CARE TRANSITIONS BETWEEN PROVIDERS TO IMPROVE HOSPITALIZATION RATES

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CARE TRANSITIONS BETWEEN PROVIDERS TO IMPROVE
HOSPITALIZATION RATES

• Presented by
• Carol Ann Thomas
• Manager, Patient Safety and Quality Improvement
• St. Peters Hospital Home Care
• Albany, New York

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About Us

• Hospital-Based CHHA structured as a Department
  of SPH
• One of 13 home care agencies within Catholic
  Health East
• JCAHO Accredited
• Magnet Designation
• Active census of approximately 350 - 400 patients
• Service approximately 3,000 patients per year
• Serve Albany and Rensselaer Counties
• Staff are divided into four multidisciplinary
  geographic teams
• Clinical Staff 32 FT RN 14 PT 3 OT 1 RD 8
  HHA
• Approximately 74 Traditional Medicare 8
  Managed Medicare
• 75 of our referrals come from acute care setting
• ACH Rate is 23

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Other Things About Us

• Utilize Beyond Now as our point of care system
• Benchmark outcomes with OCS across the Catholic
  Health East system
• Benchmark patient experience with NRC across the
  Catholic Health East system
• Have a telehealth program using Honeywell-HomMed

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Cross-Continuum Approach

• As a Department of a hospital, high degree of
  integration in operational matters
• Benchmarking is done across hospital
  departments/units
• Participation on hospital committees allows for
  the sharing of expertise and ideas for
  improvement
• The JCAHO tracer methodology and the NPSG promote
  greater cross-continuum exchange of information
  in patient care
• P4P Initiative suggests greater need for disease
  management programs

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CHF Hospital to Home

• Developed as a collaborative effort with acute
  care multidisciplinary team
• Patient Educational booklet focusing of self
  management were compiled through research of best
  practices.
• Divided into two sections Monthly calendar and
  educational information
• Standardized orders are utilized in the hospital
  for patient care regardless of point of entry
• Education begins in the hospital prior to
  discharge utilizing the standardized educational
  booklet

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CHF Hospital to Home

• Kick off during Congestive Heart Failure
  Awareness Month (April)
• Home Care visits of RN and RD offered to all CHF
  patients
• Home Care referral information indicates patient
  participation in the CHF Education Program as
  well as support group enrollment
• Home Care nurse assesses patients learning
  progress/status through interactive teaching
  flowsheet/D/C instructions and continues to
  utilize the same educational booklet that the
  patient was given prior to hospital discharge
• Home Care RN begins the program for patients
  referred from other than SPH
• Information is conveyed at the time of discharge
  to another provider of care

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Results

• Promotes Self Management
• Consistency of health education
• Patient hears the same message from all involved
  health providers
• Validates patient/family understanding of
  educational content and health instructions
• Greater chance of patient compliance to health
  regimen
• Greater continuity of care
• Patients feel more empowered
• ACH Rate is 15 - 19

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Other Cross Continuum Disease Management Projects

• CAD/CABG
• COPD/Smoking Cessation
• Diabetes
• Pain Management
• CVA

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Next Steps

• Currently piloting a ACH Risk Assessment to be
  utilized by Discharge Planners as well as Home
  Care Practitioners
• Incorporating the Risk Assessment into the
  referral/transfer hand-off processes

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Acute Care Delivery Model

• Magnet status promotes advanced nursing practices
• Nurses apply for higher level of practice (Levels
  1 4)
• Nurses practicing at different levels required
  reorganization of traditional nursing roles
• Care Delivery Models were researched
• Adaptation to a new model resulted in change in
  varied other roles as well

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Discharges Under New Model

• Problem Inconsistent/Inaccurate information
  exchange at D/C from Acute Care Setting to Home
  Care increased
• No one person responsible for D/C functions
• Increased use of clerical assistance was employed
• Health Information Systems do not interface
• Decentralized to Centralized Discharge Planning
• Problem Many Discharge Planners have not worked
  in Home Care
• Not all D/C Planners are nurses many do not
  understand Home Care criteria for admission
• Learning curve for new D/C Planners

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Discharge Planning Contd

• Continual feedback given for content of
  information received highlight errors,
  omissions, as well as successes
• Patient Event Reporting mechanism for critical
  information omitted
• Planned open communication sessions to
  review/revise processes
• Home Care participation on Discharge
  Planning/Case Management QI Committee

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Discharge Planning Contd

• Two HC Liaisons assigned in the hospital
• Function
• 1) Hospital Staff education about Home Care
  services
• 2) Follow current HC patients while
  hospitalized for increased continuity of care
• 3) Ensures hand-off of HC current status info
  and medications
• 4) Act as contact for HC practitioners in
  following patients across settings
• 5) Available on site for collaboration on
  hospital-based care committees
• 6) Increase interdepartmental and
  inter-facility communication, ie, hospital/home
  care/rehab/nursing home/ED

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Cross Continuum Initiative Medication
Reconciliation

• Collaborative effort between acute care,
  pharmacy, physicians, home care, rehab, nursing
  home
• Piloted as a hospital process and expanded to
  cross continuum initiative
• Developed medication reconciliation order form
  for hospital records and incorporated into
  referral/discharge process
• Completed form provides a medication history of
  hospital course and current discharge medications
• Developed wallet sized patient med list cards for
  patient to maintain and bring to physician
  offices/ED/etc.

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Home Care Initiative Medication Reconciliation

• Multidisciplinary HC CQI project to revise
  current processes/policies
• Developed story board approach utilizing
  resources from IPRO and the Beyond Now system
• Developed standardized practitioner guides for
  assessing and managing medications in the home
• Educated staff regarding new reconciliation
  processes, establishing staffing expectations
• Requested that both the medication reconciliation
  form AND a copy of the medication discharge
  instruction be sent with every referral to
  overcome learning curve
• Developed Home Care Daily Medication Log to be
  used in patient teaching (larger print)
• Distribute/assist in completing med card/log with
  every home care patient as part of the admission
  process
• Patient instructed to take medication information
  with them for every medical visit, and to place
  in Vial of Life, if participating.
• Practitioner updates medication record with every
  change

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Patient Experience

• Revised patient experience survey to incorporate
  measurement of cross continuum processes
• Examples of survey items added
• During this hospital stay, did staff talk with
  you about the help you would need at home?
• During this hospital stay, did you receive
  information in writing about what symptoms or
  health problems to look out for after you left
  the hospital?
• Sometimes in the hospital, one doctor or nurse
  will say one thing and another will say something
  quite different in telling you how to care for
  yourself. Did this happen to you?
• Did someone on the hospital staff explain the
  purpose of the medications you were to take at
  home in a way that you could understand?
• Did they tell you what danger signs about your
  illness or operation to watch for when you went
  home?
• Did your HC nurse give you clear instructions in
  how to take care of yourself?
• Did your home care nurse give you clear
  instructions about your medications?
• Did the Home Care staff provide your family with
  enough education to assist you with your care?
• Did you receive clear instruction on how to take
  care of yourself when you were discharged from
  home care?

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Thank You!

• CONTACT INFORMATION
• Carol Ann Thomas, RN, MS, CPHQ, COS-C
• Manager, Patient Safety and Quality Improvement
• St. Peters Hospital Home Care
• 159 Wolf Road
• Albany, NY 12205
• 518 525 6004
• 518 525 6002 (fax)
• cthomas_at_stpetershealthcare.org