population have not
graduated from high school
• 57.7% of Hispanic , 25 and older have not
graduated from high school
• 41.9% of less <18 are below 100%
poverty level
• 56% of Hispanic <18 are below 100%
poverty level
Our Hospital
• HMC is the largest provider of inpatient
and outpatient healthcare services to the
poorest community in Mass.
• The Robert Wood Foundation research
concludes that poor health is closely
related to poverty.
• 100% of adult patients admitted to the
hospital from Holyoke Health Center are
cared for by a hospitalist
Bed Capacity
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ER sees roughly up to 140 patients per day
Stroke Center
22 ER bed capacity plus 4 Fast Track
Trauma room
ICU – 11beds
Tele- 30 beds
MedSurg- 55 ( capacity to add 30 beds if
overflow floor opened)
• Psych- 17 beds
• Maternity - 12
According to :
• Agency for Healthcare Research and
Quality
• Centers for Disease Control and
Prevention
• American College of Emergency
Physicians
The numbers
Nationally
• More than 9 in 10 ED visits in 2008 were
related to acute conditions and half also
involved chronic conditions.
• ED visits increased by nearly 22 million or
23% , faster than the U.S. population,
between 1997 and 2007.
U-Turn
• “With new healthcare reform laws, and
smarter ways of thinking about optimal
medicine, the ED is being asked to pave a
much different path, a U-turn lane for
patients who can be more effectively –and
less expensively- cared for at home or
another setting.”
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Source: Cheryl Clark, Senior Editor of Health Leaders Media.May,2011
Quick Facts
• Readmisson Rate holding
steady at under 14% for
all cause but observation
rate climbing
• Patients were being
readmitted in less than 7
days of discharge
• Patients who had
“refused” rehab or
services were now in the
ER and getting
readmitted
Rates
• Our readmission rate since CHF Program
went from
• Oct 2010 15% to Oct 2011 ,11.3%
• Nov 2010 16% to Nov 2011 ,11.7%
• Dec 2010 14% to Dec 2011, 13%
• We were holding steady at less than 14% ,
our goal.
Readmissons
Our CHF patients were not being
readmitted, SO who were?
1. Observation patients , especially on
weekends
2.Readmits who had left in less than 7 days
3. Patients who had refused services or
rehab
All Cause Readmissions
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August and Sept CHF Program Education Started
January ’12 LEAN Event/ CTT in ER
March ’12 CTT cut to 4 hours per day
LEAN EVENT
Main focus was to look at the Admission
through discharge process.
Items adressed:
• Multidisciplinary rounds
• Observations vs Admissions criteria
• Med reconciliation
• Patient Navigator
Obs vs Admit Criteria
• Hospitalist reported not having enough
information on the criteria for obs vs admit
• ER physician reports not enough
information on criteria
• Both physicians state, they needed “help
with decisions to admit or observe”
Observations
3/12
Team
hours
cut
12/11
down
to 4
Team
hours
started
per
in ER
day
M-F
Patient Navigator
• Need SOMEBODY to
connect the dots!
• Patient is not kept up
to date on their daily
tests and results and
plan
Left us with the question
• WHO IS DRIVING
THE BUS?
STAAR PROGRAM
• LEAN Event
Aligned with STAAR
Initiatives, which aligns
with the PatientCentered Medical
Home Initiative
Observations we Made
When a STAAR initiative was implemented or removed , it
had an impact:
• Aug/Sept 2011 CHF Program education began
• Jan/2012 , LEAN Event, ER education began
• March 2012, the RN from the CTT decreased hours to
only 4 per day
• Made very clear that the ER was left out of the loop
• ER staff at the LEAN event not aware of the work we
had started on the inpatient floors
• Many of the topics discussed at the LEAN EVENT had
STAAR Alignment
SILOS
• Found we were still
working in SILOS
• The LEAN event
brought some key
people together from
Quality, STAAR,
Frontline Staff, Docs,
Ancillary depts who
all had the same hope
( to provide the most
efficient patient
centered care)
AHA!
• We had totally missed
an opportunity to
impact readmissions
in the ER!
Decision made to Visit the ER
• Educated staff on Teach Back, Health
Literacy
• Educated ER staff on educational
materials we were sending patients home
with
• Partnered with ER staff to identify high risk
patients who they already knew
Plan, Dec 2011
• To decrease the amount of avoidable all
cause readmissions within 30 days of last
discharge by assigning a “transition team”
in the ER who can be consulted by ER
physicians and hospitalists to assist with
“treat and release” to an appropriate
setting when acute care is not necessary.
This team will also advise on admission
and observation status
Who and What?
• Transition Coordinator( Betsy) will team up with
Social Work ( Laura)
• CTC will identify any ER patient who may be a
readmission and communicate with the ER
physician on appropriateness of disposition
• CTC will communicate with PCPs, VNA ,
specifically the Health Center when the patient
arrives to collaborate on a possible discharge
plan or to discover issues that may impact the
possible readmission
Transition
• CTT will assist with communication
between the ER physician and hospitalist
• CTT will provide information of services
provided in other levels of care to the
physicians if acute care is not required
• If the patient is discharged to VNA ,LTC or
STR or with a follow-up appt, CTT will
insure the “warm handover” is done
Enhanced Communication
• CTT accepts calls from VNA’s
• LTC, STR and most often, the Holyoke
health Center prior to a patient arriving.
• Important information is shared
• Treatment plan is discussed
• Clinical picture reviewed & communicated
( Betsy and Laura)
Evaluation
A log will be kept to track all the possible
readmissions, how many were readmitted
and how many treated and released
Relationships
Health
Center
families
Community
Services,
Shelters,etc
VNA
ER
LTC ,STR
PCP
ASAP
Community
Pharmacist
Home Health Scenario
• VNA calls CTC in ER to alert of patient returning
• Warm handover done from VNA with reason for
visit and current med list is faxed.
• CTC delivers info to ER physician
• CTC follows patient clinically until ready for
either admission or discharge
• Services available discussed with ER physician
Disposition
• If patient returning to home, warm
handover done to VNA including treatment
plan and any med changes.
• If indicated a call will also be made to the
PCP
Our Partner
Our Mission at the Holyoke Health Center is to improve the health of our
patients by providing quality health care and supporting comprehensive
community-based programs to create a healthy community.
Preventive and
acute care
Chronic care
management
Public Health Focus
100% of our medical
assistants, front desk
staff, and switchboard
are bilingual/bicultural
92% of patients have incomes below
200% of Federal Poverty Level
90% are Latino/Puerto Rican from
downtown Holyoke community
2nd highest overall mortality rate
Highest rate alcohol & drug
related deaths
9th highest mortality rate from
heart disease
5th highest rates of suicide
3rd highest rate of HIV infection
2nd highest rate of teen births
4th highest for rates of
preventable hospitalization for
asthma, angina & bacterial
pneumonia
3rd in rates of Gonorrhea &
Chlamydia
Highest rate of publicly funded
prenatal care
Meeting Our Mission
• As part of the Patient-Centered Medical Home
Initiative, HHC has hired 3 new Clinical Care
Managers (CCM) , experienced RNs or NPs,
who are working with specific providers’ patients
especially those who frequently present to the
ER and /or are Hospitalized.
• The CCMs offer each medical team, in-depth
support for the high-risk and complex patients.
This includes f/u care for ER and Hospitalized
individuals within 48hrs of discharges.
Shared Information
HMC shares access with HHC to their Meditech
system, where real time clinical information can
be accessed, by our PCP, CCMs and nurses.
This information includes:
• Names of our Patients presenting to the ER
• Names of In-patient admissions
• Lab work
• Images
• Consultation reports
• Discharge planning
Collaboration with HMC
As a result of this shared information, HHC
PCP and CCMs have been able to :
• Call ahead to announce a patient
presenting to the ER
• Allow physician-to-physician conversations
• Call in Pt’s home med lists
• Anticipate patient’s needs upon disch
• Collaborate with the case managers and
the CTT for disch planning and f/u care.
ER Discharge Collaboration
• HHC receives daily ER report for each
(indentified) HHC Pt seen at HMC
• HHC CCMs review reports, then make F/U
contact with each Pt within 48 hrs
* Telephone Call by CCM to assess needs
* Did-You-Know letter
ER Follow-Up Visit
• Review of d/c Plan
• Medication Reconciliation
• General Assessment with focus on the
presenting problem
• Assess need for community services, etc.
Some Data from Our Test
January 2012
– 23 possible readmits;
– 9 were treated and assigned to another level of
care.( 7am-3pm)
February 2012
- 48 possible readmits ; 21 were treated and
released ( 7am-3pm)
March 2012
- (CTC cut down to 4 hours p/day instead of 8)
37 possibles; 15 were treated and released (7am-11am)
Future Goals
• Automatic notification 24/7 to a Transition Team anytime
a readmission comes in
• Improve communication to all PCPs, similar to the HHC
• Spread the process of “calling ahead” to SNFs and LTCs
• Decrease the use of inappropriate observation status
• Decrease the readmission rate to <10% for all cause
• Establish Palliative Care & Hospice process from the ER
BARRIERS
• Health Literacy continues to be a barrier
• Patients not knowing their MDs and their
home meds
• Inconsistent communication between
hospital providers (MDs, RNs) and PCPs
• Limited electronic registers and tools for
communication
Not So Good Stories
Success Stories