How a Skilled Nursing Facility Reduced its Hospital Readmissions Rate

How a Skilled Nursing Facility Reduced its Hospital Readmissions Rate

B14 Poster Abstracts / JAMDA 13 (2012) B14eB24 Quality Improvement Category A Transition into Long Term Care (LTC) Geriatrics Rehabilitation: A “Pre...

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Poster Abstracts / JAMDA 13 (2012) B14eB24

Quality Improvement Category A Transition into Long Term Care (LTC) Geriatrics Rehabilitation: A “Pre-See” Admissions Program (A Focus on Medication Reconciliation) Presenting Author: Reecha Madan, MD, UTHSCSA Family and Community Medicine/Geriatrics Author(s): Reecha Madan, MD, Loren Fisher III, MS, S. Liliana Oakes, MD, CMD, Yanping Ye, MD, CMD; and M. Rosina Finley, MD, CMD

Background: Many healthcare providers have not practiced in the settings to which they are sending patients and are unfamiliar with the care-delivery details of these settings, and may transfer patients inappropriately. Ineffective transitions can lead to poor outcomes such as inappropriate treatments, delays in diagnosis, severe adverse events, patient complaints, increased costs, and increased lengths of stay. Objective/Aim: Phase 1: To increase pertinent information by 60% collected during the phone call the nurse gets prior to transfer of patient to the nursing home using the nurse-nurse communication tool. Phase 2: Medication reconciliation was added to clarify appropriate use of medication. Quality Improvement Methods: Design: Quality improvement. Setting: A local nursing home in the San Antonio area. Patients: Phase 1: Included 12 chart reviews of admissions and readmissions into the nursing home. Phase 2: Included 20 chart reviews of admissions and readmissions into the nursing home. Intervention: Phase 1: A nurse to nurse tool was introduced to the staff to use during the phone call that is received from the acute care hospital prior to transfer of the patient. Data was then collected and compared from 12 charts; 6 that utilized the original tool and 6 that did not. The following information was reviewed and compared: ACH Discharge paperwork and available ACH records, Nurse-Nurse Telephone Communication Records, NH Admission orders, Pharmacy, Rehabilitation, Dietary and NH records including MAR, TAR, lab collection and follow-up healthcare provider appointment records. Phase 2: The tool was revised to add more check boxes rather than free text to cut down time and amount of writing for staff, and medication reconciliation process was added to this tool. Results: Phase 1: Analysis revealed an increase in pertinent data collection by 70.3%. Examples of inconsistencies found in the chart reviews included “NH culture translations” made in the process of MD translations of transfer orders into admission orders during the NH nurse to admitting MD telephone calls: Hydrocodone 5mg/325 mg (transfer order); Hydrocodone 5 mg/500 mg (admission order; dosage provided in the NH stock cart); Hydralazine ordered at lunch, dinner, and bedtime in addition to a B-Blocker at bedtime (transfer order). Given BP readings identified during the admissions process, the bedtime Hydralazine dose was not included on the admission order; 2 gm sodium diet (transfer order) was translated as no added salt diet (admission order); 1 inconsistency included Lovenox without a stop date (transfer order); and Lovenox without a stop date (admission order). In this NH, Lovenox is a drug which requires an association with a stop date. Phase 2: 50 % of the charts reviewed included the usage of the revised tool including the medication reconciliation process, and of those 10, 30% included details of the medication reconciliation requested. Conclusions: 1) Nurse to nurse and nurse to physician collaborations contributed to increased efficiency and fewer miscommunications. 2) The inclusion of medication reconciliation contributes to appropriate and rational use of medications. Author Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Hospice: A Story of Innovation Presenting Author: Jyoti Rajeev Walavalkar, MD, NAVAHCS Author(s): Jyoti Rajeev Walavalkar, MD

Background: Northern Arizona VA (NAVAHCS) had increased Average Length of Stay (ALOS) of patients in the acute care setting most appropriate for Hospice Care. It was identified that an innovative solution allowing for easier access for admissions to hospice was needed. Utilizing the VA-TAMMCS framework a system redesign was initiated. Objective/Aim: 1. Increased satisfaction of Veterans, Hospitalists, Nurses, and Executive Leadership related to an improved process for admissions to the inpatient hospice unit. 2. Improve the report of services on the Bereaved Family survey to a minimum of 65 percent by the 2010 survey date. 3. Decrease the number of patients admitted to the medical floor/ICU that is appropriate for admission to the Hospice inpatient unit, thereby decreasing the overall ALOS for acute care. 4. Within three months of implementation there would be a decrease of patient deaths occurring in the acute inpatient setting with 60% of deaths occurring in the Inpatient Hospice unit. Quality Improvement Methods: A systems redesign was implemented to evaluate and redesign the “admit to hospice” process. The process improvements focused on early and easier access to hospice and palliative care services Development of a crisis list for “real time” admissions educating providers and our Veterans on the focused change process. Results: Staff accomplished the highest scores on the Bereaved family satisfaction global item with 74% of families stating that the overall care of the veteran received during the last month of life was “excellent.” Prescott VA also had 90 % of the facility deaths occurring within inpatient hospice unit. Conclusions: In evaluating NAVAHCS ALOS (average length of stay) in the acute care setting was 5.71 FY10 Qtr. 1 with Diversion hours at 217 per month. The direct admit to hospice change process was implemented in FY10 Qtr. 2 with FY10 Qtr. 3 ALOS measuring 4.2 and Diversion hours an average of 37 per month. To sustain the process NAVAHCS has developed a Standard Operating Procedure outlining the steps necessary for direct admission to hospice. A Crisis List has been created where Veterans and staff can refer appropriate patients for admission to hospice without presenting to the Emergency Department. Author Disclosures: Jyoti Rajeev Walavalkar, MD has stated there are no disclosures to be made that are pertinent to this abstract.

How a Skilled Nursing Facility Reduced its Hospital Readmissions Rate Presenting Author: Ashkan Javaheri, Mercy Medical Group Author(s): Ashkan Javaheri

Background: Asbury Park Nursing and Rehabilitation center (APNRC) is a 139 licensed-bed Skilled Nursing Facility in Sacramento. The national average for patients readmitting to the hospital within 30 days of their SNF admission is 25%. Hospital readmissions are a critical component to upcoming healthcare reform and will affect hospital reimbursements; it is also an important quality of care indicator. Objective/Aim: The hospital readmission rate at APNRC in 2008 was 22.6%. To reduce the hospital readmission rate, APNRC started this quality improvement project. Quality Improvement Methods: Since 2008, APNR has implemented numerous interventions aimed at further reducing the hospital readmission rate and improving quality of care. These interventions include INTERACT-II communication tools (SBAR), electronic medical record for physician notes (on-call physician access to notes), implementing POLST forms for all patients and confirming prior to transfer, a quarterly nursing education series using AMDA clinical guidelines, a comprehensive assessment upon admission, continuous inter-disciplinary team care conferences to discuss goals of care, and the on-site presence of MD/PA 4-5 times per week.

Poster Abstracts / JAMDA 13 (2012) B14eB24

Results: As a result of these interventions, the hospital readmission rate has decreased from 22.6% to 16.23% in 2009, 15.63% in 2010 and through August the 2011 average is 14.6%. Conclusions: This poster demonstrates the effectiveness of a team based approach, clinical guidelines and POLST form in detail. Author Disclosures: Ashkan Javaheri has stated there are no disclosures to be made that are pertinent to this abstract.

Implementing INTERACT (Intervention to Reduce Avoidable Acute Care Transfer) Distance Learning Curriculum to Reduce Avoidable Acute Care Transfer and Improve the Quality of Care in a Skilled Nursing Facility Presenting Author: Yangping Ye, MD, CMD, UTHSC at San Antonio Family & Community Medicine Author(s): Yangping Ye, MD, CMD, Alethea Phippis, RN, Sharla Reiman, RN, Debra Carr, GNP, MSN; and Robert W. Parker, MD

Background: Thousands of NH residents are hospitalized each year. In fact, 25% of Medicare patients discharged from an acute care hospital to a nursing home (NH) are readmitted to the hospital within 30 days. Recent reviews indicate that a substantial proportion of these hospitalizations may be avoidable, including hospital transfers for clinical conditions, such as heart failure, urinary tract infection, and pneumonia, that may be safely treated in the NH with early identification and appropriate management. Objective/Aim: 1. Implement INTERACT program at NHs to improve the interdisciplinary education and quality of care. 2. Reduce 30 day readmission rates by 20% in 1 year. 3. Improve advance care planning discussion and documentation to 100% of standard in 1 year. Quality Improvement Methods: A core interdisciplinary team including physician, nursing, rehabilitation, case management, social worker, staff educator, and quality management attended INTERACT distance learning curriculum on site twice a month for 6 months. Additional staff completed the required learning modules online. The INTERACT tools were implemented during change of conditions and hospital transfers. The project coordinators collected the data on monthly hospitalizations and census during the 6-month distance learning program of INTERACT (MarchAugust 2011) and the one year baseline data (March 2010-Feburary 2011). Hospitalization rates were measured as hospitalizations per 1000 resident days. Results: We have developed a medical staff committee which oversees the progress, obstacles and plans for the future. We have an interdisciplinary team to implement the INTERACT quality improvement program at this nursing home. There was a 21% reduction in hospital admission during the implementation of INTERACT from the same 6-month period in the previous year. The program helped this nursing home to have zero avoidable acute care transfer for four months (May thought August 2011) based on the rating of INTERACT QI review tools. Conclusions: We have shown inappropriate transfers can be reduced or eliminated. The Interdisciplinary team education using INTERACT curriculum was effective to reduce avoidable acute care transfers and hospitalizations. The medical staff steering committee, the active participation of all staff involved in patient care, and a system that integrated team education, communication and patient centered care medical home model all contributed to the improvement. In light of this encouraging pilot study, we are initiating a system wide INTERACT program at the other NH and three assistant living facilities within the same continuous care retirement facilities. Author Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.


Medication Reconciliation in Transition Of Care: Broken Telephone or Patient Safety Goal? Presenting Author: Liron Danay Sinvani, MD, Hofstra North Shore LIJ Author(s): Liron Danay Sinvani, MD, Judith Beizer, PharmD, Gisele WolfKlein, MD, Meredith Ackerman, MS, Larry Lutsky, PhD; and Charles Cal, RN

Background: The transition of care from the hospital to the community has been extensively studied, demonstrating medical errors in half of patients after hospital discharge. However, there has been a dearth of studies focusing on the transition of older patients from the hospital to skilled nursing facilities. Objective/Aim: To evaluate the number and types of medication discrepancies as geriatric patients transition across a large Health Care System using medication reconciliation lists. Quality Improvement Methods: Chart review using randomized electronic medical records (EMR) and paper chart medication reconciliation lists across three separate transitions of care through a large Health Care System: inpatient admission to hospital discharge (time I), discharge from inpatient hospital setting to a sub-acute rehabilitation facility (time II) and sub-acute rehabilitation admission to discharge home or to a long term care facility (time III). A medication discrepancy was defined as any unexplained change in the recorded medication and reviewed by the PI (L.S.) and the Chief of Pharmacy (J.B.). Medication discrepancies were grouped as omissions, additions, dosing changes, changes in route of administration, duplications, and exchanges within the same class of medications (Tija, J Gen Intern Med. 2009). Discrepancies were further grouped by intentional versus unintentional. Descriptive statistics of the study population were computed In addition, weighted proportions were calculated for the discrepancies. All analyses were conducted using SAS version 9.2 (Cary, NC). Results: In the 44 charts analyzed, average age was 71.4(range: 4191), with 68% female, 77.2% surgery versus 22.7 medical, and an average hospital stay of 8.6 days (Std :7.10) and 15.64 days (Std: 7.21) in skilled facilities. The total number of medications documented on hospital admissions were 284, total number on hospital discharge was 472, total number on sub-acute rehab admission 545 and on sub-acute discharge 385.There were 1006 total medical discrepancies across all three transition sites: 358 (Time I); 318 (Time II) and 330 (Time III). Percentage of unintentional discrepancies was 12%, 11% and 16% respectively. Cardiovascular drugs, hypoglycemic agents and opioids/pain control medications did not show significant changes across transition of care. Most discrepancies occurred amongst GI medications (83, 105 and 103 respectively) and vitamins/minerals and supplements (82, 56 and 41 respectively). Furthermore, there were no skin care treatment on admission to or discharge from hospital, but 12 on admission to rehabilitation and 1 on discharge. Conclusions: In 2006, the Joint Commission mandated that accredited health care organizations “accurately and completely reconcile medications across the continuum of care”. Our study outlines the pressing need to better coordinate medication reconciliation in older patients as they transition from the hospital to long term care. Author Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.

Nursing Home to Hospital Transfer Reduction Using a Structured Root Cause Analysis Presenting Author: Brian Heppard, MD, Evercare Author(s): Brian Heppard, MD, Terry Wihlen; and Asma Bawaney, MD, CMD

Background: Nursing homes vary in their ability to treat patients in place. Factors affecting nursing home to hospital transfers include the clinical status of the patient; staff, physician, patient and family