presentation id: cd2 m arch 13, 2014. disclosure slide today’s presenters do not have any relevant...
TRANSCRIPT
Presentation ID: CD2
March 13, 2014
Disclosure Slide
Today’s presenters do not have any relevant financial interests presenting a conflict of interest to disclose. Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation. The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non-ACHE) for this program toward advancement, or recertification in the American College of Healthcare Executives.
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At the conclusion of the presentation participants will be able to:Identify the roles of nurse leaders and
physicians in redesigning the future care delivery system across the continuum of care.
Describe an innovative clinical process entitled Structured Interdisciplinary Bedside Rounds used to achieve desired value-based metrics.
Delineate the role of the Clinical Nurse Leader as a change agent in redesigning care delivery systems.
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A Model Designed to Improve Patient and Hospital Outcomes
Program and Implementation GuideWellstar Kennestone Regional Medical Hospital
Laura Caramanica, RN PhD CENP FACHE, FAANVP & Chief Nursing OfficerSonia Camphor, MDMedical Director of Accountable Care UnitsCarole Harman, BSN, MSA. RNExecutive Director of Nursing, Acute Care Service Line
Accountable Care is….Having a reimbursement system that
emphasizes primary care, wellness and population health management
Taking fiscal and clinical accountability for the population
Actively engaging patients to take more responsibility for their health
Building hospital-physician relationships and partnering in a deeper way with patients, populations and payors
Improving the health of our communities and decreasing health care costs by proactively managing chronic care and patients’ health needs6
Current State of Healthcare System Delivery Care delivered in unorganized silos
No orchestrated care pathways
Network may not be high value-driven
No integrated comprehensive health information
Providers’ goals & outcomes not aligned
Payors not partnered with aligned & incented providers
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FEE FOR SERVICE TO INTEGRATED CARE, NEW PAYMENT MODELS AND RISK
Population management•Population analytics•Care management•Financial modeling and management•Legal•Physician integration
High-value episodes•DRG and episode targeting•Care models and gainsharing•Data analytics•Cost management
High-performing hospitals and physician networks•Best outcomes in quality, safety•Waste elimination•Most efficient supply chain•Satisfied patients
Bundled payment
Shared savings
Value-based purchasing:HACs, quality, efficiency, cuts
Capitation
Readmissions/HAC Penalties
Source: Center for Accountable Care Intelligence, “Growth and Dispersion of Accountable Care Organizations: June 2012 Update (06/2012)
– 310 ACOs in 45 states and the District of Columbia– First ACOs (10 organizations) part of the PGP Demonstration project beginning in 2006
– 32 CMMI “Pioneer” participants, program began January 2012– Roughly 30% physician organization led
– Medicare Shared Savings Program– 04/01 – 27 ACOs selected to participate.
– Majority of organizations physician organization led– 07/01 – 89 ACOs selected to participate in this second cohort
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CMS Shared Savings ProgramFocus on the Triple Aim =
Better health, Better Quality, Lower Costs
Current FFS payments to providers continue
CMS establishes an ACO benchmark for “bending the cost curve”
Must achieve a “Minimum Savings Rate” (MSR) + performance on 33 Quality metrics
50/50 cost savings sharing between CMS and ACO
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Why Are We Doing This?ACO Future State
Create seamless coordinated world class carePut beneficiary and family at the centerProactively manage beneficiary care Attend carefully to care transitionsManage resources carefully and respectfullyRemember patients over time and placeEvaluate data to improve care and patient outcomesInnovate around better health, better care and lower
costsInvest in team-based care
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Background How do you optimize clinical outcomes for
patients nurses and physiciansProperly Designed Hospital Units (ACU)Institute Medicines STEEEP Dimensions of Care Safe, Timely, Effective, Efficient, Equitable and
Patient CenteredTeam Based Setting
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Story of Harm
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Mrs. BB is 80yo lady: Admitted in January by urologist for nephrectomy stayed in
Hospital 5 days (acute renal failure, hyperglycemia) went home with Cr=1.9/Hct=26 all previous medications continued (patient’s Nephrologist/Cardiologist/PCP not aware of surgery)
10 days after discharge Mrs. BB came to see Nephrologist complaining of weakness, somnolence, “just not feeling well” hypoglycemic, Cr=2.9, Hct-22 admitted by Nephrologist most medications discontinued
Hospital Stay – one week Seen by:
three different nephrology MDs and one AP three different cardiologists two different pulmonologists two different GI MDs Urologist
On their way home (Friday @7pm) patient’s daughter called family member-MD asking what to do with her blood sugars/diabetes medications (prior to discharge BG=200) and stating patient c/o urinary urgency.
OpportunitiesNo Lead Physician
Patient/Nurse do not know who is in chargeRN discussing POC with 30+ providers
Patients regularly discharged after 4pmRN needing to paging multiple physicians leads to
delayed dischargePatient satisfaction with discharge process very
low (HCAHPS)Patients’ understanding of the “next steps” very
low
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SolutionsEstablish Accountable Care Unit (ACU) with
following attributes:Unit-based Hospitalist-led teamsStructured Interdisciplinary Bedside
Rounds (SIBR) – MD, RN, CNL, Care Coordinator, Pharm. D, (PT. Dietary)
Redesigned MD-RN collaborative partnership
Unit level performance data (HCAHPS, LOS, discharges before 2pm, readmission rate, cost-per-case)
The structured ACU&SIBR were introduced by Dr. Jason Stein (Emory University) and adapted for this presentation
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Definition:A geographic inpatient area consistently responsible for clinical and cost outcomes it produces
The structured ACU&SIBR were introduced by Dr. Jason Stein (Emory University) and adapted for this presentation
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Building hospital-physician relationships and partnering in a deeper way with patients, populations and payors
Design Features of Team-Based ModelPatient-Centered Team-Based Work Flow
SIBR Roll CallPatient/FamilyHospitalistNurseClinical Nurse LeaderCare CoordinationClinical Pharmacist
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Transition CoachCharge NurseAs Staffing/Pt needs
allow: Physical Therapy Respiratory
Therapist
SIBR Ground RulesAll patients 5 days/weekAll SIBR team members must be
presentStart and finish on time Rounds end only after patient’s plan-
for-the-day has been verbalized and patient/family had an opportunity to ask questions
The structured ACU&SIBR were introduced by Dr. Jason Stein (Emory University) and adapted for this
presentation18
The Structured Dialogue of SIBREmphasis on Role Clarity
Introduce All Team MembersUpdate Status: (45 sec)
Overnight events & Review patients goal of the day (On in room white board) Vital Signs & Pain ControlFluid and Food Intake Urine and Bowel OutputMental Status and ADLsPhysical Findings/Pathophysiology
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Report “abnormals”
The Structured Dialogue of SIBREmphasis on Role Clarity
Checklist for Quality and Safety (15 sec)Foley CatheterCentral or Pic LineVTE Prophylaxis Pressure Ulcers/StagePlan of the Day and Assign Responsibilities
Discharge Planning Checklist (30 sec)Discharge Needs Discharge day and realistic timeFollow up Appointment
Patient Education (30 sec)20
Clinical Nurse Leader (CNL) Masters Prepared RN (University of
West Georgia) CNL functions as clinical leader for
RNSs, Clinical Care Partner, &ancillary staff
Comprehensive knowledge about each patient in their unit
Provides continuity of care for patient in the hospital to offset fragmentation
Acts in the role of ‘traffic control’ in coordinating rollout of the plan for care
Acts as the primary liaison for physicians, other disciplines, and families
Monitors competency and provides mentorship to team members
and students21
MDsRNs, CCP’s, and Students
CNL
FamiliesOther Disciplines
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ACU and the CNL
• Leads interdisciplinary team, fosters collaborative in SIBR Rounds
• Addresses gaps in care with Physicians and Nurses• Develops complex plan of care• Mentor for nursing staff• Translates & integrates evidence into practice• Emphasizes systems to accomplish health promotion,
risk reduction, & preventing readmission• Facilitates quality & LEAN process improvements at the
bedside• Conducts comprehensive unit-level assessment to
establish plan for improvement in efficiency, effectiveness & outcomes
• Mentor Staff
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Average Length of Stay ALOS 6S /7W ALOS 6N /7N ALOS 7W TOTAL LOS
BEFORE JAN 2013
AFTER JAN 2013
BEFORE JAN 2013
AFTER JAN 2013
BEFORE JAN 2013
AFTER JAN 2013
BEFORE JAN 2013
AFTER JAN 2013
4.00 3.89 4.21 4.01-
3.81 5.01 4.89
Δ2.39%
% DISCHARGES PRIOR TO 2 PM
BEFORE JAN 20
AFTER JAN 20
24.20% 43.44%
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*Implemented ACU Jan 20, 2013
Accountable Care Unit Outcomes
ACU 2PM Discharge Comparison
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Accountable Care Unit Outcomes
2 PM Discharge Compliance
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Accountable Care Unit Outcomes
Cost per Case SavingsBefore January 20th 2013 After January 20th 2013
$8,134 $7,954
•364 patients/month X 8months X $180 = $524,160 (Annualized $786,240)
•HM at KRMC annual census 8,000 = potential savings ~$1,440,000/year
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Accountable Care Unit Outcomes
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ACU HCAHPS Outcomes
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Lessons LearnedPositive impact on Nursing staff
Potential for system-wide large-scale impact
Transformation is a process - not an eventUnderstanding the stages of change and
common pitfalls increases chances of successful transformation
Transformation requires investment of human and financial capital
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Greets Patients /Introduces Team
Overnight EventsVital Signs and Pain
I & OADLs
Addresses Medication Questions
Addresses Discharge Plan
Supports Clinical Aspects of Care
Quality Safety
Checklist
Active Problem listTest results
Consult FindingsFamily Inputs
Foley Catheter
Central Line
DVT-Prophylaxis
SCD
Pressure Ulcers
Glycemic Control
Hospitalist synthesizes all information inputs from SIBR team and summarizes the patients care plan
for the day, updates anticipated discharge date and time. Answers patient questions.
Med Red Side Effects & Complication
New or Discontinued Medication
Follow Up Appts.
Addresses Issues that Measure or Affect
Clinical Quality
Answers Questions as to
Processes
Discharge Assessment
Family Support Issues
Addressed
Home Health Requirements
Discharge Medications
Unit Charge NurseRemains Outside the Patient
Room during SIBR. Holds Primary RN Phone,
Coordinates Additional resources such as PT/OT, Acts
as Timekeeper.
STOP3
Minutes
SIBR Process Map for Accountable Care Unit (ACU)
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A Model Designed to Improve Patient and Hospital Outcomes
Program and Implementation Guide
Contact us at:[email protected]
Carole Harman, BSN, MSA. RNExecutive Director of Nursing, Acute Care Service LineWellstar Kennestone Regional Medical HospitalMarietta, GA