Best Practices in Transitions to Post

Best Practices in Transitions to
Post-Acute Care Facilities
Hospital Medicine 2013
May 19
Heather Zinzella Cox MD, CMD
Director Post Acute Services
IPC Delaware
Robert Young MD, MS
Division of Hospital Medicine
Northwestern University
Speaker Disclosures:
Dr. Heather Zinzella-Cox:
Novartis Pharmaceuticals Speakers Bureau
Dr. Robert Young: Nothing to disclose.
Post Acute Care Partnerships
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Improve Patient Safety
Reduce Readmissions
Decrease LOS
Hospitalists outside
hospital
• Bundled Payments/ACO
• Good Business model:
referrals/hospital
leverage
Areas of Post Acute Care
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Inpatient Rehabilitation Facilities (IRF)
Long-Term Acute Care Hospitals (LTACH)
Skilled Nursing Facilities (SNF)
Long Term Care Facilities (LTC)
Assisted Living Communities (AL)
Continued Care Retirement Communities
(CCRCs): Independent Living (IL), AL,SNF, LTC
• Outpatient
Inpatient Rehabilitation
Facilities (IRF)
• 3 Medicare Qualifying Criteria
– Reasonable expectation that pt will get significant
functional improvement over reasonable time
– Pt can tolerate and participate in a minimum of
3 hrs of daily PT/OT
– Patient is medically stable
• PPS
60% Rule
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Spinal Cord Injury
Congenital Deformity
Amputation
Major multiple trauma
Hip fracture
Brain Injury
Neurological disorders ( e.g. Multiple Sclerosis, Parkinson’s)
Burns
3 arthritis conditions which failed outpatient therapy
Stroke
Joint replacement for both knees or hips when surgery immediately preceds
admission, when BMI >50 or age >85
IRF PATIENTS
• 80%
medicare/medicaid
• 80% d/c home
• 10% d/c to hospital
• 10% d/c to SNF
IRF
Models of Practice
• Physiatrist led
• Hospitalist led
IRF Units
• Orthopedic
• Traumatic Brain Injury
• Neurologic
• Spinal Cord
• General
Long Term Acute Care Hospital (LTACH)
• Acute Care hospitals treats medically
complex pts with prolonged LOS
• Freestanding vs Hospital based
• Same licensing, certification as STACHs
• Organized bylaws, rules, and regulations like
STACH but unlike SNF
LTACH Patients
• Medical complex,
“chronic critical illness”
or “post intensive care
syndrome”
• Longer LOS : 30 vs. 6
days
• LTACH, must have
average LOS >25 days to
receive medicare
payments.
LTACH stats
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20% discharges on Mechanical Ventiliation
33% had pulmonary dx
40% prevalence of skin/wound dx
90% admitted from ACH, 10% wound care
clinic
Source: MedPac Datapack June 2011
LTACH Providers
• Must be privileged and
credentialed.
• Most bylaws require
daily attending
physician evaluation.
• Consultants on staff
and available.
• NO limitation or
expectation of visit
frequency
Advantages of LTACH practice
• Admissions are elective and predictable.
• Slower throughput and LOS than STACH.
• High severity but stable, requiring single daily
visits.
• Small hospitals which allow for much
interactions with leadership and committee
participation.
Challenges of LTACH practice
•
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Small with small medical staffs
Limited consultant choices
Less and slower ancillary resources
Fewer diagnostic and surgical capabilities
compared with STACHs
Nursing Facilities
“In a hospital they throw
you out before you are
half cured, but in a
nursing home they
don’t let you out till you
are dead.”
– George Bernard Shaw
Skilled Nursing Facilities (SNFs)
• Skilled Nursing is defined “ the treatment and
continuing observation and assessment of
the medically stable and unstable chronically
ill patient.”
• Free standing vs. unit in NF
• Wide range of services for diverse patient
population
SNFs
• Payor Medicare Part A/Managed Care/Private
Pay
• Medicare (10%)
– Max of 100 days. 20 days no copay. 80 with copay.
– 3 day hospital stay (within 30 days)
– PPS: covers room, medications, diet, nursing
services, medical supplies, DME, medications
– Pt must meet skilled service requirements
Medicare Qualifying Skilled Services
• PT/OT/Speech one hour
a day
• Wound Care
• PEG feedings
• Chronic Oxygen therapy
• Dialysis Patients
• Diabetes monitoring
Nursing Facility Residents
• Short Stay: 1-6 mos
– Terminally ill (respite)
– Short term rehab
– Subacute
• Long Term
– Cognitively impaired
– Cognitively + physically
impaired
– Physically impaired
– Medicaid 50%
SNF/LTC patients
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Medically complex but “stable”
Do not require daily physician visits.
Most with completed diagnostic work up
45% patients are >85 yo
10% are under 65
SNF provider Models
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Facility Employed or Closed Model
Independent Physician Model
Mid level provider based Model
Skilled in regulatory issues, wounds,
dementia, nutrition, palliative care
Practice Challenges
• Regulatory issues
– Narcotic prescriptions,
Psychotropics, foley
• Limited IT resources/no
EHR
• Limited Access to
Diagnostic Testing
• Pharmacy limitations
• Nursing Training and
Experience
• PPS/Utilization Costs
Nursing Facilities
Assisted Living
• Non Medical/Self
Directed Care
• No requirements for
medical director
• Typical Services
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3 meals a day
24 hr security
Med reminders only
ADL assistance
Transportation/appt
assistance
Home Health Care
• Patient must meet criteria
– Medicare beneficiary
– Requires a covered service
– Homebound
– Physician F2F form
– Plan of Care for patient reviewed by MD
Homebound Definition
• Home Absences
– Infrequent
– Short duration
– Taxing Effort
• Taxing Effort
– Cane, walker, WC
– Help to get into car
– Help of another to leave
house
Intermittent Services Required
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Skilled nursing
PT
OT
Speech
Intermittent: <21 days,<8hrs/day<7 days a wk
Trends in HHC in 2011
• Increased utilization of HHC
• Increased number of visits per home health
patient to 36 visits per episode.
• Skilled and therapy visits account for >80%
of visits vs. Home Health aide 16%
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Skilled Nursing 52%
Therapy 33%
Home Health Aide 16%
Medical Social Services 1%
Source: MedPAC 2012 data
Hospice
• Home based
• Inpatient based
• SNF’s and Hospice
– Med A services
– Hospice does not pay
for SNF room and board
Discharges From an
Acute Care Hospital
46%
32%
16%
2%
Long Term Acute Care
Hospital
5%
Hospice
Inpatient
Rehabilitation Facility
Skilled Nursing Facility
Home Health
Source: Medpac Databook June 2012
Federal Spending in Billions
$35.0
$31.8
$30.0
$25.0
$20.0
$19.6
$13.0
$15.0
$10.0
$5.4
$6.7
$5.0
$Long Term Acute Care
Hospital
Hospice
Inpatient
Rehabilitation Facility
Skilled Nursing Facility
Home Health
46%
50%
42%
45%
40%
32%
35%
30%
26%
Spending
25%
15%
10%
5%
Discharges
17% 16%
20%
9%
7%
5%
2%
0%
Long Term Acute Care
Hospital
Hospice
Inpatient
Rehabilitation Facility
Skilled Nursing Facility
Home Health
Choosing the appropriate level of service
• Who should choose?
• What factors affect the decision?
• Where is most appropriate post discharge
setting? All not created equal.
• When should patient be discharged?
• Why…now you know…
Transitions for Acute Care
Hospitals to Skilled
Nursing Facilities
Future PAC Environment
• Patient, not setting
• Common assessment
instrument
• Bundled payments/ACOs
• New quality metrics
• Expanded readmissions
policies
MEDPAC, March 2013
Factors Driving
Transition Efforts
• Hospital Readmissions Reduction Program
and other ACA programs
• High SNF margins vs. LTC margins (Medpac 2012):
– SNF average margins over last 10 yrs =
– LTC margins (2008-2010)= -1.2%
– Median margin = 3.3%
>10%
• Anticipation of population accountability
SNF Transitions in General
Our hospital
wants its SNF
readmission
rate down…
Where do I
start?
•
Very little, if any, rigorous
process/outcomes data
•
Types of interventions are
reaching saturation
•
Most are multi-component
interventions (similar to inpatient
strategies)
•
The keystone to these efforts are
cross setting- collaborative teams
(including ED representatives)
•
Practice rigorous process
improvement
Define
Measure
Analyze
Improve
Control
Define
Know your SNF Environment
Large amount of variation between SNFs
• Capabilities (meds, IV, therapies)
• Location (freestanding vs. TCU/SNU)
• Ownership
• Specialty units (joint
replacement, CHF, behavioral units)
• Staffing
(RNs, LPNs, CNAs, SNFists, PCPs, Geriatricians
)
Define
Know your SNF environment
Variation in state regulations
• Communication documentation
• Staffing
Communication Infrastructure
• Health Information Exchange
• Hospital’s systems to transmit information
• ? Access to your EMR
Define
Who is in your neighborhood?
Social Network Analysis:
National Coordinating Center (ICPC)
Provides:
• A visual representation of
the PAC transitions within a
community
• Examine the transitions
with a desired level of
volume.
• Readmission data
• Determine which are the
influential institutions
(nodes) to prioritize efforts
• Cross influences from other
hospitals in your market?
Define
Who is in your neighborhood?
Case Management Referral Software:
• Most widely used is: Allscripts Post Acute
Solutions- Formerly ECIN
• Used to send referrals to SNFs
(assessments, demographics, communication
system)
• Can be used to determine where patients are
going, readmissions back to your facilities
• Can be used to track communication (follow
up phone calls) with PAC sites
Define
Who is in your neighborhood?
Other Interesting Data Fields
Available through ECIN:
• DRG
• DRG CMI
• Payment Source
• By Service
• Assessment Summary
• LOS
• Time of referrals
• Date and time of Discharge
• Readmission/Report
• Avoidable days
• Delay report
Define
Sample Reports
Courtesy of Allscripts
Measure
Community Outcomes
Institution/Community level metrics to consider:
• Transition rates
• Readmission rates (including PAC settings)
• Admission rates
• ED visit rates
Your State QIO can
help you get this data
• Observation stay rates
for Medicare Patients
• Mortality rates
• Disease specific readmission rates
Measure
ACO and Bundled Payment Metrics
Accountable Care Organization
33 metrics
• NQF 5-6: 7 from HCAPS
• CMS: Risk Standardized
Readmission Measure (all
cause)
• NQF 97: Medication
reconciliation
• NQF 101: Falls risk
assessment
Bundled Payment
BPCI:
For models 2 and 3
• Medication reconciliation
after discharge
• Staffing hours per day per
beneficiary
• Others – negotiated with
CMS
Analyze
Figuring out the cause
• Process mapping &
failure modes effects
analysis
• Root cause analysis
People/Staff
D/C summary completed
by CCHS/MD
Process
Identify accept MD/Provider
MD Communication
RX in timely fashion
RN Communication
Quality of RN report
Timeliness of D/C
Chart Copy
Improving Discharge process for CHF/COPD Patients Transitioning from 5C to SNF:
How does Improved Communication Impact Readmission Rates:
Internal Knowledge of PCOC/
handoff (RN)
Ofc phone call
Key:
Streamline of D/C info
Communication
Process
Patient
Patient Admitted to 5C
Dx: CHF/COPD
Treatment Plan/
Plan of Care
initiated
PCF, RN, SW, CM
Collaboration
Inpt. Vs. Obs.
? SNF
Placement
probability
Order for PT Eval
Skill Level
Needed (IV Abx,
Wound Care)
MD complete
Interagency &
Med. Rec. forms
MD dictate D/C
Summary
Patient Identified for SNF
(if Pt. from home needs 3
night stay to qualify for
Medicare)
Med Rec
Nursing
Referrals
placed to
SNF
SW discusses
eligibility w/Pt. &
Family
CM coordinates
Insurance


Ins. Coverage
Qualify
Med Rec Updated
Patient Admitted
from
HOME
Social Work
REFERRAL
Social Work
Referral
for
SNF Placement
Patient Admitted
from
SNF
SNF review
chart and patient
for placement
SNF
acceptance/declination
Actual Facility/Provider
determined
Med. Rec not updated - delegate
More User-friendly Interagency
Decision
Entire Chart
Resources/Staff
“Choice”
MD
CHART COPY (24* TIME)
Chart too much info
(Streamline)
Quality of Documents
Copied prematurely
New Packet
SS/CM
RN Report
Communication Packet
5C tool, InterAg., Med Rec,
Scripts, D/C Summary
PCF/RN
communicates
SNF
determination
w/MD
Lack Clinical Guidelines
HIMS Process
MD orders
DISCHARGE
MD:MD
Communication
RN REPORT
BM w/3 days
Interagency form
Report to receive RN
SW coordinates
with existing SNF
for bed hold/
status
Regulatory forms Interagency
Completion/accuracy of D/C form
Form Completion
Initiate CHF/
COPD
Checklist
?Quality & timing of Report
Include PLOC
Verify Dx. Specific Checklist
is completed
SS
arranges
transportation
PATIENT D/C TO SNF
D/C phone call 24 - 48 hours post d/c
Policy
Clinical
Guidelines
Analyze
Figuring out the cause
Others the factors:
• Timing of referrals, acceptance, transfer, and
readmissions
• Staffing ratios
• Acute care case characteristics
(LOS, diagnosis, severity, unaddressed
terminal illness)
• Provider (physician, nursing, staff)
• Completeness of documentation
Improve
Taxonomy of Hospital and SNF Transitions
Interventions
Acute Care
Skilled Nursing Facility
Discharge paperwork
Disease specific order sets
Post discharge follow up
Nursing warm handoffs
NP and PAs to follow patients @ SNF
Acute care transfer paperwork
Contact information from sending SNF
provider
Inventory of SNF services
INTERACT,
eSNF
Bridging Interventions
Collaborative Teams:
•Root Cause Analysis
•Aggregate data analysis (Community Level)
•Coordinate joint quality improvement efforts
ED engagement- protocols regarding the return of patient to SNF
Medication reconciliation
Goals of care
Physician warm handoffs (Bi-directional)
Health Information Exchanges/RHIOs
Improve
Discharge Paperwork
• Discharge checklist
• Medical record: H&P, progress, consult
notes, labs, test results- treatment plan
• Clear orders for next setting
• Contact information
• Interagency, universal transfer forms
• Narcotics and schedule drug scripts
• Nursing screens
• Health care directives: POLST/MOLST
• Discharge summary
Improve
Other interventions
Education regarding SNF transitions
• Family and patients (priming expectations)
• Acute care physicians, nurses, and social workers
(making sure pt needs match facilities capabilities)
Post discharge phone follow up
• Calls made to make sure of complete transfer of
documentation and orders
• Disease specific orders implemented
• See if additional info is needed
• Get feedback on communication
Improve
Other Interventions
Medication Reconciliation
• Marquis
• Need to include original medication list
• Other suggestions?
Warm Physician Handoffs
• Directories of SNF providers
• NU method- have SNF/NH admissions staff page our hospitalist
with phone # to reach accepting SNF provider (minimize
searching)
• Discuss goals of care, family and patient dynamics, highlight
treatment plan
• Ultimately last check on whether the transfer is appropriate
Disease Specific Ordersets
Remember that slightly less than half of
these patients are readmitted from SNFs
with the same diagnosis (Ouslander, JAMDA
2011)
Improve
INTERACT 3.0 (Interventions to Reduce Acute Care
Transfers) is:
• A quality improvement program based in LTC
•
Focuses on management of acute change in
condition.
•
Clinical and educational tools as part of program
•
Strategies for every day use in LTC
http://interact2.net/index.aspx
Improve
INTERACT
Hospital
Hosp-NH Transfer
checklist, Data list
ED
NH
Capabilities
List
Skilled Nursing Facility & LTC
INTERACT Quality Improvement Tools
NH-Hosp Transfer
checklist, Data list
Can the patient INTERACT Communication within the NH (e.g.
specialized SBARS)
return from the ED
to the NH for INTERACT Decision Support Tools for Change
in Condition (Triggers & Care Paths)
treatment??
INTERACT Advance Care Planning Tools
Improve
ED Engagement
For some evaluation in
the ED setting is
appropriate.
How do we help our
ED colleagues feel
comfortable about
sending appropriate
patients back?
Control
Don’t practice DMAI…
Continue to work
within the
collaborative
groups:
• Monitoring
population, proce
ss (at least
compliance with
interventions) &
outcomes
metrics
Control
Don’t practice DMAI…
• Continue to perform RCAs on readmissions
and problematic transfers
• Rapid cycle improvement for issues that arise
• Ask QIO for updated SNA to see how things
have changed over time
Need More Help?
Partner with Your QIO
Control
State based private contractors to CMS
• Improve quality of care for CMS beneficiaries
• Originally work in quality assurance-> quality
improvement projects (multiple in the PAC setting)
• Coordinate submission of data for public reporting
for Hospital, NH, Home Health Compare
Thanks for your attention!
Contact Information
Further questions or comments?
Feel free to contact us at:
• Heather: hzinzella@ipc-hub.com
• Rob: r-young@northwestern.org