Transcript A Nurse-Led Multidisciplinary Team Approach to Improving

A Nurse-Led Multidisciplinary Team
Approach to Improving Heart Failure
Patient Transitions and Reducing
Readmissions
Christine Thompson, MS RN CNS CCRN CHFN
Charlene Kell, EMBA RN BSN CCRN
Research Days - South San Francisco 22 October 2014
Confidential to Stanford Hospital and Clinics
Reducing avoidable readmissions of heart failure
patients on the national agenda
• Heart failure (HF) currently affects 6.5 million adults in the US
• Prevalence of HF projected to increase by 25% by 2030
• Hospitalizations are responsible for the majority of $39 billion spent
annually for HF care
• The Centers for Medicare & Medicaid Services (CMS) has mandated
reporting of hospital-level 30-day readmission rates for HF, acute myocardial
infarction, PNA (now inclusive of other diagnoses)
• CMS penalties initiated Oct 2012
Journal of the American College of Cardiology Vol. 60, No. 7, 2012
© 2012 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00
Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.03.066
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Acknowledgement
• Two year grant focused
on reducing HF
readmissions (2012-2014)
• Triad leadership
structure
– MD, Administrator,
CNS
• Partnership with local
clinic (PAMF)
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Primary HF Patient Readmissions – where we were . . .
Baseline Data – CY 2011
Primary HF Patients
500
475
450
400
350
300
250
# Patients (2011)
200
148
150
93
100
33
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Goals:
• Reduce 30-day
readmissions by 30%
• Reduce 90-day
• readmissions by 15%
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0
Discharged
Patients
30- Day
Readmissions
90-Day
Readmissions
90-Day ER
Utliization
90-Day
Observation Stay
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Using Clinical Effectiveness framework to ensure
sustainable outcomes…
Our patients
will be supported
by…
Physicians
Nurses
Pharmacists
Dieticians
Respiratory
Therapists
Social
Workers
Patient
Advisors
Performance
Excellence
Clinical
Informatics
HIMS
Coding
Clinical
Bus Analytics
Aging Adult
Services
Case
Managers
…a multidisciplinary
care team…
Quality
…whose work is
shaped by a crossfunctional SHC team…
…and supported by the
Cardiovascular
Data Mart that
provides the “single
source of truth” data
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Heart Failure Interventions: A LEAN-based Approach
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Redesign of HF Patient Transitions of Care: Interventions
• HF CNS Consult Order
• Risk assessment and flagging
high-risk patient in EPIC
• Medication reconciliation processes
redesigned, including MD workflows;
enhanced medication education
• Enhanced patient/caregiver
education using teach back
• Follow up appointments made prior
to discharge
• Post-discharge phone follow up
with template integration into EHR
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Care Transitions: Community Stakeholder Meetings to Develop
Standards for Skilled Nursing Facilities and Home Health
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Readmission Metrics from Electronic Health Record to HF
Dashboard
Individual or multiple rules can be
selected to filter the patient cohort
Current State displays 30 days
readmit rate, 90 days readmit rate,
and Balance measures for last 30
and 90 days
Actual discharge and readmit counts for
the rates are displayed below the gauge
Trending Chart toggles between readmission rate and patient readmit count
Readmission
Trending Chart
compares last 30
and 90 days rate
to previous
months, quarters
or year
Filter
dashboard
view by
unit, age
etc.
Current filter selections
displayed here
The Bar Charts compare the Index Admission Length Of Stay to Readmit Length Of Stay and the Days to Readmit
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Collaboration: Promoting Nurse as Educator
– Two hour workshops on
health literacy and teach
back for staff on three key
patient care units
– Creation of video
• Nursing Education website
• Stanford YouTube
– Incorporation of teach back
into unit orientation
– Spread to multidisciplines,
inpatient & outpatient
– Documentation in EMR &
tracked on Dashboard
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Teach Back on the HF Dashboard
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Collaboration: Medication Safety
• Improved Medication
Reconciliation processes on
Admission and Discharge
• An accurate, understandable
medication list at discharge
• Pharm Techs in ED to assist with
creating current med list
• New Transitions of Care
Pharmacist role implemented, 7
days/week for HF & complex
Medicine patients
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Redesign of HF Educational Materials
• Multidisciplinary; patient
reviewed
• Updated & synchronized
inpatient/outpatient
materials
• Multilingual
• Hardcopy materials & SHC
website
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Communication
• Monthly “What’s New in
Heart Failure Care”
newsletter e-mailed to staff
• Monthly multidisciplinary
Heart Failure Operations
Team meetings with
community partners
• Weekly Heart Failure Clinical
Effectiveness Council
meetings (HF CEC)
• Use of HF Dashboard for
“Active Daily Management”
on patient care units
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Collaboration: Community Outreach
• Aging Adult Services
partnership home visits
– Home monitoring pilot
• Patient Partners (P2) with
Stanford School of Medicine
(in-home health coaching)
• Skilled Nursing Staff
education on HF patient
assessment, care, and
patient family education
• Quarterly roundtables with
SNFs and Home Health
providers
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Patient Engagement in our Heart Failure Program
• Two committed volunteers for our Heart Failure Program
serving 2 ½ years --- themselves HF patients
• Invaluable contributions to our HF Readmissions Reduction
work
• Review/critique the HF patient education tools
• Attend monthly multidisciplinary HF Operations Team meetings
• Participated in Rapid Process Improvement Workshop (RPIW)
using LEAN methodology for Medication Reconciliation
• Participated in Value Stream Mapping for Heart Failure Patient
Care from point of entry into our system to transition home
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Empathy Mapping: Overview
• Interview completed by a trained hospital volunteer
using open-ended questions
– SAY:
What are some quotes and defining words
the patient said?
– DO:
What actions and behaviors did you notice?
– THINK: What might the patient be thinking?
What does this tell you about his or her beliefs?
– FEEL: What emotions might the patient be feeling?
• Empathy mapping allows us to synthesize observations and
draw out unexpected insights
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How can Empathy Mapping help?
• Identify prevalence of contributing factors or barriers to
successful self-management for health, particularly in highrisk patients
• Insights on the patient’s experience of care processes and
perception of communication
• Promotes patient reflection; feeling heard
• Opportunity to address patient-specific issues
• Evaluate aggregate data for themes and trends that can
inform re-design of processes of care to better meet physical
and emotional needs
• Design and refinement of a healing environment of care
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SHC Primary HF Readmissions: April 2013 – March 2014
(Baseline CY 2011: 20% 30-day; 30% 90-day Readmit Rates)
HF Readmissions Pre- and Post-implementation
35%
31%
30%
26%
25%
20%
20%
Pre Intervention
Post Intervention
15%
10%
10%
10%
7%
5%
5%
3%
0%
30- Day
Readmissions
90-Day
Readmissions
90-Day ER
Utlization
90-Day OBS Stay
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Reducing Avoidable Readmissions Heart Failure: Moore Cohort
Baseline to Project Implementation Statistically Significant Reduction
Baseline
Post Interventions
start date to YTD
(30 day d/c data
availability)
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Lessons Learned
• Designing & implementing a patient-centered program for HF
care that improves outcomes and reduces readmissions is a
cross-functional team effort, spanning the care continuum – not
a project but a culture change
• Active collaboration with community partners essential
• Leveraging the EMR facilitates improved communication to and
consistent care practices
• “Keep the patient at the center”: patient engagement and
participation is critical to success
• Creating analytic tools that provide accessible, real-time metrics
to frontline staff & managers reinforces the effectiveness of
nurse-sensitive interventions (e.g. use of teach back, postdischarge follow up calls)
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Future Directions
• Spread of HF readmissions reduction standards across other
secondary HF populations to improve patient care transitions
• Continue to review/refine current patient care interventions and
add new interventions after pilot-testing
• Collaborate with non-specialty providers (e.g. Primary Care,
General Medicine) on Best Practices for HF management
• Strengthen community partnerships and create evidence-based
community standard
• Continue to develop & analyze our own prospective risk
assessment tool utilizing data elements in the EMR
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Resources
• Coleman EA, Min SJ, Chomiak A & Kramer AM. Post hospital care transitions:
patterns, complications, and risk identification. Health Services
Research.2004.39(5):1449-1465.
• Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J.
Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition
Home for Patients with Heart Failure. Cambridge, MA: Institute for
Healthcare Improvement; 2008. Available at www.IHI.org.
• Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide:
Improving Transitions from the Hospital to Community Settings to Reduce
Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare
Improvement; June 2012.Available at www.IHI.org.
• Christine Thompson: [email protected]
• Charlene Kell: [email protected]
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