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Reducing Avoidable Hospitalization in Long Term Care

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Reducing Avoidable Hospitalization in Long Term Care Powered By Docstoc
					   Lisa Byrd PhD
  APRN, FNP-BC
Nurse Practitioner
    Gerontologist
Skilled Nursing Facilities (SNF)
 1.5 million residents in 16,400 nursing facilities in the
  United States
                  Between 2000 – 2002
 the number of licensed assisted living
and board and care facilities increased
                 from 32,886 to 36,399
Long Term Care: SNF & ALF
 1994     5.5 million older adults
 2000 13 million older adults
 2050    27 million older adults
 30% will require SNF
    25% will be >75 years old
    40% will be in fair to poor health
Assisted Living Facilities
 Over 50% of elders >75 years old live alone
                                                   .
 Adults requiring assistance with ADL’s:
    75-79 y/o      16%
    >80 years      30%
 Projected to be 1.9 million elders residing in
  ALF by 2030
 Increasing regulations due to increased
  healthcare needs
Hospitalizations
SNF
 1/3 are hospitalized each year
    450,000 per year
 Costs
    average $6500 per hospitalization
    plus a 30 day SNF for 1/3 of those hospitalized @ $350/day
    $10,000 per hospitalization
 $4.5 billion annually
Increase in Hospitalizations
 SNF residents with multiple complex
  conditions
 The growing nursing shortage
 A recent increase in lawsuits
    Hospitalizing patients to avoid litigation
 ALF residents becoming sicker prior to
  seeking hospitalization
 Cost growth that outpaces payment rates
    leaving homes without the resources to
     care for residents
Characteristics of Residents
 SNF’s:                            ALF’s :
    The increasingly sicker and       Less functionally &
     more disabled population           cognitively impaired
     served by nursing homes            residents
    Significant number with           Not monitored as closely as
     cognitive impairment               SNF residents
     making reporting of
     symptoms difficult to
     interpret
Issues affecting patient care
 Infectious diseases         Polypharmacy
 Evaluation for infection    Pressure ulcers
 Influenza                   Weight loss
 Clostridium difficile       Urinary incontinence
 Asymptomatic bacteriuria    Vision evaluation
 Pneumonia                   Physical rehabilitation
 Behavioral disorders        CARE PLANNING
 Psychotic symptoms              Advance care planning
 Aggressive behavior             Cardiopulmonary
 Wandering                        resuscitation
 Sexual activity                 Hospitalization
 Falls                           Re-hospitalization
 Dehydration                     Palliative Care
Infectious diseases
 Evaluation for infection
    Prompt assessment
    Follow-up care
 Influenza
 Pneumonia
    Leading cause of death in elders
    Dental caries is the leading cause of pneumonia in elders
 Clostridium difficile
    Complication of antibiotic usage
    Deadly for Elders
 Asymptomatic bacteriuria
    Treatment not necessary of no history of septicemia
Behavioral disorders
        Dementias
           Alzheimer’s disease
           Vascular dementia
           Parkinson disease dementia
           Others: Lewy Body, Pick’s disease
        Behaviors
           Aggressive behavior
           Wandering
           Sexual activity
           Sundowning
        Psychotic symptoms
           Evaluation of environment
           Evaluation of medications
        Medication management
           Appropriate use
           Therapeutic dosing
           Periodic dose reduction & withdrawal as necessary
Other Care Issues
     Falls
        Environment
        Balance testing
        Strength training
     Dehydration
        Offering water
     Pressure ulcers
        Treatment
        Prevention
     Weight loss
        Expected
        Untoward
     Urinary incontinence
        Type: Stress, Functional, or Mixed
        Treatment
 •Multiple medication usage
•Periodic review & reduction
Health Promotion
 Podiatry care
 Psychiatry evaluation for residents taking
  antidepressants & antipsychotic medications
 Vision evaluation
 Physical rehabilitation
 Often Neglected-Dental care
Care Planning
  Advance care planning
  Cardiopulmonary resuscitation
  Hospitalization
  Re-hospitalization
  Palliative Care
  Hospice
Complications caused by treatment
Hospitalizations
 Substantial % of acute hospitalizations
  are avoidable
 Hospital acquired complications
    Delirium
    Foley catheter
      incontinence
    Pressure ulcers
    Polypharmacy
How Much Can Be Saved?
$4.5 billion annually
    % of reduced      Estimated
   hospitalizations    National
                       Savings
        30%           $1.4 billion

        40%           $1.8 billion

        50%           $2.3 billion
Reducing Avoidable
Hospitalizations
 Improves Quality of Life
 Decreases Costs
 Increases Resident’s Satisfaction
          Georgia Study
          July-December 2007
 377 Nursing Facilities in Georgia
    104 average hospitalizations
 Highest admissions
    Higher number of certified beds
    Higher % Medicaid patients
    Lower % of Caucasian residents
    Fewer advanced directives
    Substantial problems accessing
     healthcare providers
         Medical directors, Physicians,
          Nurse Practitioners, & Physician
          Assistants
Arizona Long-Term Care System (ALTCS) live in ALFs or boarding
homes
Pilot Program:
  2 ALFs provides an interdisciplinary team
     PCP, NP, and RN care manager—on-site
  NP serves as a clinical consultant and coach for the
   clinical care manager
  Marked improvement in advanced care planning
   and family communications
  Hospitalization rates have been reduced by 60-70%
   as compared to members residing in other ALFs
Model: Physician-Nurse
Practitioner Team Approach
 Prescribing
  practitioner rounds on
  a scheduled basis
  weekly
 Protocol system for
  reporting problems
 Protocol system to
  treat
 Appropriate follow-up
  assessment
Care Issues
 Assessment and management of geriatric syndromes—dementia, depression,
    falls, incontinence—as well as chronic illness prevalent in the ALF setting
   Identification of members at highest risk for avoidable hospitalizations and
    providing proactive care management
   Assessment of members at risk for polypharmacy, on high-risk medications, as
    well as drug/disease interactions
   Fostering improved comprehensive and continuous advanced care planning
   Identification of the most appropriate clinical quality measure for an ALF
    population
      such as the Assessing Care Of Vulnerable Elders
     [ACOVE] guidelines
           Addressing Care Issues
 Education
    Geriatric Concepts
    Prescribing Practitioners
    All Nursing Home Staff
 Communication
    Proper language to describe in detail
    Shift change & 24 hour reports
    Protocol system
       Immediate notification
       Report within 24 hours
       Place in log to notify prescribing
         practitioner
 Frequency of visits by prescribing practitioner
    2 to 3 days per week
    Higher acuity of care
 Evaluations & tests based on treatment plan
    Patient preferences
    Advanced directives
 Appropriate follow-up assessment
 Acute Change in Condition (ACOC)
Acute Change in Condition
(ACOC)
 Sudden, clinically important
  deviation from the resident’s
  physical, cognitive, behavioral, or
  functional status
 Clinically important deviation
  could cause significant
  complications or death
Common Diagnoses Associated with
Acute Transfers to Hospital
 Respiratory Symptoms
 Urinary Tract Infections (UTI)
 Cerebrovascular Accidents (CVA)
 Cardiovascular Changes
 Falls
 Gastrointestinal Bleeding
Goals
 Prevent problems
 Primary aim
    staff to recognize changes in condition
 Identify nature, severity, & cause of the problem
 Accurately evaluate & promptly manage problem
 Prevent avoidable transfers to acute setting
Accountability
 Staff must recognize and report
  accurately
        Develop protocol for reporting
        All caregivers are responsible for
         reporting changes
 Healthcare Providers must be
  responsive to staff reports
 Healthcare Providers present to round
  on a routine basis
    Significant reduction in acute
     hospitalization when practitioner in
     nursing facility 2 to 3 days each week
Reporting Acute Change in
Condition (ACOC)
 Evaluate current condition
 Determine possible cause & expected course of problem
 Identify all of the resident’s medical conditions
    Create a list
    Match disease states with potential problems
 Identify resident’s at risk for poor outcomes
    Skin breakdown
    Weight loss
    Death
 Identify interventions that may reduce potential problems
    Turning & positioning
    Dietary modifications
    Laboratory monitoring
    Reduction of medications
Procedure for Reporting Acute
Change in Condition (ACOC)
 Communicate changes routinely
   Shift change
   24 hour report
 Be prepared
   Communicate all relevant data in an organized manner
   Use proper terminology
 Sufficient documentation
     Symptoms
     Observations
     Conversations with healthcare providers
     Orders obtained
Appropriate Transfers to Acute
Setting
 Acute abdominal pain of moderate to
  severe intensity with intractable
  vomiting
 Chest pain that cannot be readily
  attributed to non-cardiac causes
 Fall with potential fracture
 Hypertensive crises
    SBP>230 mmHg
 Active GI bleed with hypotension &
  tachycardia
 Respiratory distress that does not
  respond to oxygen, nebulizers, or
  suctioning
Pre-Existing Conditions:
Potential Complications
 Cardiovascular
    Congestive Heart Failure
    Hypertension
 Functional
    Impairment of one or more
     ADL’s
    Impaired mobility
    Recurrent falls in past 3
     months
    Prolonged bedrest
    Urinary retention
 Metabolic
    Diabetes
    Malnutrition
    Weight loss
Pre-Existing Conditions:
Potential Complications
 Systemic/General
     Postoperative status
     Pain
     Pressure ulcers
     Multiple medications
 Other
     Cancer
     Cerebrovascular disease
     Endocrine disease
     Gastrointestinal disease
     Infectious diseases
Awareness of Potential
Complications
 COPD            Acute dyspnea
                  Respiratory infections



 Diabetes        Fluid/electrolyte imbalance
                  Hypoglycemia


 Hip fracture    DVT
                  Pulmonary embolus


 GI bleed        Acute recurrence of bleed
Awareness of Potential
Complications
   Acute myocardial infarction    DVT
                                   Pulmonary embolism
                                   Dysrhythmia

   Atrial fibrillation with       Bleeding
    anticoagulation/medication
                                   Stroke
    changes

                                   Acute dyspnea
   CHF
                                   Pulmonary edema

   Neurogenic bladder
                                   UTI
Awareness of Potential
Complications
 New medication         Fall
                         Delirium

 Parkinson’s disease    Aspiration
                         Agitation/change in
                         mental status

 Stroke                 Recurrence of stroke
                         Acute bleeding due to
                         anticoagulation
Developing Protocols: Acute Change in Condition
Staff Responsibilities
 Know the resident
 Consistency in assignments
 Recognize & report changes
 Assess symptoms & physical functioning
 Document detailed descriptions of observations &
  symptoms
 Report any changes to oncoming staff
 Communicate changes & request follow-up
 Advise charge nurse or unit manager if follow-up does not
  occur
Reporting Problems
 Immediate
 Non-immediate
 Routine
Establish Reporting Protocol
            Test                  Report Immediately                                 Non-Immediate

CBC                WBC > 12,000*                                                     WBC>10,000 without
                   Hemoglobin (Hgb)<8*                                               symptoms
                   Hematocrit (Hct)<24*
                   Platelets<50,000*
                   *Unless values are consistently at these levels or practitioner
                   is aware

Chemistry          Blood/Urea/Nitrogen (BUN) >60 mg/dl                               Glucose consistently >200mg/dl
                   Calcium (Ca)>12.5 mg/dl                                           HgbA1C (any value)
                   Potassium (K)<3.0, >6.0 mg/dl                                     Albumin (any value)
                   Sodium (Na) <125                                                  Bilirubin (any value)
                   *Unless values are consistently at these levels                   Cholesterol (any value)
                                                                                     Triglycerides (any value)
                                                                                     Other Chemistry values

Consult Reports    Consultant report recommending immediate action                   Routine consultant report
                   in patient’s management                                           recommending routine action or
                                                                                     changes in patient’s management




                   New or unspecific finding                                         Old or long-standing findings
X-Ray
                   (i.e. pneumonia, fracture)                                        No change
Reporting Protocol
Vital Signs   Report Immediately   Non-Immediate

 Blood Pressure             SBP>210 mmHg                 DBP routinely >90 mmHg
                                 <90 mmHg                Resting Pulse >120 on
 Pulse                                                   repeat exam with no
                            DBP>115 mmHg
 Respiratory Rate           Resting Pulse >130 or <50    symptoms
                            Pulse >110 with symptoms
                            of dyspnea or palpitations
                            Oral Temperature >101F


 Weight Loss                                             New Onset of anorexia
                                                         with or without weight loss
                                                         5% or more within 30 days
                                                         10% or more within 6
                                                         months
Managing Protocols
 Diabetes
    Tight control of glycemia not appropriate for a majority of elders with multiple co-morbid diseases
    Sliding Scale
 Hypertension
    Monitoring with good control
 Dementia
    Proper use of medications to slow cognitive decline
    Management of behavioral problems
    Appropriate monitoring of laboratory values
    Periodic medication reduction & discontinuation
 Bladder protocol
    Timed toileting
    Incontinence management
 Bowel protocol
    Appropriate regimen
 Establish a pressure ulcer protocol supported by evidence based outcomes
 Medication management
    Reduction of polypharmacy
Acute Change in Condition
Practitioner Responsibilities
 Includes Physician, Nurse Practitioner, & Physician Assistants
 If notified by telephone
    Listen to initial concern
    Ask sufficient questions
    Formulate tentative diagnosis
    Develop plan of treatment
 Ensure treatment plan is in line with advanced directives
 Visit patient within a timely manner when direct observation is
  necessary
 Remain available by telephone until condition stabilizes
Support
 Supporting the nurse
 when appropriately
 communicating a
 problem to the
 practitioner
Education
 Normal Aging
 Diseases common in
  Elders
 Medications &
  interactions
   Geriatric dosing
   Beer’s list
 Treatment protocols
Communication
   Open communication between all interdisciplinary team
    members
   Tell a Story
        Do not assume the practitioner ‘knows’ the patient
   Terminology
        Poor
            Patient is not eating/drinking
        Better
            Patient only ate 50% of breakfast and 30% of lunch and
             usually eats >90% of meals
            Patient is not eating solid foods
            Patient seems to be having pain with swallowing
            Patient is refusing fluids
        Poor
            Patient is not their usual self
        Better
            Patient did not interact with staff as usual
            Patient did not participate in usual activities’
      Reporting Protocol
 Information about patient
 History of present illness
 Past medical history
  including medications,
  recent trauma, allergies,
  recent treatments
 Review of pertinent systems
 Physical examination
Follow-Up Care
 Laboratory monitoring based on diagnoses & medications
 Respiratory Symptoms
    Effective response to treatment plan
    Assess for potential aspiration problems
 UTI
    Appropriate treatment according to C&S
    F/U UA not necessary in asymptomatic after treatment
 Pressure ulcer management
    Visual inspection
    Routine inspection until resolution of ulcer
    Consider herpes simplex due to stress
    Consider fungal infections hindering resolution
 Diabetes management
    Tight glycemic control may put some elders at risk
    Appropriate sliding scale insulin
Review of
Recommendations/Reports
 Timely Assessments
 Document pertinent information
    Urine C/S
         If on antibiotic
         Allergies
         If on coumadin
    PT/INR-
      Document coumadin dose
      If on antibiotics
      Recent changes made
      Previous PT/INR
      Evidence of bleeding or bruising
 Document response of practitioner
    If recommendation not accepted-document why
         Dose reduction not accepted due to previous dose reduction or patient exhibiting
          symptoms necessitating the medication
Ways to Increase Acuity of
Care
 More Skilled Staff
    Higher RN to LPN ratio
 Education
 Consistency of
  assignments
 Report ACOC
 Aggressive care at facility
    IV
    Wound Care
Factors to Provide a Higher Acuity
of Care
*Availability of on-site evaluation by a physician, nurse
  practitioner or physician’s assistant
 Quality of care by a Registered Nurse
    improved care management at transitions from hospital to home
     or from hospital to skilled nursing facility
 Availability of laboratory results within 3 hours
 Ability of the NH to initiate and maintain intravenous
  hydration
 Better implementation of Protocols
     Reducing Avoidable
     Hospitalizations
 Education
 Support
 Routine
 Consistent assignments
 Know patients
 Frequency of visits by practitioner
 Develop protocols for reporting
  problems
 Be prepared when communicating
  problems
     Terminology
     Being prepared when calling
     Tell a story
 Follow-up
References
       Advancing Excellence in America’s Nursing Homes. (2009). Retrieved May 13, 2009 at
        http://www.nhqualitycampaign.org/star_index.aspx?controls=nursing_homes
       AMDA (2009). Clinical Practice Guidelines: Acute Change in Condition.
       Carlson, J., Gerding G, & Estoup M. (2005) Evaluation of demographics and medication use in
        patients with dementia in assisted living and skilled nursing facilities.
       Costs and Potential Savings Associated with Nursing Home Hospitalizations. December 2007
        Publication AZ-8SOW-1A-120407-01. Quality Counts: Arizona Nursing Home Quality Initiative.
        Retrieved May 2, 2009 at
        http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=575198
       Elderly/Long-term Care: Certain interventions have the potential to reduce costly and risky
        hospitalizations of the frail elderly. US Department of Health and Human Services-AHRQ-April
        2008. Retrieved May 13, 2009 at http://www.ahrq.gov/research/apr08/0408RA14.htm
       Erikson, R. (2008). Managed Medicare & Assisted Living: The Evercare Experience.Annals of Long
        term care (16) 1524-7929. Retrieved June 6, 2010 @
        http://www.annalsoflongtermcare.com/content/managed-medicare-assisted-living-the-evercare-
        experience
       Straub, B. (2008). Perspectives from CMS: Towards Continuous Improvement in the Future. Centers
        for Medicare & Medicaid Services (CMS) 2008 American Health Quality Association Annual
        Meeting.
THANK YOU
Lisa Byrd PhD CFNP Gerontologist
 Provider Health Services LLS based in Memphis, TN
 Actively Practicing Nurse Practitioner
 Assistant Professor-The University of Mississippi Medical
    Center in Jackson, MS
     Master’s level-Geriatric Nurse Practitioner Program
   Legal Consultation for Nursing Home cases
   Educating Staff
   National Speaker
   Publications
   Editor GAPNA section of Geriatric Nursing (GN)
   Website: www.ProviderHealthServices.net
   Email: DrLByrd@yahoo.com
DrLByrd@yahoo.com

				
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