114-revised-home health in action final · 11/5/2013 1 home health in action: successful...
TRANSCRIPT
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Home Health In Action:Successful Implementation of
Home Health Quality Improvement (HHQI)Home Health Quality Improvement (HHQI) Tools and Resources
Objectives
At the conclusion of this session, the participant will be able tobe able to:• Design evidence‐based change strategies to improve hospitalization and oral medication rates utilizing the HHQI tools and resources
• Interpret their agency’s HHQI Data Reports and focus lit i t i id tifi d f dquality improvement in identified areas of need
• Identify and describe similarities and differences between QI programs
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Riverside ActionRiverside ActionIn Reducing Acute Care Readmissions
ACH ScoresACH Scores
At Riverside our ACH 20
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2013
Scores are evaluated monthly. We do this through the use of a benchmarking program. It provides real time data so that adverse outcomes can be assessed and interventions can be communicated and implemented quickly
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20
2013
implemented quickly.
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RHH RTHH RSMHH RWRHH
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Collaboration Collaboration with ACFwith ACF
Home Health collaborated with the Hospital to reduce
Patient Centered Care Projects◦ CHF Readmission Hospital to reduce
readmissions. The realization of penalties for ACH readmissions was a reality for October 1. Penalties assessed as much as 1% of Medicare reimbursement.
Project◦ COPD◦ Diabetes◦ Venous Thrombosis/EmbolusD li i i th Eld l◦ Delirium in the Elderly
Measures InitiatedMeasures Initiated
We found that not one single method of BPIP produced the results
Frontloading VisitsTelehealthChronic Disease produced the results
but a combination depending on the population we were serving. The Emergency Care Plan was incorporated into our orientation booklet and every patient has
Chronic Disease Management Training for all Nursing Staff911/ GYR Form Medication Reconciliation
that reviewed on the first visit. Case Management
Model of Care
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Measures Measures InitiatedInitiatedCase Management
Model◦ Discussion of Start of
We found that the recommendation found in the BPIP of using the Interdisciplinary Group setting produced a better look at Readmission Risk.
Care- Hospital Risk Assessment◦ Issues with CG/Family◦ Medication ReconciliationFall Risk ◦ Fall Risk ◦ Braden Scale
Hospital Hospital CCare Managementare ManagementCare Management
◦ Collaborative endeavors to identify risk on d i i Incredible opportunity
to collaborate and assess readmission risk.
admission◦ Transition Coordinators available to identify needs and risks◦ Central Intake approach as another level to id tif identify challenges/opportunities
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IPOC and LIPOCIPOC and LIPOCInterdisciplinary Plan’s of care are a part of our target for Patient-Centered, Interdisciplinary Team Based
Nurse
NutritionPharmacyInterdisciplinary Team-Based Health Care. They have been extended to Longitudinal Interdisciplinary Plans of Care that encompass the entire continuum of care in our Health System.
Patient Rehab ServicesPhysician
Social Services
Community Agencies
Care Management
Community HelpCommunity Help
The Area Agencies on Aging in our area partnered with us not
Community Partnerships◦ Area Agency on Aging partnered with us not
only for the home health patient but those who are discharged from our hospitals who are not eligible for home care.
g y g gprogram-◦ Virginia Partnership for Patient Care Transitions
Pharmacies
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Measures Measures InitiatedInitiatedTelehealth
◦ Daily Communication◦ High Touch
Telehealth provided an avenue to touch the patient every day .
g◦ Phone Calls◦ Rearranging Visits to fit the need of the patient
Monitoring our Monitoring our ProgressProgress
Monitoring gave us an
Monitor Home Health CompareReviewing Adverse Events Monitoring gave us an
opportunity to remediate clinicians in a more timely fashion to impact our outcomes
EventsUsing Benchmark Program◦ Monitor monthly readmits◦ Zero in on Clinicians who may be more apt to o ay b o ap osend patients back for readmission
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Hospital and Hospital and Health System Health System Collaboration Collaboration
Being Hospital-Based
Transitions of CareSafe handoffsRight Part of the
has given us a wonderful opportunity and needed help in reducing ACH. We now have many partnerships established and a great collaborative work for improving patient
Continuum of CareAdvance Care Planning and End of Live CareGeriatricianAce Unit improving patient
outcomes. Ace UnitNICHEPhysician Practices
Our Mission Right Our Mission Right NowNow
The Riverside Home Health Agencies are a
Focus is on Care TransitionsRobust Chronic Disease g
part of a health system wide initiative to reduce costly hospitalizations.
Management ProgramHealth CoachesCertified Diabetes EducatorCertified Wound-OstomyCertified NurseCertified NurseSBARTeach Back
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Staff Participation Staff Participation and Collaborationand Collaboration
The HHQI Best Practice Campaign encourages
Leadership MeetingsStaff MeetingsQuality is a part of
Campaign encourages communication about our Quality Initiatives. We believe that is very important to out success. At the present time our scorecard includes ACH, Oral Medication Management and Ambulation as the three projects. Senior Leadership in our organization looks at that Quarterly.
RHS Culture◦ Every staff person is evaluated annually on their participation in the Quality Program◦ RHS has a scorecard
d ACH i th t f and ACH is on that for our Agencies
VHQC and HHQI VHQC and HHQI Initiative Initiative
Riverside Agencies have found the BPIP to be valuable tools for reducing hospital readmissions. The tools are very for reducing hospital readmissions. The tools are very comprehensive and evidence-based. Don’t reinvent the wheel.
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LIVINRITE HOME HEALTH SERVICESREADMISSION REDUCTION PROGRAM
EXCELLENCE IN TRANSITIONSCOLIN JC ELLIOT, BA, BSC, PTCHIEF ADMINISTRATIVE OFFICER
LivinRite home health agency and hospitals working closely to reduce the hospital’s risk of patient re-admissions.
Two of the most commons reasons for hospital re-admissions are medication
LivinRite Home Health Program Goals
perrors and failure to see a physician.
Both could be reduced if patients were supervised through home care visits after discharge.
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60% of re-admissions are in the first 7 days
By revamping discharge policies in collaboration with the “Rite” HH company, hospitals can more fully utilize collaborative community relationships
Develop ‘grass root’ partnerships with SNFs , ALFs and Hospice agencies within the local area(s)
LivinRite created an “ER on wheels” concept
LIVINRITE HOME HEALTH SERVICES
READMISSION REDUCTION PROGRAMEXCELLENCE IN TRANSITIONS
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ACH PROGRESS?Introduced in 2011, a national quality improvement
initiative to reduce unnecessary readmissions for cardiovascular patients.
The goal was to reduce re-admission rates among patients discharged with heart failure or acute myocardial infarction by 20% by Dec 2012. LivinRite Achieved 21%. This has been maintained.
LivinRite 2012
LivinRite 2013 YTD 26%
National Average
Virginia Average
LivinRite 2011
LivinRite 2012
27%
26%
33%
26%
How often the home health team began their patients’ care in a timely manner
100% 99%
SOC with 48 hoursLivinRite
Virginia Average
86%
88%
90%
92%
94%
96%
98%
91% 91%
Virginia Average
National Average
This information comes from the Home Health Outcome and Assessment Information Set (OASIS) C during the time period April 2012 - March 2013
LivinRite Virginia Average
National Average
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How often the home health team taught patients (or their family caregivers) about their drugs.
98%
100%98%
Medication Reconciliation @ Each VisitLivinRite
Virginia Average
86%
88%
90%
92%
94%
96%
92%
National Average
92%
This information comes from the Home Health Outcome andAssessment Information Set (OASIS) C during the time period April 2012 - March 2013
86%
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Following guidelines for management of comprehensive patient education “disease management programs.” These guidelines are established in conjunction with hospital based coalitions, i.e. Prince William and LEAP initiativeWilliam and LEAP initiative.
LEARNING from our community to apply EXPERTISE in an ACTION-oriented PARTNERSHIP)
Interact ToolsSBAR (Situation Background
Assessment Recommendation)
www.vhqc.org/qualitywww.vhqc.org/quality--CareTransitions.aspCareTransitions.asp
Heart Failure (HF)
30-day Readmission Patient Interview
Best Practice Intervention Packages (BPIP)
Transitional Care Model (TCM)
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Providing 12 hr RN shift coverage (8am-9.30pm) / 7 days per week to ‘front load’ Hospital & SNF discharges.Ensures ability to provide evening & weekend admissions.99% of Cases opened within 48 hrs of99% of Cases opened within 48 hrs of discharge (1% with MD order)SOC nurses are ICU, CCU, ER & ‘step down unit’ trained.Inter-disciplinary team, MD, SN, PT, OT, RD, HCA, MSW.
Mobile in-home chest X-rays, EKG, Doppler, PS02 & vitals monitoring.Strong infusion & medication management focusIn-office supervisors to provide followIn office supervisors to provide follow up patient calls to strengthen care provision. Includes daily Tele-medicine calls from in-office RN.RDs & MSWs on staff for maximum patient education.
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Tele-Medicine->Daily RN callsTele-Health-> BiometricsIn-home X-ray, EKG, ABIIV Diuretics In-home
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Home Health In Action:Successful Implementation of
Home Health Quality Improvement (HHQI) Tools and ResourcesTools and Resources
Cindy Sun, MSN, RNHHQI Lead Cardiovascular RN Project Coordinator
Home Health Quality Improvement
Goal: Improve the quality of care home h l h i ihealth patients receive
Special Project funded by Centers for Medicare & Medicaid Services
Evidence‐based practice
Free tools, resources, & networking
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Phase 3: Sept. 2012 – July 2014
Focusing on quality of home health care measured by :
• Reduction of avoidable ACH • Improvement in oral medication management
• Improvement of immunization rates• Improvement of cardiovascular health
Continuing HH focus, but all care settings and patients encouraged to participate
( )Introducing Underserved Population Network (UP)
More than 10,000 participants
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Readmissions
• Almost one‐fifth of the Medicare beneficiaries who h d b di h d f t f ilithad been discharged from an acute care facility were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days (Jencks, Williams, and Coleman, 2009)
• Nearly 90% of readmissions are unplanned and potentially preventable which translates into $17potentially preventable, which translates into $17 billion or nearly 20% of Medicare’s hospital payments (Hernandez et al., 2010)
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ACH Essential Interventions
• ACH risk assessment
• Emergency Care Planning
• Front loading based on risk assessment
• Easy access to a nurse (24/7 call, office nurse)
• Phone monitoring and/or telehealth
• Patient self‐management programs
www.HomeHealthQuality.org
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BPIP
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BPIP Sub menus
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Corss Settings BPIP
BPIP ScheduleRelease Date Focused BPIP Primary BPIP LAN Creation
November 1, 2012 Patient Self‐Management X
February 1, 2013 Underserved Populations (UP) X
April 2, 2013 Medication Management X
June 3, 2013 Immunization & Infection Prevention X
August 1, 2013 Cardiovascular Health Part 1: Aspirin as appropriate & Blood pressure control
X
November 1, 2013 Cardiovascular Health Part 2: Cholesterolmanagement & Smoking cessation
X
February 3, 2014 Disease Management: Part 1 X
April 1, 2014 Disease Management: Part 2 X
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Educational Resources: ACH
Patient Hospitalization Risk Form
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Educational Resources: ACH
• SBAR
Ph i i• Physician Communication Tool
• Specific for High Risk Patients
Educational Resources - HF
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Educational Resources
Educational Resources
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Educational Resources: Warfarin
Educational Resources: Warfarin
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Educational Resources: Mobility
Educational Resources: Mobility
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Educational Resources: ACH
Network & Span tabs
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UP BPIP
Underserved Populations
My Action Plan
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Teach Back
Medication AdherenceAdherence
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Cardiovascular HealthNovember 2nd 4:00 pm
Screenshot of Data Reports Portal
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ACH
ACH National
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Hospitalizations Day of Week
ACH Monthly
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Reasons for Hospitalizations
Oral Meds monthly report
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Oral Meds state and national
Report for Oral Meds
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Other Great Resources
Assistance – How Can HHQI Help?
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Assistance – How Can HHQI Help?
• Promoting Your S th hSuccesses through:– Agency of the Month
– Blogs
– BPIPs
– e‐Bulletins
Questions?
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Thank You!
To reach me:
And of course, we can always be reached at
[email protected]@wvmi.org
References
• Hernandez, A.F., Greiner, M.A., Fonarow, G.C., Hammill, B.G., d h dHeidenreich, P.A., Yancy, C.W., Peterson, E.D., and Curtis, L.H.
(2010). Relationship Between Early Physician Follow‐up and 30‐Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure. The Journal of the American Medical Association, 303,1716‐1722.
• Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Rehospitalizations among Patients in the Medicare Fee‐for‐Service p gProgram. The New England Journal of Medicine, 360, 1418‐1428.
• Melnyk, B.M., & Fineout‐Overholt, E. (2011). Evidence‐Based Practice in Nursing & Healthcare (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
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HHQI
This material was prepared by the West Virginia Medical Institute, the Quality ImprovementOrganization supporting the Home Health Quality Improvement National Campaign, undercontract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.Department of Health and Human Services. The views presented do not necessarily reflect CMSpolicy. Publication Number: 10SOW‐WV‐HH‐MD‐081313.