haltt: hospital admissions lessened through therapy tuesday, april 28, 2015 h.a.l.t.t. hospital...

HALTT: Hospital Admissions Lessened Through Therapy

Tuesday, April 28, 2015

H.A.L.T.T. Hospital Admissions Lessened Through Therapy


Presented by

Heather Meadows, SLP

PREMIER THERAPY

701 Sharon Road Beaver, PA 15009

800.875.7041www.EmbracePremier.com


1. The attendee will be able to describe the prevalence of readmissions as well as the targeted diagnoses.

2. The attendee will identify the potential roles that OT, PT, and Speech could play in reducing readmissions.

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OBJECTIVES


3. The attendee will design a program which identifies at risk residents utilizing root-cause analysis and a comprehensive plan to address issues.

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OBJECTIVES


• Nearly 18% of hospitalizations of Medicare patients are the result of readmissions.

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The Accountable Care Act


• To reduce these costs, the Hospital Readmissions Reduction Program was introduced through the ACA.

• This requires CMS to reduce payments to hospitals with excess readmissions effective 10/1/2012.

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The Affordable Care Act


• Readmissions are defined as an admission to subsequent hospital within 30 days of a discharge from the same hospital.

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Readmissions Defined


• CMS targeted diagnoses: Breakdown of readmissions

– CHF 24.8 %– Pneumonia 18.4%– Acute Myocardial Infarction 19.8%

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Adopted Readmission Measures


• In the fiscal year 2014, IPPS final rule, CMS adopted additional readmission measures for:

– Acute exacerbation of Chronic Obstructive Pulmonary disease (COPD)

– Elective Total Hip Arthroplasty (THA)– Elective Total Knee Arthroplasty (TKA)

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National Readmission Measures


• Hospitals will receive bundled payments covering not just the hospitalization, but the care after the hospitalization.

• Hospitals with high rate of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period with those targeted diagnoses.

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The Goal of ACA


• The combination of incentives and penalties should lead to better care after a hospital stay and result in less readmissions.

• Savings of approximately $25 billion dollars over 10 years is expected.

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Expected Outcome


• 2011 Q4 – 18.2 % sent back to hospital within 30 days of their SNF stay

• 2014 Q2 - 15.6 % sent back to hospital within 30 days of their SNF stay

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Current Data for SNF Readmission


• This is a overall 14.3% decrease from the 2011 readmission totals.

• An estimated 58,000 readmissions were prevented, saving the health care system almost $599 million.

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Results


• A new bill calls for the U.S. Department of Health and Human Services (HHS) to introduce an “all-cause, all-condition” hospital Readmission Measure for SNFs by Oct. 1, 2015.

• A Resource Use Measure began to reflect an all-condition, risk-adjusted, potentially preventable hospital readmission rate for SNFs by Oct. 1, 2016.

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HR 4302 – Protecting Access to Medicare 2014-New for SNFs in 2015 and 2016


• SNF performance would be reported publicly on the Nursing Home Compare website, but HHS also would be required to send quarterly reports to SNFs with confidential feedback on their performance against the measures beginning Oct. 1, 2016.

• SNFs will have the opportunity to review and submit corrections prior to the information becoming public.

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HR 4302 – Protecting Access to Medicare 2014-New Bill


• You can access H.R. 4302 at:

http://www.gpo.gov/fdsys/pkg/BILLS113hr4302enr/pdf/BILLS-113hr4302enr.pdf

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HR4302




• What corporate programs and outcomes are you using (Quality Assurance/Performance Improvement, QAPI)?

• Do you have facility specific protocols in place?

• What current opportunities exist?

• Do you have tracking systems for readmissions?

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Assess Facility Readiness


• Do you have integrated coordination opportunities available?

–ACOs (Accountable Care Organizations)–Bundled Payments for Care Improvement

(BPCI) Initiative– Initiative to Reduce Avoidable

Hospitalizations Among Nursing Facility Residents (RAVEN) UPMC

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Partnering Opportunities


Advancing Excellence• America’s Nursing Homes National Campaign was

founded in 2006, by 28 organizations including nursing homes, quality improvement experts, and government agencies to improve the quality of nursing homes.

• Evidence-based resources were developed to support quality improvement efforts in nursing homes, ensuring better care for the residents and staff that care for them.

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Advancing Excellence

• It is the first national effort to measure quality in the nursing homes through measurable clinical quality goals and organizational improvement goals.

• Every nursing home can participate by focusing on two or more goals, and utilizing resources developed by group to meet their goals.

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Advancing ExcellenceGoals choices are:

Clinical quality goals

• reducing pressure ulcers• improving pain management• increasing mobility• reducing infections• reducing antipsychotic use

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Organizational improvement goals • increasing staff retention• improving consistent staff assignment• reducing unnecessary hospitalizations • promoting patient-centered care



• Many of these goals are interrelated. Improvement in one area can impact other goals, such as improving mobility with residents, and may reduce pressure ulcers or improve pain with the residents.

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• You are able to use resources from their website to initiate quality improvement in your facility, and utilize guidelines, forms, and tracking to report/track progress and show improvement with each goal.

Source: Advancing Excellence, www.nhqualitycampaign.org, Accessed 3-23-2015

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http://www.nhqualitycampaign.org/


INTERACT 4.0• INTERACT stands for Interventions to Reduce Acute Care

Transfers.

• It is a quality improvement program to improve the identification, evaluation, and communication about changes in the residents’ status.

• Projects are supported by CMS and now funded through Commonwealth Fund, involving nursing homes in Florida, New York, and Massachusetts.

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INTERACT• The overall goal of the program is to reduce the

frequency of transfers to the hospital, which have been proven to be both difficult and costly.

• The program is comprised of communication, care path, clinical and advanced-care planning tools for care teams to use to reduce unnecessary readmissions to the hospital.

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INTERACT• Tools and algorithms are available for teams to use as guidelines

to implement systems and improve readmission rates.

• It is meant to improve the early identification, evaluation, management, documentation, and communication of acute care changes of the residents in SNF, HH, and AL environments.

• Implementation guidelines , tools, and resources can be found on the website.

Source: INTERACT website: http://interact.fau.edu

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INTERACT• Several of the tools can be utilized for at-risk quality

improvement and tracking programs:– Stop and Watch Tool– SBAR Form– Hospital Rate Tracking Tool– Quality Improvement Tool

You may use any of the resources from the website free of charge but cannot modify them in anyway.

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INTERACT TOOLS

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INTERACT/HALTT• The two programs are similar in that they both are

designed to illicit early identification of problems, prompt timely and proper assessment of resident, and implement a care plan.

• HALTT also allows for root cause analysis of resident issues and assignment of duties to the appropriate care team member to improve risk area of the resident.

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HALTT Risk Areas1. Unstable blood sugar2. CHF or COPD3. Fall history4. Reduced intake by mouth5. Change in medications6. Unstable or changes in vitals7. Fluctuating functional status8. Behavior changes9. Change in lung sounds10. Pain

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HALTT• Assignment of duties to IDT members are completed

at the first Stand Up meeting and/or UR meeting following the identified issue of the resident.

• Communication of plan of care is given to entire care staff and families.

• Accountability to complete duties are checked at the next UR meeting when update to team is expected.

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•Therapy can help support the facility in decrease readmissions to the hospital through:

– Comprehensive assessments– Alertness to vital signs and risk factors– Communication to nursing, families and physician– Education to caregivers–Monitoring of status– Consistent scheduling with resident– IDT involvement– Discharge planning with team

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Does Your Therapy Play a Role?


How can therapy reduce the risk of readmissions tothe hospital?

1. Complete comprehensive assessment with the appropriate plan of care.

2. Be an extra watchdog for changes in vital signs.

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What Role Can Therapy Play?


3. Timely communication of change in status to proper team members to address and possibly involve a physician early in process (written communication).

4. Get residents moving or in better positions to reduce risk of pneumonia, infection, or falls (greatest % of readmissions).

5. Participate in Falls, Wounds, and Pain programs consistently.

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6. Educating resident and caregivers, so they understand their risks, is the best way to control disease process and achieve a safe and highest functional level.

7. Communicate to home health agencies, equipment companies, physicians, and caregivers the discharge

plans/needs to help resident return to a safe environment .

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Prior Level of Function

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Begins at Admission

1. Eating- indicates risk of poor nutrition or assist needed2. Dressing- indicates what level of independence

resident may be3. Ambulation/Transfers- indicates possible balance

problems or fall risk4. Bathing/Bathroom use- indicates level of

independence5. Cognition- indicates possible safety concerns


Prior Level Of Function

– Swallowing- can indicate any choking or aspiration risks– Functional Decline/Falls- if falling at home more likely to

fall in facility– Previous therapy in present year- could indicate ongoing

problem– Medication Review-can indicate side effects or poor

adjustment to new medications

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Begins at Admission


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PLOF Form


Vital Sign Checks• Temperature• Blood Pressure• Respiration Rate• O2 Saturation• Heart Rate or Pulse• Pain• Shortness of Breath

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Vital Signs

• The vital sign check, along with our functional assessment, during treatment could really help with early detection of issues.

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Vital SignsTemperature– Baseline should be established and checked daily by

nursing.– An increase of body temperature can indicate a

systemic infection, inflammation or hyperthermia.– A spike in temp 20-30 minutes after eating could

indicate possible silent aspiration.– A decrease in body temperature can also be a concern

(i.e. poor circulation, heart problems).

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Vital SignsHeart Rate or Pulse– Pulse rate varies with age. – Normal adult beats per minute are typically 50-80

beats.– An increase in pulse rate can occur with, but not

limited to, pain and infection.– A decrease or irregular pulse rate could indicate a

serious health issue or illness.

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Vital Signs

Respiration Rate– Should note if wheezing, exertion with breathing,

and other sounds occur– Varies with age– Normal adult rates are 12-28 breaths per minute

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Vital Signs

Respiration Rate– Increased respiration rate could mean possible

infection or pain.– Decreased respiration rate could indicate

weakness and system failure.

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Vital Signs

Blood Pressure– It is indicative of how well the heart is functioning.– It is comprised of two measurements: • systolic pressure: measures the force of blood with

maximal contraction of the heart• diastolic pressure: the resting pressure when the heart

relaxes

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Vital SignsBlood Pressure– Normal blood pressure is 120/80 (systolic/diastolic).– Abnormal pressure would be anything over 130

systolic and 85 diastolic pressure.– Hypertension is when the systolic pressure is

consistently between 140 -160 mmHg.– Hypotension is low blood pressure below 120

systolic pressure consistently.

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Vital SignsPain– This is considered to be an important, but often

overlooked, vital sign in adults.– It can greatly impair a person’s function and lead to

other medical issues such as depression, contractures, immobility, sleep deprivation, and wounds.

– Should be assessed at:• Admission, quarterly with nursing review, each shift if pain

management is part of care plan, if change is noted during review, and when intervention is implemented to see if effective for pain reduction.

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Vital Signs

Pain Scales are used to show changes (good or bad)with any intervention and to establish a baseline– Nonverbal Pain Assessment– Faces Pain Scale– Visual Analog Scale– Pain Thermometer Scale– Comprehensive Pain Assessment-cognitively intact

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Vital SignsPain Scales– Brief Pain Inventory– Initial Pain Assessment Tool– Memorial Pain Assessment Card • Mood Scale• Relief Scale

– Patient Comfort Assessment Guide

Source: www.rehabmeasures.com

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Vital SignsDyspnea- Shortness of Breath– It is normal with heavy exertion, but it is abnormal if it

occurs with everyday functions.– It can indicate problems with asthma, pneumonia, cardiac

ischemia, lung disease, congestive heart failure, acute MI, COPD, and panic or anxiety disorders.

– It is important to report this to a nurse/physician in a timely manner.

– Assess the intensity with any distinct sensation, such as (effort, chest tightness, and air hunger) distress involved and impact on daily functions.

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Vital Signs

Standardized tests

– Modified Borg Scale– MRC breathlessness Scale- 5 grades of

dyspnea based on the circumstances in which it arises.

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Vital SignsGait Speed– Gait requires input from many different systems in

the body.– Proper coordination of all these systems produces

normal gait, and if any systems are unhealthy then gait can be affected.

– Gait speed changes or abnormalities can be an indicator of system problems or failures in the body.

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Vital Signs

Standardized Tests– Tinetti– 6 minute walk test– Timed Up and Go test– Timed 10 meter walk test– Timed 10 meter walk test with 1-2 cognitive tasks

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Vital Signs

• A decline in gait speed predicts a decline in attention.• A decline in gait speed predicts an increased chance

of mortality.• The more normal gait speed ( 7 seconds = 3 mph for

10 meter walk) the better health and quality of life a person will possess.

Source: Levine, Pete, BA, PTA, Using Gait Speed as a Marker for Progress, Advance for Physical

Therapy and Rehab Medicine, Vol.21, Read 3-26-2015

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Vital Signs• Abnormal vital signs could be the first warning that an

impending medical decline may be occurring.

• Early detection and then treatment could ward off intensifying symptoms and possible transport/admission to hospital.

• Nursing monitors vital signs, but therapy could also report them and be an added watchdog for issues that may be arising with the resident.

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• Add patients who trigger upon admission either from PLOF form or nursing/therapy assessments to Risk List.

• Review these patients at the morning meeting or UR with IDT .

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Know Your At Risk Patients


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Target List


• Use a tool to deep dive issues– Pause: What is the Root Cause?– Medical Necessity Form- Nursing Note to indicate

medical need for therapy or other intervention.– If fall history or at risk- complete comprehensive Fall

Assessment.– Look at all areas that could send patient back to

hospital and also positively impact your QMs: Pain, Pressure Ulcers, Weight Loss, etc.

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Root Cause of Issues


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Pause: What is the Root Cause?


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Medical Necessity Form


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Current QualityMeasures


• This should consist of a weekly comprehensive review of all risk factors, not just for falls.

• Proper referrals to address needs are determined by the IDT, and assignment sheets are completed.

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Utilization/Resident Review


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Assignment Sheet


• Each resident will continue to be monitored and their progress and status of plan reported in morning meeting.

• Assignment sheets will be reviewed in weekly meetings, and modifications may be made by IDT.

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Daily/Weekly Monitoring


• Document all information during Falls meetings and interventions.

• A log can be used but should have nursing note or IDT note 1x a week for everyone and everything discussed in meeting. (Can use Medical Necessity Note).

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Communication and Training


• Once the end result is achieved, communicate to all care staff and make sure all training is complete.

• Use sign off sheets during training with dates completed, who attended and who instructed.

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• Update documentation that plan was put into place, all care staff trained, and resident successful with adaptations. Nursing will follow for next two weeks for carry over.

• Nursing should write a note on carry over and positive impact to function and quality of life for resident.

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Nursing Log and Note


• Team will recommend discharge from At Risk List.

• Written status/adaptation should be present in a private place, so care staff can access it easily during care.

• Residents will be reviewed quarterly.

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• Review of Discharge Checklist by the IDT will be completed prior to discharge.

• All training of care staff and families must be done prior to discharge from program.

• Updates are given at the morning meeting and the resident is removed from target list.

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Discharge


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Discharge Checklist


• New admit from hospital status post CVA.– 80 year old female admitted post CVA two weeks

ago with L- sided hemiparesis– Past Medical History: DM, atrial fib, and right hip

fracture two years ago

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Case Scenario


• Prior to a hospital stay, the resident was independent with all ADLs, ambulation without a device, homemaking skills, and lived in her own apartment with supportive family nearby. She was able to do light housekeeping and drove a car.

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Case Scenario (con’t)


• She has reported, and family indicates, a fall about two weeks before going into the hospital.

• She has numbness in her feet from DM.

• Family reported that she has lost motivation since her husband passed away two months ago.

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• New Admit: Nursing/MDS complete:– PLOF assessment– Fall Risk assessment– What’s Your Risk assessment

• Resident triggered as a high risk for falls on the assessments due to decreased functional ability, significant decline from PLOF, uncontrolled DM, and fall history.

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• Nursing places resident on Target List as “at risk”.

• Resident is discussed with IDT in next morning meeting as having issues, and all therapies are ordered to complete evaluations.

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• Resident is discussed in morning meeting, and update is given as preliminary plan.

• Resident discussed in Weekly UR/Resident Review meeting by entire IDT.

• Utilize Tool for Root Cause.

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• Assignment sheets are completed by Nursing in UR with issues identified, persons responsible, and date of completion.

• Document on Log brief explanation of IDT decisions and refer to assignment sheets.

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• Update team each morning on plans.

• Review Assignment sheets at Weekly UR meeting– Hold staff accountable.

• Write in actions taken for the previous week and if completed or ongoing.

• Add new assignments if needed.

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Progress and Review


• IDT can recommend removal from Target List when all parts of plan completed.

• Review Discharge Checklist in UR with IDT to make sure all is done.

• IDT will recommend in next morning meeting to remove resident from “at risk” target list.

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Discharge


• This person, unless discharged to another environment, would be reviewed quarterly upon clinical rounds to make sure plan still appropriate or if a comprehensive assessment is needed again.

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Quarterly Review


QUESTIONS?

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THANK YOU!

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1. Centers for Disease Control and Prevention. Adult Falls. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Accessed February 2014.

2. Tools to Implement the Otago Exercise Program: A Program to Reduce Falls 1st Edition, CDC. Accessed October 2013

3. Tinetti, Mary E. M.D., www.fallprevention.org/pages/fallfacts.html 2005.4. Root Cause Analysis: www.health.state.mn.us/patientsafety/toolkit.html

Accessed April 1, 2014.

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Resources

http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

http://www.fallprevention.org/pages/fallfacts.html

http://www.health.state.mn.us/patientsafety/toolkit.html


5. Comprehensive Accreditation Manual for Long Term Care Refreshed Core, January 2011

6. Internet: http://www.jointcommission.org Accessed February 3, 2014.7. Internet:

http://www.primaris.org/sites/default/files/resources Accessed April 3, 2014

8. Internet: http://www.ahrq.gov/professionals/systems/longtermcare Accessed April 3, 2014.

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Resources (con’t.)

http://www.jointcommission.org/

http://www.primaris.org/sites/default/files/resources%20Accessed%20April%203

http://www.ahrq.gov/professionals/systems/long


9. Currie, Leanne, D.N.S., M.S.N., R.N., assistant professor, Columbia University School of Nursing, Patient Safety and Quality: An Evidence- Based Handbook for Nurses. Chapter 10, 2007.

10. Centers for Disease Control and Prevention, STEADI-Stopping Elderly Accidents, Deaths and Injuries: Fall Risk Checklist: Accessed February 4, 2014.

11. Taylor, Jo. A., R.N., M.P.H., Parmalee, Patricia, Ph.D., Brown, Holly, M.S.N., A.P.R.N.-B.C., Ouslander, Joseph, M.D. The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities: AHRQ, October 2005.

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12. Guidelines for Nursing Homes: OSHA 3182-3R, 2009.13. Internet: http://www.cms.gov/regulationsandguidance Accessed

February 2014.14. The Centers for Medicare and Medicaid Services. MDS 3.0 Quality

Measures: User’s Manual v.5.0 03-01-201215. Bischoff-Ferrari, Heike, A., M.D., M.P.H., Dawson-Hughes, Bess, M.D.,

Willett, Walter, C., M.D., P.H.D., Staehelin,Hannes, B., M.D., Bazemore, Marlet, G., M.D., Zee, Robert, Y., M.D., Wong, John, B., M.D., Effect of Vitamin D on Falls, A Meta-analysis. April 28, 2004

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http://www.cms.gov/regulationsandguidance


16. Internet: http://www.jama.jamanetwork.com/article Accessed April 4, 2014.

17. Rubenstein, Laurance, Z., M.D., M.P.H., Merck Manual Professional. Falls in the Elderly. November 2013.

18. Journal of the American Geriatric Society. AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: March 2012.

19. The AGS Foundation for the Health in Aging: www.healthinaging.org Accessed February 4, 2014.

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http://www.jama.jamanetwork.com/article

http://www.healthinaging.org/


• https://www.interact2.net, INTERACT Tool, Accessed 3/5/2015• https://www.nhqualitycampaign.org, Advancing Excellence, Accessed

3/23/2015• Measuring Vital Sign’s, http://www.healthline.com,2/24/2009• Rehabilitation Measures Database, http://www.rehabmeasures.org,

accessed 3/5/2015

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https://www.interact2.net/

https://www.nhqualitycampaign.org/

http://www.healthline.com,2/24/2009

http://www.rehabmeasures.org/


• Vital Signs, http://en.wikipedia.org, accessed 3/5/2015

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http://en.wikipedia.org/

haltt: hospital admissions lessened through therapy tuesday, april 28, 2015 h.a.l.t.t. hospital...

Documents

hospital admissions

subsequent hospital

result of readmissions

readmissions definedhaltt

prevalence of readmissions

excess readmissions

breakdown of readmissions

readmission totals