Reducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating The Expertise of the Expertise of the Expertise of the Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care

Viktoriya Fridman, ANP-BC, RN • Barbara Sommer, RN, MA, CEN, NE-BC • Barbara Donovan, RN • Aphene Fraser, RN, MSA • Luis Medina , RN-BC • Danielle Walker, RN

Marcia Nelson, DO, R.Ph, RN • Gregory Todd, MD • Thomas Smith, DNP, RN, NEA-BC • Edward H. Wu, R.Ph., CPHQ

Maimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NY

Identification of Need Identification of Need Identification of Need Older patients experience more complications during hospitalization and on transition from the hospital to home. During transitions, older patients with multiple chronic conditions and complex therapeutic regiments are at risk for medical errors and frag-mentation of care. Many patients encounter a variety of problems in the first weeks post discharge and are therefore readmitted to the hospital within 30 days. Avoidance of readmissions depends on the ability and expertise of hospital staff to uncover under-lying problems, prevent complications and facilitate the transition from hospital to home. Moreover, lack of clear communication upon discharge regarding changes in the medication regimen, significant signs and symptoms to report and appropriate scheduled follow-up care, adds to the confusion of the patient and caregivers.

Current EvidenceCurrent EvidenceCurrent Evidence One-in-five discharged adult medical-surgical patients will be re-hospitalized within 30 days. 50% won't have any interaction with a clinician prior to readmission. Improving communication among key members of the care team is essential to keeping patients safe and informed. Engaged and empowered patients are more likely to understand and follow their discharge instructions correctly. This will help prevent readmission within 30 days. Researchers have found that numerous issues arise after the patient leaves the hospital. For patients at increased risk for readmission, some investigators recommend both comprehensive discharge planning and a phone call to patients (or caregivers) within 48-96 hours of discharge to assess the patient's clinical status and ability to implement planned treatment and follow-up care.

PurposePurposePurpose To enhance the ability of the health care team to deliver high quality transitional care for hospitalized older adults by blending two models of care: NICHE and BOOST. Goals include: Reduce 30 day readmission rate

Increase patient/family satisfaction

Reduce length of stay

Improve patient/family preparation for discharge transition

Reduce discontinuity and fragmentation of care

Improve staff satisfaction

BackgroundBackgroundBackground A project funded by the New York Community Trust from 2010 to 2011 was implemented at Maimonides Medical Center in Brooklyn, New York. Both NICHE and BOOST models of care were implemented simultaneously on two pilot medical units (Kronish 7 & Gellman 7 East). Fifty-five percent of the discharged patients on these two units are over the age of 65. Moreover these two units have strong physician and nurse co-management teams. The nursing culture is also focused on providing excellence in care to older patients.

MethodsMethodsMethods Monthly core-team meetings

Daily interdisciplinary discharge rounds

Monthly Geriatric Journal Club

Nursing Grand Rounds, presented by staff nurses on the pilot units

Patient and family education via NICHE and Micromedex posters and handouts

Hospital intranet communication and marketing of the program of care

Use of NICHE designation posters & brochures

ImplementationImplementationImplementation This project included the implementation of two programs: Nurses Improving the Care of Healthsystem Elders (NICHE) and BOOST (Better Outcomes for Older adults through Safe Transitions).

Appointed an interdisciplinary steering committee.

Launched NICHE-BOOST Training conferences, and online webinars.

Implemented the Geriatric Resource Nurse (GRN) Model of Care.

Integrated BOOST principals of transitional care model in to the Geriatric Resource Nurse educational platform.

Utilized BOOST tools for care transitions.

Restructured weekly interdisciplinary rounds by empowering nursing staff and im-proving interdisciplinary team relationship. SPICES assessment tool was integrated in-to the rounds framework and approach.

Use of evidence-based practice protocols.

Enhanced nurse-physician collaboration throughout all phases of acute care.

ComponentsComponentsComponents NICHE evidence-based protocols

★ SPICES assessment tool. Designed SPICES wall boards that are utilized during interdisciplinary rounds.

★ “Try This” Best Practices in Nursing Care to Older Adults series

BOOST tool kit to facilitate transitions of care:

★ Teach-Back Methodology. Implemented the teach-back process of patient education to ensure patients/caregiver's understanding of post hospital care requirements.

★ Follow-Up Patient Calls to assess the patient's condition and adherence to discharge instructions at home within 72 hours of discharge. The calls were conducted and im-plemented by an advanced practice nurse using a short questionnaire.

★ “Patient-Friendly” Discharge Note was developed and implemented on two pilot units. Discharge Note is initiated and completed by staff nurses. Medication reconciliation and care notes are provided to the patients on the date of discharge in one folder. A copy was utilized during follow-up calls to assess patient knowledge.

★ Schedule Follow-up Appointments within 7 days of discharge to assure timely access to key healthcare providers after an episode of inpatient care as required by patient’s condition and needs.

★ Fill Prescription Program. Patients are able to prefill their medication prescriptions at the hospital-based pharmacy. The clinical pharmacist completes the medication reconciliation list and provides patient/caregiver education by utilizing the teach-back methodology.

★ Nursing, medical and non-physician geriatric staff education:

GRN training for staff nurses.

Nursing Grand Rounds presented by Geriatric Resource Nurses and physician champion “The Pathway to Excellence in Care of Older Adults”.

Medicine Grand Rounds led by BOOST Principal Investigator Mark V. Williams, MD

New protocols: Delirium, CAM, BOOST tools.

Teach-Back Methodology

Interdisciplinary Interdisciplinary Interdisciplinary CollaborationCollaborationCollaboration The interdisciplinary health care team working closely with the patient and their family is important in identifying issues of concern. The core team members are: Nursing: NICHE-BOOST Coordinator, CNO, Senior Nurse Leaders, Nurse Managers,

Staff Nurses

Hospitalists: Physician Champions

Case Management: CM Leadership, Unit-based CM, Clinical SW, SW Assistant

PI: Quality Analyst, Data managers

Pharmacy: Clinical pharmacist and pharmacy technician

Nutrition

Rehabilitation: PT, OT, ST

Patient Relations: Patient Representative

ChallengesChallengesChallenges Short time frame. The grant was funded in July 2010. Core team members completed

both trainings in November 2010 and project went live in February 2011.

Delayed Patient-Friendly Discharge Note implementation due to IS technical glitches.

Impact on team dynamics of new residents every month

Competing leadership priorities within the Department of Nursing

HCAHPS data are hospital based and not unit specific

ConclusionConclusionConclusion During this pilot project, older adults hospitalized on both pilot units received high quality transitional care delivered by expert Geriatric Resource Nurses and core members of an interdisciplinary team. Results demonstrated reduction in length of stay and re-hospitalization during a 30-day period. Comprehensive discharge planning, patient education through the teach back methodology and post discharge follow-up calls are core components of the transitional care model. Integrating NICHE and BOOST care models helps mitigate the effects of discontinuity and bridges the gap between hospital and home for patients with complex or multiple health problems. In addition, the NICHE-BOOST model has the potential to profoundly improve both the quality-of –life for patients and the financial well-being of the healthcare system.

FollowFollowFollow---Up Calls AnalysisUp Calls AnalysisUp Calls Analysis Several researchers have found that despite excellent in-hospital discharge planning, numerous issues arise once the patient leaves the hospital. During seven months of project implementation all 770 patients discharged home were called within 72 hours after discharge. All age groups were included in follow-up call program. 54% of all patients were > 65 years of age. 68% of all patients were reached with 2 call attempts. 32% of patients were not reached due primarily to (1) no answer, (2) language barrier.

Diverse language and culture groups were followed during this study which challenged the follow-up call program. 21% of all discharged patients were non-English speaking were 6.7% Chinese, 3.6% Spanish and 9.7 % Russian.

Inquires explored during the interviews included (1) current health status, (2) ability to fill prescriptions, (3) understanding of discharge instructions, (4) determination if there was a scheduled provider follow-up appointment, (5) determination if home care services had begun, if required.

25% had a variety of problems within the first 72 hours after discharge. Common issues identified were: (1) worsening clinical symptoms, (2) no follow-up provider appoint-ment, (3) unfilled medication prescriptions, (4) need for discharge instruction reinforce-ment, (5) need for home care services, (6) medication questions/concerns. All issues were addressed in real-time on the phone call with an additional follow-up if necessary.

One month follow up call data analysis revealed that 16.4% of patients/caregivers were not able to recall discharge instructions from discharge form and needed further reinforcement.

Did everything to help your pain?Did everything to help your pain?Did everything to help your pain?- score increased by 2.47% (66.7 - 68.3)

Nurses explained things understandablyNurses explained things understandablyNurses explained things understandably- score increased by 10.9% (63.3 - 70.2)

Nurses listened carefully to youNurses listened carefully to youNurses listened carefully to you- score increased by 6.4% (64.6 - 68.7)

Treated w/courtesy/respect by NursesTreated w/courtesy/respect by NursesTreated w/courtesy/respect by Nurses- score increased by 4.2% (73.1- 76.2)

Although this is not unit specific data there is a probability that patient satisfaction was improved on two pilot units. In addition, most of the patients expressed their appreciation of post-discharge support during follow-up calls.

An analysis showed that all hospital units had a decrease in LOS due to a concurrent hospital-wide initiative, but NICHE-BOOST units showed higher reduction than the controls.

Unit K7- reduced by 19.35% (6.94 - 5.60 days)

Unit 7E- reduced by 11.40% (6.78 - 6.00 days)

Unit 6E- reduced by 8.44% (6.55 - 6.00 days)

All Medical Units- reduced by 10.65% (6.36 - 5.68 days)

ResultsResultsResults Data were compared 7 months pre-intervention (Jul-10—Jan-11) and 10 months post-intervention (Feb-11— Nov-11). The results demonstrate improvements in length of stay, 30 day readmission and patient satisfaction. The two pilot medical units K7 & 7E were compared to both one control medical unit and all medical units. Patient satisfaction was analyzed based on hospital specific data.

Average Length of StayAverage Length of StayAverage Length of Stay

Average 30Average 30Average 30---Day Readmission RateDay Readmission RateDay Readmission Rate

An analysis showed that both pilot units had a significant change compared to both the control unit and all medical units. Even though 7E had a readmission rate spike of 19% in the month of July, the number dropped to 6 in the subsequent two months. This fluctuation is possibly due to low unit census, high number of discharges and first month of new intern rotation.

Unit K7- reduced by 24.0% (13.1% - 9.9%)

Unit 7E- reduced by 16.1% (15.5% - 13.0%)

Unit 6E- reduced by 2.7% (12.77% - 12.43%)

All Medical Units- reduced by 3.1% (14.1 – 13.7%)

Patient Satisfaction in Nursing CarePatient Satisfaction in Nursing CarePatient Satisfaction in Nursing Care An analysis of patient satisfaction with nursing care revealed a slightly positive change in four nursing-sensitive questions.

ReferencesReferencesReferences Alper, E., Greenwald, J., O'Malley, T.A. (2012). Hospital discharge. UpToDate. Retrieved from http://www.uptodate.com/contents/hospital-discharge. Coleman E.A., Misky G.J., Wald H.L. (2010). Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. Journal

of Hospital Medicine. 5(7), 392–397.

Bixby, M. B., & Naylor, M. D. (2009). The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults. Try This: Best Practices in Nursing Care to Older Adults. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_26.pdf

Burke, M., Boal, J., & Mitchell, R. (2004). Communicating for better care: improving nurse-physician communication. American Journal of Nursing, 104 (12), 40-48. Retrieved from http://ovidsp.tx.ovid.com/sp-3.3.1a/ovidweb.cgi

Capezuti, E., & Brush, B. L. (2009). Implementing Geriatric Care Models: What Are We Waiting For? Geriatric Nursing, 30(3), 204-206.

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360:1418.

McGaw, J., Conner, D. A., Delate, T. M., Chester, E. A., & Barnes, C. A. (2007). A Multidisciplinary Approach to Transition Care: A Patient Safety Innova-tion Study. Permanente Journal, 11 (4), 4-9. Retrieved from http://xnet.kp.org/permanentejournal/Fall07/transition_care.pdf

Snow, V., Beck, D., Budnitz, T., Miller, D. C., Potter, J., Wears, R.L.,...Williams, M. V. (2009, August). Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. Journal of Hospital Medicine 4 (6). doi: 10.1002/jhm.510

ProcessProcessProcess

Reducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating TheReducing Patient Readmissions by Integrating The Expertise of the Expertise of the Expertise of the Geriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional CareGeriatric Resource Nurse (GRN) with the BOOST Model of Transitional Care

Viktoriya Fridman, ANP-BC, RN • Barbara Sommer, RN, MA, CEN, NE-BC • Barbara Donovan, RN • Aphene Fraser, RN, MSA • Luis Medina , RN-BC • Danielle Walker, RN

Marcia Nelson, DO, R.Ph, RN • Gregory Todd, MD • Thomas Smith, DNP, RN, NEA-BC • Edward H. Wu, R.Ph., CPHQ

Maimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NYMaimonides Medical Center, Brooklyn NY