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Readmissions Sally Finley RN CCM Deaconess Hospital Challenges with Transition from Paper to Electronic Transfer Hand-offs Scanned paper H&P’s did not appear on electronic report Discharge Med Reconciliation Orders to be carried out at facility Schedule II narcotic scripts Overwhelmed the recipient ◦ Flowsheets don’t print pretty ◦ Wasted paper Codes for responses were not provided ◦ Ex. Fall risk score showed as a number but did not include what our definition was Feedback in Development of Electronic Transition Report/Packet Gerontology Network Safety Coalition – Hand-off Sub Committee ◦ Standardized Referral Report ◦ Standardized Transition Packet Referral Liaison Caregiver accepting patient upon transfer ◦ Electronic Referrals – Internal & External Council on Aging LTAC, Rehab, SNF’s have access to EMR from their facility ◦ Upon electronic referral they can access entire chart ◦ Regional Network Services trains the staff at the facility ◦ Home Health – near future Access to EMR Patient Discharge Process Map Insurance Co. Family ADON/ room Home Case assignment Srvcs Mgmt Patient pre- admitted PT,OT , to hospital Social Speech Patient in Work Receiving ICU facility(s) Patient Patient Patient admitted Patient receives discharged to hospital care discharge from ED or Reg delivered order hospital Teaching Physician Patient on unit Therapies Home Patient at Facility placement home Home services Equipment Transportation Insurance authorization Transport Home medications Follow-up appointments On the Road to Change Centralized commercial Utilization Review Plan to centralize Medical Necessity RN Caregiver to assume discharge planning for pattern able and predictable RN CM and SW focus on complex, high risk patients Redesign Case Management Model to address care needs and decrease fragmentation in care Redefine role of RN Case Manager, Social Worker and RN caregiver Optimize EMR utilization to facilitate care coordination Case Management to Care Coordination Chief Nursing Officer Six Sigma Black Belt RN Unit Nurse Manager & Team Leader Manager of Case Management RN Case Managers Social Worker Bedside RN’s Care Coordination Pilot Previously screened 100% of patients in beds & intervened on different levels based on ◦ Payor ◦ Anticipated discharge needs ◦ Medical Necessity determination ◦ LOS & Observation time limits ◦ Facilitation of timely care, tests & treatment Change in Focus of RN Case Manager Developed Trigger tool for RN to consult Case Management for Discharge Planning Preliminary Indicators ◦ Age > 75 ◦ LOS > 5 days ◦ Readmit within 30 days ◦ Dependent Care ◦ Frequent Falls ◦ Uninsured Change in Focus of RN Case Manager Spearheaded by Case Managers ◦ Diagnosis of ongoing disease -High Readmit diagnosis ◦ No PCP ◦ Living alone or unable to care for self ◦ Inadequate social support ◦ Homeless ◦ Low health literacy ◦ Readmit within 30 days or 3rd admit within 6 months ◦ Palliative Care Screen Screening for Readmissions Patients discharged home and considered High Risk are called by a Case Manager post discharge Non-High Risk patients are called by a nurse post discharge Electronic work lists generated off of CM screen ◦ Caller able to access chart and assess prior to call ◦ Caller documents in telephone encounter and ties call to that visit High Risk Call Backs Medication changes Follow-up appointments Disease/procedure specific signs & symptoms Redirect back to instructions given at discharge Direct patient to call PCP if appropriate Call Back Focus Patient Centered Care Physicians – PCP & Hospitalists Chronic Disease Management Palliative Care Relationships with Community ◦ Nursing Homes ◦ Home Care Agencies ◦ Council on Aging Medical Home Payer Liaisons Collaboration and Relationships have never been more important… Angela M Beck, RN, BSN, MSHSA, CPHQ Value Based Purchasing Health Care Reform and Case Management Health care reform – a historic change! Its future uncertain – but it is not going away The effect on case management practice yet to be determined Health Care Reform and Case Management Goals of health care reform: • Better care (and better access) • Affordable care and containment of costs • Healthier lifestyles Health Care Reform and Case Management These goals are at the heart of case management. We know that case management brings many benefits to those we serve! Health Care Reform and Case Management Many provisions with some already in effect, some beginning this year and some in upcoming years. One provision: Value Based Purchasing Health Care Reform and Case Management VBP – rewards quality through payment incentives and transparency with goal to improve quality, safety and affordability of health care services Goal – high quality care at the lowest cost with an exceptional patient experience. Health Care Reform and Case Management Focus: 70% core measures 30% patient satisfaction Health Care Reform and Case Management Response: Must be open to new ways of thinking and doing! More researching of regulations, directives, transmittals from CMS, Joint Commission standards, state variations, affecting day to day practice Health Care Reform and Case Management Integrated Unit Based model Concurrent review for core measures Communication of data to all stakeholders A very engaged Board with monthly reporting to the Board QI Committee Health Care Reform and Case Management Discharge phone calls Standardized work processes with discharge and medication reconciliation Collaboration with community partners – CPSC and Green River Partnership for Care Coordination Health Care Reform and Case Management Quality Caring Model (emphasizes relationships) Spirit of Excellence Champions Health Care Reform and Patient Empowerment Sherry Aliotta, RN, BC, BSN, CCM St. Mary’s Health System The patient is non-adherent and is repeatedly readmitted. The patient is “drug seeking” and rates you poorly on the HCAHP’s The patient legitimately decides not to have a treatment, but it results in poor outcomes or repeat admissions What are the Implications, When? A Quote from a Bedside RN “Why is it that the hospital gets penalized for all of this, and the patient has absolutely no consequences?” ◦ What’s wrong with this statement? Some studies suggest that in selected situations, using a model that emphases patient decision making, patients would choose a less aggressive use of invasive procedures and expensive treatments with marginal benefit. (Lenert, 2009) Several studies illustrate the links between patient empowerment, autonomy, and improved outcomes. In dialysis patients, Patient empowerment led to a statistically significant decrease in mortality of 39%. This contrasted with 24% decrease in the provider and patient team Some Empowerment Facts No consistent definition in the literature. Patient empowerment embraces the concept that patients have the right to make their own choices regarding their treatment and care. (Barrie, 2011) Empowerment is centered on the belief that patients should be in control of their own care The creation of an environment where the patient can behave as responsible adults, and that the decision is made at the point where the knowledge is the highest Definition of Empowerment This has been represented as the minimal expectation of the patient continues in treatment all the way to active participation in treatment decision making. This model would classify engaged as: ◦ Active participation in care ◦ Attending and Preparing for Appointments ◦ Seeking appropriate care ◦ Using additional resources to maintain engagement Factors Necessary for Empowerment Engaged The patient understands their illness or conditions, the treatment options and risks, and has a good understanding of the health care system-including insurance benefits and other available resources. Informed Recognize the varying levels of preference regarding collaboration. Studies show that the elderly and patients with more advanced or serious illness may have a decreased preference for collaboration. Studies showed there was more conflict and distress when the patient preferences are not met by their provider. This lack of alignment with decision making results in poor adherence. Collaborative It is possible to be engaged, but not committed. Lack of commitment may result in unfilled prescriptions and disregard for other treatment recommendations. On the other hand, high levels of commitment may help the patient through those times when they are experiencing unpleasant side effects or not responding as anticipated. Committed The patient needs to be able to understand and cope with the uncertainty of outcomes. They must be able to tolerate this to proceed with treatments in the face of the unknown. Tolerance of Uncertainty This model requires the case manager to continue to acknowledge and foster the patient’s autonomy. The patient has to have trust in their case manager and providers of care so they know when to proceed and when to challenge. Patients provided with this environment and opportunities do perceive their level of competence and their ability to handle their illness Underlying Assumptions Case managers often deal with patients who suffer repeated and debilitating exacerbations, live on the streets, without proper food and clothing, and with isolation and a lack of social support. It is hard for us to imagine that these circumstances would be chosen. Our ability to focus on empowerment is further complicated when their choices don’t make sense and seem irrational, irresponsible, or unsafe. We each have our own level of tolerance for accepting their choices. (Purkis, 2009). Our decisions are not really about whether we can support these patients in their choices, but whether we can continue to support patients who chose to live at risk. In other words, the patient is only free to exercise those forms of freedom that keep them within the bandwidth of acceptable behavior The Reality Type 1: Divergent Nurses Type 2: Convergent Nurses Their response were always holistic Responses more reflective of the bio-medical model Analyze the interactions of the relationships between health, Emphasis on individual behavior change by patients controlled by illness, social structure, and culture nurses. Consider the patients total environment and how these could Seek to empower patients by moving them from unhealthy impact the patient’s health lifestyles to healthy lifestyles. Respects the patient’s views and tries to understand them in the Impose behavioral control by using fear and blame context of their social lives Refuses to make a quick decision based on the medical criteria Power over approach alone Considers a range of solutions to what may appear as a single Patients are recipients of their professional knowledge problem Power with approach Attempts to find common ground between them and their patient. Nursing Characteristics “Pay to Play” increased stake in the process Paradigm Shift to Recognize the Patient Has the Power, and We Need to Provide the Facts and Options Health Care Provider Response How will HCR Impact Empowerment?
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