ACMA 2021 National Conference - Poster Session Submissions by ACMA

Implementation of a Nurse Navigator Protocol to Decrease Postoperative Complications Jillian Knudsen RN, MSN, CNL, CMSRN, ONC and Heather Schulte RN, BSN, ONC PLAN

According to AAOS, total hip and knee replacement volumes are on the rise with volumes expected to more than double by 2030. Even with the elective nature of these surgeries, postoperative complications continue to raise attention across many organizations.

Reviewed best practices Adopted clinical practice guidelines Development of a nurse navigator protocol addressing: Elevated BMI Uncontrolled diabetes Cardiovascular history Unmanaged OSA Respiratory health Substance dependence Post discharge readiness

STUDY

ACT

Since the implementation of the protocol, North Kansas City Hospital has seen over a two percent decrease in its Medicare complication rates. Use of a standardized protocol to optimize patients before total hip and knee replacement can decrease complication rates and improve overall surgical outcomes.

Sustainability

• Gradual increase in volumes of patients sent for optimization • Started with CJR population • Added all payer > 65 • Extended to high risk only • Goal of 90% use

Lessons Learned

AIM

North Kansas City Hospital’s total joint program set out to identify the highest risk patients for postoperative complications and develop a program and protocol to lower those risks by optimizing patients preoperatively.

• Complications is multifactorial • patient, staff, environment • Not all are preventable by optimization • patient compliance, unforeseen events (i.e. trauma, illness, etc.) • Consider adding hard stops and additional criteria • Tobacco testing, albumin, anemia clinics • Documentation of compliance • Incentive Spirometer use

Improving Transition Planning for Sepsis Survivors: A Transition Partner Program Presented by: Lisamarie La Vallee, MSN, RN, ACM - Mercy Hospital Folsom Care Coordination Crystal Ruiz, Clinical Liaison – Blossom Ridge Medical Inc. Sacramento California Project Date Range: March 2020-June 2020

INTERVENTION

Background and Significance Sepsis survivors face a variety of complications after hospitalization. These include functional limitations, cognitive impairment, worsening of chronic health, and readmissions. Of patients with severe sepsis, 42.6% were readmitted within 90 days (Prescott & Angus, 2018; Prescott, Langa, & Iwashyna, 2015). Unplanned readmissions following a sepsis hospitalization are associated with a longer length of stay and higher costs compared to other conditions evaluated (Mayr et al., 2017). In the United States (U.S.), sepsis accounts for 12.2% of 30-day readmissions and 14.5% of the total cost of readmissions (Mayr et al.). Sepsis survivors also face late-term mortality and impairments related to functional status, mental status, and cognition after hospitalization (Karon, 2018). Additionally, survivors of sepsis of varying severity face long-term reductions in quality of life (Winters et al., 2010). INTERVENTION OBJECTIVES 1. Reduce hospital readmission in the Sepsis Survivor population 2. Improve post-hospitalization discharge planning for the Sepsis Survivor population 3. Develop collaborative post-acute partnerships INTERVENTION OVERVIEW The framework suggested by Prescott and Angus (2018) guided the development of the Sepsis Transition Partner Program at Mercy Folsom Hospital. This pilot is meant to be built on incrementally based on the supporting research mentioned above. The goal of this initial pilot is to improve post-acute support for sepsis survivors and reduce readmission rates in this patient population. The target population for this pilot was defined as patients who appear on the facility’s Sepsis Surveillance report, have Medicare insurance, and who are anticipated to successfully discharge from the hospital. PATIENT SELECTION STRATEGY

Discharge to Home Pathway: • Contact patient with 24-48 hours after discharge • Sepsis Bag Provided (within a week of discharge) • See pathway below • Occurs within 2nd week post-discharge • Instructions on equipment provided in Sepsis education bag • Introduction to the educational pieces provided (obtained from Sepsis Alliance) Home Contact #1 • Assess patient for any signs/symptom development

Home Contact #2

Home Contact #3

• Occurs with 3rd week post discharge • Assess patient for any signs/symptom development • Provide education regarding how life is now after surviving Sepsis

• Occurs within 4th week post discharge • Assess patient for any signs/symptom development • Provide education on how to stay ahead of a Sepsis diagnosis

Discharge to SNF Pathway: • • •

Within a week post discharge facility (SNF) that patient has selected is alerted to patient that has a Dx of Sepsis and is working with the Sepsis Program Weekly check-ins to establish patients progress and determine when patient may possibly discharge home Upon discharge from SNF, home pathway initiated (see above)

DATA Readmission Rates March 2020-June 2020 18.00% 16.00% 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00%

Cost Estimates: Amount spent by Dignity = $350 per patient Cost Saving Estimates:

Control 7- Intervention Day 7-Day Readmission Readmission Rate Rate

Control 30- Intervention Day 30-Day Readmission Readmission Rate Rate

$7000-12000 saved per sepsis readmission

PATEINT FEEDBACK “I would highly recommend this program to other patients that have suffered from infections [sepsis], I had the best experience possible, and I felt like I had someone I could always turn to if I was worried about something” – (family member of Sepsis patient)

“Having so many health problems, it was so nice to know that I had a friendly group of people I could call for any reason. I wasn’t sure what to expect, but I sure did learn a lot about sepsis and how to never let it take over my body again” – (James, Sepsis patient)

“I consider this program to be a god send, I almost took my grandmother to the hospital when one of her machines gave me a low reading, I called the nurse and with a little education she walked me through letting it stay on a little longer and my grandmothers reading was well within in normal range, it saved me a lot of heartache” –(Sarah, granddaughter of sepsis patient)

CONCLUSION The Sepsis Program showed a decrease in rehospitalizations compared to the control group. Patients were open to the follow-up and sepsis education. A successful partnership was established. The program has continued and expanded to accept patients outside of the Medicare population as well. References Prescott, H. and Angus, D.C. (2018). Enhancing recovery from sepsis. Journal of the American Medical Association, 319(1), 62-75. doi:10.1001/jama.2017.17687 Prescott, H., Langa, K. M., and Iwashyna, T.I. (2015). Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions. Journal of the American Medical Association, 313(10), 1055-1056. Mayr, F.B., Talisa, V.B., Balakumar, V., Chang, C.H., Fine, M., & Yende, S. (2017). Proportion and cost of unplanned 30-day readmissions after sepsis compared with other medical conditions. JAMA, 317(5), 530-531. Doi: 10.1001/jama.2016.20468 Karon, A. (2018). Caring for sepsis survivors. Retrieved from https://acphospitalist.org/archives/2018/04/caring-for-sepsis-survivors.htm Winters, B.D., Eberlein, M., Leung, J., Needham, D., Pronovost, P.J., & Sevransky, J.E. (2010). Long-term mortality and quality of life in sepsis: A systematic review*. Critical Care Medicine, 38(5), 1276-1283. doi: 10.1097/CCM.0b013e3181d8cc1d

2020 Excels Roundtable Mitsy Harned, MSN RN, CCM Jordan Ellis, MHA Becky Guess, MS Baptist Health System Services

Background

Methodology

• For FY2020, BHMG set four KPIs surrounding care gap closure. This year we are focusing some of our efforts on the preventive measures for Annual wellness visits, hemoglobin A1c, breast cancer screening and colon cancer screening. The goal of preventive care is to help our patients stay healthy. • Screenings, such as mammograms and colonoscopies are effective preventive measures. The baseline performance has remained stagnant over the past 12 months. BHMG would like to close those care gaps and increase the completion in FY20 • Targeting improvement in Annual Wellness Visits (AWV) ensure that patient’s preventative care needs are addressed by their provider assisting in care gap closure.

Plan, Do, Study, Act methodology applied PLAN • Complete project charter • Determine key stakeholders for performance improvement team. • Cross departmental team: o Patient Access o Ambulatory Case Management o Value Based Care Operations o BHMG Strategic Operations o BHMG Clinical Operations o BHMG Quality Physician • Review Preliminary Data • Create patient registries in Epic based on payer contract attribution • Determine goal and stretch goals • Determine focused intervention and ongoing tracking methodology Preliminary Data Review: Humana MA AWV Volume CY 19 thru Sept 2019

Objectives • Create and maintain up-to-date registries from our payers • Identify the care gaps, down to the provider / patient level • Engage value based care educators on working through the opportunities for our providers • Data represents baseline scheduled • Optimizing our provider's schedules AWV for Humana MA attributed and patient access to accommodate patients in CY 2019 the necessary appointments • Based on review of the data, BHMG • Engage health and wellness was NOT projected to meet the goal coordinators as well as additional value-based care nurses for targeted for this payer population patient and practice outreach for patients due for annual wellness visit • Improve rates of annual wellness visits

Cross-departmental team collaborates on care gap closure through laser focus DO • Interdisciplinary team of health and wellness coordinators, nurses, and medical assistants led by value-based care director focused improvement in annual wellness visit scheduling through 4 processes. • Education provided for practice managers and directors on annual wellness visits, breast cancer screenings, and colon cancer screening requirements and how to access dashboards for performance monitoring

STUDY • Project status document completed with collaboration of BHMG and Value-Based Care leaders including up to date performance of completed AWV on a biweekly basis. • Document provided to directors of operations on regional performance • Monthly updates provided to Value Based Care and BHMG executive leaders for accountability and escalation needs

Results OBSERVATIONS • 1,749 AWVs completed over baseline in 3 month intervention period • January/February 2020: Patient outreach team limited to 2 people from 6 in CY 19 QTR 4 with additional technology to support program and additional outreach for patients attributed to other payer contracts. • Results remain improved from baseline despite COVID-19 impact • Team reconvened after Covid19 with additional resource and processes for continued improvement. • Data shows large improvement over baseline with renewed focus in Humana and all value-based contract arrangements

ACT

• Continued improvement in patient access and use of video visits with advanced practice clinicians under development • Accountability to be achieved through SharePoint site development for care gaps, Monthly educational sessions, and Qlik app development to share progress

Lessons Learned

• Charter development, engagement of key stakeholders and accountability imperative to success • Ongoing education and engagement of operational leaders necessary for sustaining improvement • Virtual visits and payer adoption of payment for AWV virtual visit types has helped the improvement efforts post-Covid-19 • Dedicated team and resources for continual performance improvement will prepare Baptist Health for downside risk and maximize risk adjustment in all payers.

Mission Possible: MVP Method…A Care Coordination Journey Shelley Stone, LMSW, ACM-SW Graphs AnMed Health’s 2019 re-admission strategy saw a re-kindled passion to tackle the complex goal of readmission reduction. A key component to our strategy was implementing the MVP Method to address Multi Visit Patients. Dr. Amy Boutwell is the nationally recognized expert in reducing readmissions and is the creator of the MVP Method. According to Dr. Boutwell, “The “MVP Method” specifically addresses this important clinical and strategic gap in the readmission reduction strategies: We can’t be successful in reducing all-cause hospital-wide readmissions if we do not know how to effectively serve the patients who incur the majority of readmissions.” Our team at AnMed had to develop a unique strategy and new skill set to understand and effectively address this set of complex patients. Despite our best efforts to reduce readmissions, we continued to see a rise in our numbers even when implementing process change and penalty population focused programs. Our 2018 readmission data review identified that 50% of AnMed Health’s readmissions were attributed to our Multi Visit Patients (MVPs). These patients are a small percentage of hospitalized patients (14.40%) who account for our high proportion of readmissions. AnMed Health like other hospitals, considered multi-visit patients as “too sick”, “too complex”; and “too disengaged from care” essentially defined as ”un-impactable”. Thus, many MVPs were excluded from our readmission strategic programs. In 2019, AnMed Health decided to try a new approach to re-admissions and develop our own MVP Method. Our team recognized the need to understand and effectively address patients with complex needs (medical, behavioral and social) and specifically focus on our own “un-impactable” patients. Our readmission leadership team committed to the core concepts of the MVP Method as developed by Dr. Boutwell. Our journey included identifying key leadership members to drive and support the process, defining our MVP population, developing an MVP re-admission dashboard, and assigning MVPs health care partners across the healthcare continuum. Our goal in 2019 was to realize a 20% reduction of overall utilization by MVPs. We surpassed our goal and continued to show success in 2020 (MVP 2.0, MVP 3.0).

Results

• Inpatient MVP

• June-December 2019 • • • •

52 MVPs were assigned Care Partners to follow for a 6 month period Significant reduction in hospitalizations noted Improved transitions of care and follow-up to address Drivers of Utilization Results: 62% reduction of inpatient utilization by MVP group

• January-June 2020

• 50 MVPs (composed of previous MVPs and new MVPs) have been assigned Care partners to follow for a 6 month period

• Emergency Department MVP Let’s Go!

• Go Live was January 2020 • 25 MVPs have been assigned Care Partners to follow them for a 6 month period

Collaboration is the Key to Success!

MultiVisit Patients (MVPs)

• Partner with the community-Cross Continuum Team Effort • Meet the MVPs where they are…

• Identify & communicate the High Risk patients; Social determinants screening • Collaborate with ‘Care Partner’ (home health, skilled facilities, etc..) • Transition Planning /Care Plan; Help with appointments, transportation vMedication Education/Access opportunities/Socialization vShare Insights in Handover/ Warm hand-off

• Leverage EMR/electronic medical record vSee a Longitudinal Plan of Care and risk score vCare Link to EMR; access to lab results, MAR, etc… vConsistent summary report and d/c summary

• Call back number/ Transitions Coordinator

Source: Atrium; CY 2018

Note: 50% of AH Readmissions in CY2018 were attributed to MVPs

References: Amy E. Boutwell, MD, MPP Developer, MVP Method & ASPIRE Method President, Collaborative Healthcare Strategies amy@collaborativehealthcarestrategies.com The ASPIRE guide (chapter 6 and tool 13)—Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions. This resource was developed by Boutwell et al. and published by the Agency for Healthcare Research and Quality (AHRQ). The guide and related toolkit located at: www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html Dr. Amy Boutwell is President of Collaborative Healthcare Strategies, and a nationally-recognized expert in reducing readmissions and improving care for multi-visit patients. Dr. Boutwell advises local, state, and national efforts to reduce hospital utilization as a core capability of a transformed high value delivery system. She is a founding Advisory Committee member of Readmissions News. Readmissions Transformation Network 2018 Playbook and resource Guide pp.14-15; webinars, October and November 2017 NEJM Catalyst Innovations in Care Delivery 2020; Vol. 1 no. 2|March-April 2020

A Pilot Intervention Project: Exploring the Effectiveness of a Transdisciplinary, Web-based, Support Group for Advanced Heart Failure Patients and Their Families.

Esther Ammon, LCSW-NJ, APHSW-C Department of Social Work & Case Management, Stanford Healthcare

Background: • • • • • •

1 in 5 Americans, ages 40 and above, will develop heart failure (HF) with this number predicted to rise by 46% percent over the next fifteen years Managing advanced heart failure (HF) is difficult for both patients and their families resulting in physical and emotional distress, decline in function and caregiver burden The World Health Organization affirms that there is need to improve support, education and enhance communication in patients with advanced HF and their families Patients with HF often experience earlier functional decline than patients with other illnesses, often leaving patient’s homebound and increasingly isolated Various delivery models have been explored to meet the needs of this population and their families., telehealth has a growing body of research Palliative care has been proven to address many issues in patients with heart failure and support quality of life

Support Group Process

Methods: • Pre and post surveys conducted to evaluate effectiveness

• 5 week, web-based, psycho-educational support group focused on exploring tools to optimize disease management, nutrition, coping, communication and advance care planning (see table below) • Co-facilitated, offering both a didactic and mutual aid component • Guest speakers provided evidence-based tools to optimize whole person, HF care • Each session ended with a 10 minute question/answer period with a HF physician • Provided a safe and confidential setting for discussion of the unique issues experienced by participants • HF resource package distributed to each participant

Table 1: Group Topics Week Topic

1 2

Coping Communication

Facilitators

RN, MD, MSW PA, MD, MSW

Conclusions & Implications:

Results: • Survey findings suggest participants experienced improvement or growth regarding pre and post intervention response • Participants provided positive feedback on the benefits of this support program and its meaningful impact on living with chronic illness • All participants recognized the benefits of advance care planning and completed an advance directive. Acknowledgements: Alison Snow, LCSW; Stanford Healthcare Department of Social Work and Case Management; Stanford Healthcare Heart Failure & Cardiomyopathy Clinic; Dr. Winnie Teuteberg, MD; Leah Groppo, RD; The NYU Zelda Fosters Study Program with generous support from The Lucius N. Littauer Foundation

Baseline

Post Intervention

How supporte d have you felt this past week?

Tips:

Baseline

How supported have you felt this week?

Had AD Did NOT have AD

How difficult has it been to manage your illness?

Post-Intervention

Nutrition

Advance Care MD, MSW Planning

RD, MD, MSW

Disease RN, MD, MSW Management

How difficult has it been for you to cope?

100% Had AD

How difficult has it been to manage your diet?

• Participants benefited from their participation in the program as evidenced by survey results • Implementing web-based psycho-education and support for patients with advanced heart failure and their families may improve patient outcomes by complementing current outpatient services and addressing common patient/family concerns without the burden of leaving home. • As technology advances, more research will be needed to identify the most effective psychosocial delivery models of care for patients with HF and their families as well as what types of palliative care interventions are most effective • Consider the transdisciplinary approach which creates a shared team mission, integrates responsibilities, with the overall goal to implement better patient care

• If facilitating web-based groups is new to you, consider completing a course, such as NASW’s online course on “Legal & Ethical Aspects of Telehealth” • Brainstorm with colleagues about effective ways to partner in promoting your group. Recruitment is crucial and time consuming • If participants are hospitalized, encourage continued participation; have them simply call in, if needed • Send materials (i.e. PowerPoint presentation) to group members in advance of each session • Consider MD involvement to promote member interest • Query your outpatient colleagues about topics to focus on or considering using your pre-survey to identify topics of interest

Outcomes of and Lessons Learned from Patients with Severe COVID-19 in a Long-Term Acute Care Hospital Pete Grevelding, PT, MSPT, NCS; Henry C. Hrdlicka, PhD; Stephen Holland, MD, FAPWCA, ABIM, MPA; Lorraine Cullen, MS, RRT, RRT-ACCS; Amanda Meyer, MS, OTR/L; Catherine Sabith, PT, DPT, NCS, CBIS; Darielle Cooper, MA, CCC-SLP ; Allison Greco, MS, CCC-SLP, Gaylord Hospital, Wallingford, Connecticut Affiliations: Gaylord Specialty Healthcare, Milne Institute for Healthcare Innovation, Wallingford, CT 06492

METHODS

RESULTS

• Using the medical records of patients treated for COVID-19 related care following discharge from short-term acute care, a single-center retrospective analysis was conducted at Gaylord Specialty Healthcare, a long-term acute care hospital (LTACH) in the Northeastern United States.

• There were 127 admissions and 118 discharges by the data cut-off. The patient mean (±SD) length of stay was 25.5 (±13.0) days. • Mean patient age was 63 years, 64.1% were male, and 29.9% of patients tested-positive for SARS-CoV-2 infection at admission. 40/51 (83.3%) patients admitted as non-ambulatory were ambulatory at discharge.

• Gait distance increased an average of 217.4 feet from admission to discharge, a significantly greater increase than the reference cohort of 146.3 feet. • 93.8% (15/16) of patients being mechanically ventilated at admission were weaned before discharge with a mean wean time of 11.3 days. • 74.7% (56/75) of patients admitted with a restricted diet were discharged on a regular diet.

• Study data was collected from March 19, 2020 through August 14, 2020.

Through coordinated care and rehabilitation, the majority of patients treated at Gaylord Specialty Healthcare for severe COVID-19, and related complications, showed significant improvement, including improvements in functional ability, cognitive communication, and pulmonary measures. Together, these data suggest patients in the post-acute phase of COVID-19 benefit from structured rehabilitation.

40 30 20 10 0

PATIENTS AMBULATORY AT DISCHARGE MALE

March April

May

June

July August

p=0.79

350 300 250 100

93.8% WEANED FROM VENT

FEET

reference 146.3 ft

p=0.0008

2100 1850 1250 1000 750 500 250 0 -250

Reference

74.7% PROGRESSED TO A REGULAR DIET p>0.99

Vent Weaning (days)

Patient admissions (n)

217.4

83.3%

p=0.23

p=0.20

COVID-19

REF

FY19

p<0.0001

Cognitive Communication Score

CONCLUSION

(±13.0)

DAYS

ADMISSIONS

LOS (Days)

Patients with Covid-19 ambulated greater distances than a comparison cohort, and weaned from ventilation and improved swallowing at a high rate of success.

127 25.5

MEAN LENGTH OF STAY AT LTACH

Gait Distance Change (feet)

• A reference cohort of 170 patients treated at the facility the three months prior (December 1, 2019 through February 29, 2020), was used to compare patient demogrpahics and outcomes.

INCREASE IN GAIT DISTANCE

9 8 7 6 5 4 3 2 1

0 Reference

COVID-19

Figure 1. Patient admissions and length of stay (LOS) trends during the COVID-19 pandemic.

Admission

Discharge

Figure 2. Patient functional ability, respiratory, and cognitive communication outcomes.

(A) During the study period, there were 127 admissions for COVID-19 related care, the highest rate being in May, 2020 with 46 patients. (B) The median patient LOS for the 118 discharges was similar between the COVID-19 and Reference cohort. Error bars represent the 25% and 75% quartiles.

The change in gait distance, from admission to discharge, of the COVID-19 cohort was compared to the Reference cohort to determine if the extent of improvement between the two groups were comparable (A); COVID n=102, Reference n=94. To measure respiratory outcomes, the ventilator wean time of the COVID-19 cohort, Reference (REF) cohort, and all patients mechanically ventilated during fiscal year 2019 (FY19), were compared (B); COVID-19 n=15, REF n=7, FY19 n=37. Using a modified NOMS score, the cognitive-communication status of referred COVID-19 patients was measured at admission and discharge (C); n=75. Error bars represent the 25% and 75% quartiles.

Figure Summary: Patient LOS was similar between COVID-19 and Reference cohorts.

Figure Summary: Patients recovering from COVID-19 displayed similar or “better” outcomes compared to the reference cohort, an observation that may be the result of a younger population, patient demographics, or baseline health status.

Background/State of the Science: • Patient readmissions are a system focus for our hospital system. As the number of COVID-19 positive patients increase, the Comprehensive Care Management (CCM) team found that patients discharging with COVID-19 were starting to readmit. In addition, calls to COVID-19 positive discharged patients revealed they were lacking in self-monitoring healthcare items such as digital thermometers, pulse oximeters, face masks, surface disinfectant, medication scheduler, and educational materials to track temperatures daily and manage COVID-19 symptoms in the home.

• The CCM team identified items that COVID-19 patients would need and considered creating a kit that contained these patient resources. These identified items would be provided to patients/families to reduce patient readmissions. Table 1. Goals of Interventions and List of Identified Items

Implementation Process/Methods: The Implementation Process: 1. Patient need identified. (family not having access to thermometers, pulse ox due to shortages from COVID-19) 2. Selected appropriate kit items for patients 3. A company was identified who could provide the items the CCM team identified. 4. Funding sources were recognized to pay for the kit: a local church and the hospital employee fund for patients. 5. Kits were ordered from supplier 6. Criteria was established for the need of a COVID-19 kit. 7. Collaboration with bedside nurses provided a way to deliver kits and instruct patient on items in kit 8. A list of patients who received kits were included on a list for follow up post discharge review and phone calls 9. Patients were called with a standardized list of questions 10. Patients also had the option to participate in the Discharge Care Coach Program for COVID patients via cell phone to assist patients in their recovery. As a part of the intervention, the COVID-19 kit was highlighted as a best practice and the idea was shared at the Post-Acute Community Coalition in collaboration with TMF, the Texas Quality Improvement Organization during a community webinar. Figures 1. and 2. include a flier from the Post-Acute Provider Community Coalition and an image of the contents of the COVID-19 Care Kits

Below is a Fishbone Diagram that lists opportunities to improve the implementation processes of the COVID-19 Care kit.

Evaluation: •

The number of COVID-19 patient readmissions was 1.4% of the total number of COVID observation + admitted patients..

•

The Community Coalition group of clinicians responded to the BSW COVID-19 Care Kit by creating two additional kits; a local grocery store and home care company kit.

•

No patients refused the COVID-19 Care Kit since the beginning of the pandemic.

•

Over 80% of the patients who responded to a follow up discharge phone call and received the COVID-19 Care kits valued the kit and verbalized that the thermometer and pulse ox were the most valued items.

•

64% of the patients discharged with COVID-19 had a follow up visit.

Future Implications: •

Collaboration with TCM RNs, those making centralized calls to COVID-19 and Non COVID-19 patients, may be helpful to improve care coordination.

•

We are hopeful that sharing this innovative approach with the Postacute provider community can encourage others to explore the same idea.

•

Collaborating with the Texas state QIO to share information about the COVID-19 Care Kit has been valuable.

•

Collaborating with nursing and other allied care staff provides a greater understanding of patients needs and the COVID-19 Care Kits.

•

There may be a future opportunity to partner with others and/or other opportunities for grant support to provide additional COVID19 Care Kits and inhalers for patients.

Fishbone Diagram People

The COVID-19 Kit was highlighted and shared during this Community Coalition virtual webinar.

Process Issue myBaylor Redesign: Update

Contact the PCPs in clinic about the kit.

Utilize hand held iPads to explain kits to patients.

Make sure the interdisciplinary understands kit. Create a handout for the Hospitalist about kit. Utilize a hospital approved vendor to purchase kit. Create a Spanish COVID Care kit Share the specific contents of the kit. Create a pulse Ox education sheet

Resources

CCM staff and Nursing Supervisors to dispense kits. Nursing to support educational efforts of kits. Track patients who receive kit. Call patients for feedback of kit.

References: •

Adams CJ, Stephens K, Whiteman K, Kersteen H, Katruska J. Implementation of the Re-Engineered Discharge (RED) toolkit to decrease all-cause readmission rates at a rural community hospital. Qual Manag Health Care. 2014 Jul-Sep;23(3):169-77. doi: 10.1097/QMH.0000000000000032. PMID: 24978166.

•

Jungkind, K. (2020) Implementing a Patient COVID Care Kit. CMSA Today. Issue 8;12-13 (on-line journal) www.cmsa.org

•

Mortenson LY, Malani PN, Ernst RD. Caring for Someone With COVID-19. JAMA. 2020;324(10):1016. doi:10.1001/jama.2020.15061

Ethical Consideration: Ideas to Improve the Implementation of the COVID-19 Care Kit

•

Use standardized questions for patients

• Metrics

List of items in the COVID-19 Care kit.

Spanish education materials were requested in order to ensure culturally competent resources were provided to patients requiring information in Spanish. In an effort to promote appropriate resource stewardship, CCM Team ensured patients provided with COVID-19 Care Kits were engaged patients and tracked who received them so duplicates were eliminated.

Stressed Out! Julie Westbrook MSN, RN, CCM, M. Victoria deCastro, MSN, MBA, RN, Diane Herzog MSN, MBA, RN, CCM Acknowledgements: Christine White MD, MAT, Susan Wade-Murphy, MSN, RN, NEA-BC, Adam Hill, MSN, RN-BC, CPN, Brian R. Wildman, MBA, Barbara Tofani, MSN, RN, NEA-BC, Inpatient Care Management Team, Gail Patten, RN, MSN, CCM

Background

Stress Score

Making the Case

Interventions

Cincinnati Children’s Hospital is a free-standing pediatric, level 1 trauma center with 670 registered beds (140 Mental Health beds) and 28,981 admissions annually (FY19).

In 2017, the Inpatient Clinical Manager, identified the need to assess and mitigate the workload of the Care Managers and Discharge Specialists. In order to facilitate this, the team developed a standardized scoring system to define stress levels. This scoring system is based upon an agreed set of quantitative metrics to define individual, quantitative stress levels. These scores are used to objectively report individual workloads in the absence of comparable subjective definitions due to the variation in the patient population. This system allowed for nonjudgmental mitigation to reallocate resources, redistribute workloads, and identify short and long-term interventions in support of team productivity and satisfaction.

Under the direction of the area AVP and VP of Patient Services, the Care Management leadership compiled data demonstrating the current organizational patient profile and outcomes. Comparing these metrics to the Inpatient Care Management microsystem, a clear picture emerged that the increase in census, complexity of patients, and discharge delays without complimentary increase in care management FTE supporting those patients was negatively affecting team members. This in turn was reflected in the staff’s responses to the employee engagement survey “My workload is reasonable” as well as feedback from staff, families and providers.

The increase in care management FTE to meet the benchmark identified by ACMA provided the team the capacity to enhance the role and relationships of the care management team with the patients, families and the teams they support. Additional enhancements included: • Created sub-teams that support a cluster of “like” patients/ units resulting in more purposeful assignments and increased capacity for covering units • Regular meetings with unit leadership (nursing and medical) • Clear expectations for care manager and discharge specialist roles • Education provided on the scope and responsibilities of care managers and their role as team leader • Culture shift to identifying care managers as an expert in complex care coordinaiton versus a unit discharge planner

Pediatric care coordination is a patient-and-family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the caregiving capabilities of families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs to achieve optimal health and wellness outcomes.

Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework Richard C. Antonelli, Jeanne W. McAllister, Jill Popp

Examining microsystem-level stress is an established methodology used at Cincinnati Children’s (Hausfeld, et al., 2016) to identify, mitigate and predict stress levels within specific areas. Care Management applied this methodology to the self-reported stress levels among individual team members. The Care Management Team huddled daily and reported his/her stress level. After several months of reporting and mitigation based on the daily huddle scores, the team identified the opportunity to report stress scores at 2pm to further mitigate stress and to study any impact of AM interventions on improving stress levels later in the day.

• The Discharge Specialists are non-licensed and work in a delegated role

Staffing Model Inpatient case management responsibilities at Cincinnati Children’s are shared between the Care Management and Utilization Review departments. The Care Management Department is responsible for the implementation of the CMS Discharge Planning CoP. Initial assessment for complex discharge needs occurs on admission by the bedside RN and is escalated to the Care Management Team via ereferral. At the time of initial stress score testing, staffing ratio was approximately 2.5 FTE per 100 beds. Changes in staffing decreased that to 1.7 FTE per 100 beds, and ultimately 2.1 FTE per 100 beds at the time of the request to increase staffing to meet the ACMA benchmark published in the 2019 National Hospital Case Management & Transitions of Care Survey.

Results Utilizing ACMA 2019 National Hospital Case Management & Transitions of Care Survey as the benchmark, the current staffing model was compared to the benchmark and from that a request was made for increased staffing to meet the benchmark. An additional request of 15% was included to cover PTO and non-productive time, as per the organization’s standards.

• The Inpatient RN Care Manager serves as the lead partner to plan, implement, and ensure safe care transitions for the most complex patients across multiple divisions and disciplines during their hospitalization and transition to home

• The discharge planning process begins on admission with an assessment by the bedside RN to identify patients at postdischarge risk. A positive screen triggers a Care Manager evaluation

Hiring and Onboarding

Location Unit A Unit B

Patient and Staff Experience Employee Feedback • Many times understaffed and working more than FTE's, no lunches or breaks. • The job is needing to be better staffed, although I believe it is currently being looked at more, it has been a struggle for the past 23 years. • There are weeks when the caseload is manageable and then there are weeks when I feel it is not. • Balance in work and personal life is an important goal for me though I do sometimes wonder if it is at the cost of great care. Family Comment • “Our time on the floor was frustrating. Our home health agency had the WORST time trying to get the information that they needed to properly meet our needs at home. They would hear one thing from one person and something entirely different from another. As a matter of fact, my daughter was discharged BEFORE all the home stuff was settled. And she NEEDS the equipment at home for her health and safety. That was not right! So our agency had to scramble around at the last minute trying to get the information they needed for her new Bipap. I was very unhappy.” Provider Feedback (ACGME 2019 Survey) “Do you feel your pediatrics education is compromised by a disproportionate amount of time spent on non-medical work on some rotations?” • “On HM (Hospital Medicine), we spend so much time in care coordination that I feel could be spent learning about patient pathology or management.” • “Disproportionately large amount of time on HM was spent doing documentation and paperwork, Home Health orders and coordination. This non-medical paperwork and documentation makes it so there is no time for dedicated learning on HM rotations”

Licensed Beds 24 16

As a result of increased staffing, there was a dramatic shift in the stress scores reported by the care management team.

FY20 2019 ACMA Worked FTE Budgeted FY20 CM Benchmark Δ based on ADC Worked FTE (4.7 FTE/100 ADC) ADC 22.00 0.70 1.0 0.3 14 0.10 0.7 0.6

Unit C

62.00

2.90

2.9

(0.0)

Unit D Unit E

25 12

20.95 17.58

1.15 0.85

1.0 0.8

(0.2) (0.0)

Unit F Unit G

11 24

6.30 19.60

0.24 0.76

0.3 0.9

0.1 0.2

Unit H Unit I Total Assigned

24 35 240

19.00 27.40 208.83

0.80 1.00 8.50

0.9 1.3 9.73

0.1 0.3 1.2

Unit J Unit K Unit L Unit M Unit N Total Pooled

16 22 41 22 41 142

14 15.64 29.32 14.20 34.40 107.6

2.5

5.0

2.5

Total Assigned/Pooled

622

525.22

11.0

14.8

4.8

Non Productive Time (15% for additional & current staffing)

Total FTE Request

2.2

6.0

With the support of the SrVP of Patient Services and Medical Director for Care Management, the request was presented to the Healthcare Delivery Committee (HDC). HDC recognized the important role care managers play in developing and implementing plans that will enable patients and families to be successful at home and provided overwhelming support for the expansion request.

Benchmark Implementation After approval of additional FTE’s to get the team to the benchmark, the Inpatient Care Management Team met with key stakeholders on several different occasions (facilitated by our HR partners) to better understand what the care coordination needs were on their units and to identify areas of opportunity to make improvements with increased care management staffing numbers. We utilized this information to design the current team structure for the Inpatient Care Management Team. This structure has allowed us to work on pre-admission planning, have a consistent presence in rounds and huddles, provide coordinated discharge hand-offs to subspecialties and ambulatory teams, and increase weekend and early evening presence. We established and continue to have regularly scheduled touchpoints with the Op-Ex leadership for these areas as well. The goals being to continue to build relationships, celebrate successes and identify gaps (especially with COVID and remote work).

Work-life balance improvement was reflected in the following employee engagement survey. • Time off respected as evidenced by ceasation of calls regarding patient needs • Reasonable workload 2019 2020 Additional Benefits included: • Dramatically increased opportunities for professional and practice development (LEAN, preadmission planning, avoidable bed days) • Increased autonomy • Positive perception of the role and practice of the care manager enhances recruiting • Proactive identification of patients at greatest risk for transition related adverse events Provider Comments (February 2020) • Diversity of patient complexity, level of illness and diversity of pathology team structure rounding structure overall getting to interact with med students working with care coordination, social work, respiratory therapist, and more! • I think the home care/discharge coordination has improved since I was last on HM. • I loved the addition of the home care huddle after rounds! This was a great change from last year and significantly helped communication and discharge planning on a busy rotation.

Implications/ Next Steps Re-evaluation of current staffing model based on patient populations and stress scores after the opening of the new Critical Care Building in November and potentially adding RT expertise to the care management team.

Utilization Management Program Redesign Integrating Configurable Work Queues in the Utilization Review Process Janet DeRocco – Pasternick RN, BSN, MBA, ONC, ACM; Charmaine Tetkoskie MSHCA, BSN, RN, NE-BC Geisinger, Danville, PA Introduction

Methods and Materials

Results

The Utilization Management program was misaligned with the organization’s strategic priorities

• Gap analysis was performed on 51 patients in observation status • Baseline data revealed 53% of the cases had opportunity to be assigned to inpatient status before discharge • Requirements for inpatient admission status: Inpatient order, documentation of LOS expected to be > 2 MN and documentation of medical necessity to support case to cross > 2 MN • Observed UM staff in situ assessing process adherence • Evaluated Physician Advisor practice behaviors across providers • Performed a data analytics focused assessment to benchmark current metrics with industry standards • Evaluated dashboard performance • Reviewed monthly denial write off reports and identified trends • Completed a value stream analysis identifying process gaps and opportunities to integrate IT within the operational workflow and electronic medical record software

Primary Outcome

• Utilization Management (UM) program utilized an outdated review process and inefficient EPIC electronic medical record dashboard • Systems for reporting were insufficient and unable to capture performance metrics • Nurse reviewer and Physician Advisor (PA) workflow did not support a reliable approach to admission, concurrent or denial reviews • Program framework was inconsistent and correlated to a high volume of inappropriate upgrades / downgrades and Medicare cases in observation (Obs) status crossing two-midnights (2 MN) The Utilization Management program was tasked with reducing the overall percentage of downgrades and Medicare observations crossing two-midnights • Gap analysis identified several areas for improvement including potential revenue for an annual net benefit between $7.6 and $10.4 million through sustainable patient status improvement • Figure1. January and February 2019 the percentage of traditional Medicare cases in observation greater than twomidnights was well above the calculated opportunity target of 10%. • Calendar year 2019 the baseline observation rate for all payers was 23.9% and 37.1% of observation case had an average length of stay greater than 48 hours Figure 1. Traditional Medicare Observation cases were grouped by how many midnights they crossed

Conclusion

• Reduced status conversions • Minimized regulatory risks and financial liabilities • Reduced lost midnights for qualifying three-consecutive-day inpatient stays and improved the timeliness of discharge to post-acute care

Figure 4. Admitted as IP, Discharged as Obs. Point of Entry “Starting care in the right admission status”

Figure 5. Admitted as Obs, Discharged as IP. Reliable concurrent review process and protocol upgrade order

Implementation

Lessons Learned

Primary Implementation • Point of Entry – Status Determination (IP vs OBS) • Milliman Clinical Guidelines (MCG) – Indicia • Evidence based decision support / medical necessity • GLOS benchmark and expected LOS Secondary Implementation • Work Queues - Routing tasks using business rules to UR & PA

Nurse

Inpatient Observation

Point of Entry RN Physician Advisor Admission Review Secondary Review

• UM program transformation occurred in less than a calendar year • Streamlining UM and PA workflow has resulted in a 78.5% reduction in Medicare cases crossing two-midnights (December 2019 – 54.8% December 2020 - 31.7%). • Gross revenue improvement of $35,275,759 exceeding the established goal by 28,072,009 at the close of a bridge year 2020 • Close of service in January 2021 the decrease in observation volume exceeded a $40 million financial improvement • Standardizing Physician Advisor role and responsibilities provided enhanced support for Utilization Management and Case Management operations • Timely and complete documentation for medical necessity screening and patient status assignment reduced one day inpatient stays • Timing of status conversations and inpatient order placement ensured methods to reach two-midnight rule benchmark • Triggering within EPIC - dynamic work queues set by business logic and router activity ensured a compliant utilization review process and a means to monitor and improve performance

Secondary Outcome • Denial management • Streamlined secondary review process • Standardized denial documentation for tracking and reporting • Annual financial benefits • Reduction in write-offs and lost inpatient payments due to downgrades • Potential increase in Value Base Purchase bonus from CMS

Admission & concurrent review Secondary review & commercial denials -- ED – Recommend Admitting Inpatient Short Stays Medicare observation LOS > 24 hours Non-Medicare payers in observation LOS > 48 hours Commercial Denials

Figure 6. IP MN Denied. August 2020, implemented updated PA role and responsibilities, implemented PA work queues

Figure 7. LOC Denials. Upfront UR process, assignment of appropriate level of care

• Majority of clinicians reported they lacked clarity around regulatory observation rules and policies • Strong management of front-end utilization review (UR) process improved back-end revenue cycle delays • Implementing MCG evidence-based criteria for medical necessity screening and progression of care improved patient placement and patient flow • Figure 10. Achieving a 10% target for the percentage of Medicare cases crossing two-midnights is not entirely an observation care problem it is reliant upon other hospital operations

Figure 10. 12-month Medicare Case Trend crossing twomidnights

• Nurse Protocol Order – Upgrade per criteria review • Performance Metrics • Observation Management • Upgrades and Downgrades • Denials • Medical Necessity • Level of Care

Objectives  Understand how to leverage and execute technology within the chosen electronic medical record to standardize and assign a focused utilization management effort  Recognize the need for reporting metrics to demonstrate improvements in initial patient status determination and reductions of inappropriate status conversations  Identify the importance of how a consistent, frontline review process will improve bed placement, hospital throughput and correlates to organization profitability  Evaluate the effectiveness and possibility of a similar method in the participant’s own organization

Figure 2. 2019 – 2020 CY comparison of Total Observation Rate with Implementation Timeline. All payers with corresponding UM program redesign.. Project implementations occurred over several months (Feb-Aug 2020)

Additional Information / References 2020 Calendar year Downgrade Case Trend Volume of downgrades compared to downgrades as a % of discharges • Total downgrades have decreased from 3.4 % (January 1, 2019) total volume post billing to a 0.3% (December 31, 2020), Figure 8 • Medicare downgrades have decreased from 3.4 % (January 1, 2019) total volume post billing to 0.8% (December 31, 2020), Figure 9

Figure 8. Total Downgrade Case Trend

Figure 9. Medicare Downgrade Case Trend

Contact Information Janet DeRocco – Pasternick RN, BSN, MBA, ONC, ACM Associate Vice President, Utilization Management jlpasternick@geisinger.edu 570.808.5433 570.574.7684 (cell) Charmaine Tetkoskie MSHCA, BSN, RN, NE-BC Director System, Utilization Management cstekoskie@geisinger.edu 570.214.8148 570.850.2476 (cell)

AddressiNg PAtieNt TrANsportAtioN Needs to IMproVe HeAlth OutcoMes Lisa Gerwe, BSN, RN Introduction

Centers for Medicare and Medicaid (CMS) recognizes the significance of social determinants 1 on health disparities and outcomes for individuals. Transportation is a Social Determinant of Health (SDOH) that greatly impacts access to healthcare 2 services and overall health outcomes. Social and economic factors such as transportation have been found to account for up to 90% of health outcomes 3 and are linked with patient longevity.

Methods

Erlanger, KY

Conclusions

Standard Workflow for Transportation Options Patient presents with a non-emergent need for transportation option durning care management outreach

Does patient have acute need for transportation?

Hospital or ED follow up or office visit with POP?

YES

Does patient have payor?

DEPARTMENT OF CARE MANAGEMENT

YES

Provide patient number for Federated.

Contact payor and confirm benefits.

Is payor Federated?

YES

• Addressing transportation needs is resulting in improved patient health outcomes •C oordination between the healthcare system and public and private transportation entities increases patient awareness of transportation options and access to healthcare appointments • Standard workflow for transportation coordination empowers patients and Care Managers to overcome transportation barriers

Objectives

1. Apply standard workflow including SDOH screening to address transportation barriers 2. Develop partnerships with both public and private transportation organizations and payors 3. Obtain grant funding for patient transportation 4. Utilize Care Management associates to assist patients to overcome transportation barriers in a manner that is inclusive of needs related to culture and disabilities

Next Steps

Review demographics for mileage, American Disability Act, and age for Tank Ramp and Tank Senior services.

Patient a candidate for Tank Ramp or Tank Senior?

YES

Provide Tank ramp or Tank Senior information.

YES

Provide patient with private pay option information.

Cancer diagnosis?

Can patient afford private pay options?

YES

Is ride to Cancer Care Center?

Refer to Oncology SW or St. Elizabeth Healthcare care coordination.

YES

Utilize grant funded local transportation option.

References

Results 2020 Patient Transportation Assistance Number of Rides

Improved Patient Outcomes Reduced ED Visits

Reduced Inpatient Visits

2. Murray, T. A. (2018). Overview and Summary: Addressing Social Determinants of Health: Progress and Opportunities. The Online Journal of Issues in Nursing, 23(3). https://doi.org/10.3912 3. Fraze, T. K., Brewster, A. L., Lewis, V. A., Beidler, L. B., Murray, G. F., & Colla, C. H. (2019). Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by us physician practices and hospitals. JAMA Network Open, 2(9), 1–14. https://doi.org/ 10.1001/jamanetworkopen.2019.11514 y ar

u n Ja

r b Fe

y ar

ch r a M

il r p

ay M

e n Ju

Grant Funded Local Transportation Assistance

Reduced No Show Count

1,400 1,200 1,000 800 600 400 200 0

10%

20%

30%

40%

50%

1. Weeks, W. B., Cao, S. Y., Lester, C. M., Weinstein, J. N., & Morden, N. E. (2019). Use of z-codes to record social determinants of health among fee-for-service medicare beneficiaries in 2017. Journal of General Internal Medicine, 35(3), 952–955. https://doi.org/10.1007/s11606-019-05199-w

ly u J

r r r r st e e e e u b b b b g o m m m u t e e c A te v c O p De No Se

Total Coordination

AddressiNg PAtieNt TrANsportAtioN Needs to IMproVe HeAlth OutcoMe Lisa Gerwe, BSN, RN

DEPARTMENT OF CARE MANAGEMENT Erlanger, KY

Introduction

Centers for Medicare and Medicaid (CMS) recognizes the significance of social determinants on health disparities and outcomes for individuals.1 Transportation is a Social Determinant of Health (SDOH) that greatly impacts access to healthcare services and overall health outcomes.2 Social and economic factors such as transportation have been found to account for up to 90% of health outcomes and are linked with patient longevity.3 Objectives

Results

1. Apply standard workflow including SDOH screening to address transportation barriers

Improved Patient Outcomes

2. Develop partnerships with both public and private transportation organizations and payors

Reduced ED Visits

3. Obtain grant funding for patient transportation 4. Utilize Care Management associates to assist patients to overcome transportation barriers in a manner that is inclusive of needs related to culture and disabilities

Reduced Inpatient Visits

Reduced No Show Count

10%

20%

30%

40%

50%

Conclusions

Methods

Standard Workflow for Transportation Options Patient presents with a non-emergent need for transportation option durning care management outreach

Does patient have acute need for transportation?

Hospital or ED follow up or office visit with POP?

YES

Does patient have payor?

YES

Provide patient number for Federated.

Contact payor and confirm benefits.

Is payor Federated?

YES

Review demographics for mileage, American Disability Act, and age for Tank Ramp and Tank Senior services.

Patient a candidate for Tank Ramp or Tank Senior?

Provide Tank ramp or Tank Senior information.

YES

Cancer diagnosis?

Can patient afford private pay options?

Provide patient with private pay option information.

YES

Is ride to Cancer Care Center?

YES

Refer to Oncology SW or St. Elizabeth Healthcare care coordination.

Utilize grant funded local transportation option.

Number of Rides

2020 Patient Transportation Assistance 1,400 1,200 1,000 800 600 400 200 0

• Addressing transportation needs is resulting in improved patient health outcomes • Coordination between the healthcare system and public and private transportation entities increases patient awareness of transportation options and access to healthcare appointments • Standard workflow for transportation coordination empowers patients and Care Managers to overcome transportation barriers

Next Steps

• Continued assessment with larger sample size to quantify the impact of transportation coordination on improved patient health outcomes • Investigate the feasibility of increasing mobile and virtual health care for patients • Grow participation in regional transportation initiatives to develop new community opportunities to address transportation barriers References 1. Weeks, W. B., Cao, S. Y., Lester, C. M., Weinstein, J. N., & Morden, N. E. (2019). Use of z-codes to record social determinants of health among fee-for-service medicare beneficiaries in 2017. Journal of General Internal Medicine, 35(3), 952–955. https://doi.org/10.1007/s11606-019-05199-w 2. Murray, T. A. (2018). Overview and Summary: Addressing Social Determinants of Health: Progress and Opportunities. The Online Journal of Issues in Nursing, 23(3). https://doi.org/10.3912

y ry ar ua nu br e Ja F

ch ar M

ril

ay M

n Ju

Grant Funded Local Transportation Assistance

ly Ju

r r r st er be be be gu ob em em em ct Au t v c O p De No Se

Total Coordination

3. Fraze, T. K., Brewster, A. L., Lewis, V. A., Beidler, L. B., Murray, G. F., & Colla, C. H. (2019). Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by us physician practices and hospitals. JAMA Network Open, 2(9), 1–14. https://doi.org/ 10.1001/jamanetworkopen.2019.11514

In it together: creating a robust interdisciplinary shared governance model in an ACO Tamera Brandon, MSN, MBA, RN; Leanne Clark, MSN, RN, NE-BC; Amy Gardner-Camacho, MSN, RN, CNE; Jennifer Harvey, MSN, RN

OBJECTIVES

• Identify the need for an interdisciplinary vs. traditional shared

STRUCTURE

SUCCESSES

governance model

• Describe the three phases used to implement an interdisciplinary

• Work-at-home pilot and implementation • Social work resource standardization • Transition to fully remote model and use of virtual platform • Revision and approval of Scope of Practice Guideline • Alternative work arrangement development and implementation • Multiple subcommittees created by role-based councils on larger

CCM Grand Council Meets every other month on the same day as Interdisciplinary Council

shared governance model

Video bridge or face-to-face

• Define measurable outcomes of successful implementation

One delegate from each discipline from NTX/CTX (eight total)

INTRODUCTION

projects to improve efficiency, exemplifying successful engagement in the shared governance process

• The Comprehensive Care Management (CCM) team, part of an accountable care organization (ACO) associated with a large integrated healthcare organization, serves 805,000 members across a large geographic area.

• The CCM team consists of a dynamic group of:

° Nurses ° Community health workers

° Health coordinators ° Pharmacists/pharmacy techs ° Social workers

• 2018 employee engagement survey identified the need for

CTX Interdisciplinary Council

Education Council

Quality Assurance Council

Epic Super User Council

Preceptor Council

Meets quarterly

NTX/CTX

Meets 1st Tuesday of each month

NTX/CTX

Video bridge/Webex

NTX/CTX

Video bridge/Webex

Meets 3rd Tuesday of each month

Meets 2nd week of each month One member from each discipline from each location (12 total)

NTX Interdisciplinary Council

Meets quarterly

Meets 2nd week of each month Two members from each discipline (10 total)

Video bridge/Webex

Video bridge or face-to-face

increased staff autonomy and heightened staff engagement.

• Structure was needed that truly reflected the multidisciplinary reality of the staffing model.

IMPLEMENTATION PHASE I

CTX-SW Council

CTX-HC Council

CTX-RN Council

Meets 1st week of the month via Webex

Quarterly face-to-face

(one to two from each location)

NTX-Pharmacy Council Meets weekly (eight members plus CTX pharmacist)

NTX-RN Council

NTX-SW Council

NTX-HC Council

Meets 1st week of the month (one to two from each pod)

NTX-CHW Council Meets 1st week of the month (one to two from each pod)

° Collaborate with other disciplines

•

° Align workflows and projects ° Escalate recommendations for higher-level decision-making G rand Council

RESULTS

• Success is measured using biannual staff engagement surveys and ongoing growth of the shared governance model. • Outcomes were measured using the 2019 employee engagement surveys subsequent to phase one of shared governance implementation. Initial results show notably improved scores for the following questions:

Employee Engagement Survey Results 2020*

2021

% increase

Communication changes in programs, policies and procedures are handled well.

42%

51%

65%

87%**

45%

2. Adapted health system Nursing Shared Governance charter to meet the needs of the interdisciplinary structure

I am appropriately involved in decisions that affect my work.

57%

59%

76%

81%**

24%

3. Provided leadership training specific to BSWQA structure for chair and co-chair staff level leaders

BSWH delivers high-quality services to its patients and members.

85%

82%

90%

97%

12%

I go above and beyond to help BSWH be successful.

94%

98%

91%**

-3%

until they were competent (four to six months)

• Additional collaborative councils developed

° Notable improvements in three out of four Employee Engagement Survey questions

RESOURCES Allen, S., Kneflin, N., Morath, H., Casper, T. (2019). How Cincinnati Children’s Hospital Approaches Shared Governance. Retrieved from healthleadersmedia.com Hoying, C., Allen, S. (2011). Enhancing shared governance for interdisciplinary practice. Nurs Admin Q. Vol 35 (3), 252-259. doi: 10.1097/ NAQ.0b013e3181ff3ald Ireson, C., McGillis, G. (1998). A multidisciplinary shared governance model. Nursing Management 29(2) 37-39. Retrieved from http://www. nursingmanagement.com Mercer | Sirota (2018). Dynamic Alignment Model. Purchase, NY

4. Provided initial support for role-based councils

PHASE II

believe it is successful as indicated by:

leadership in workplace decision-making is creating a better work environment and improving employee engagement.

2019*

• Staff leaders now facilitate council meetings independently

• Although there are still opportunities for improvement in the model, we

• Empowerment of employee autonomy and a paradigm shift to shared

2018*

• Leadership helped facilitate meetings and mentor staff leaders

CONCLUSIONS

successful initiatives

Mercer | Sirota People Survey Question

° Connects interdisciplinary councils from each geographic region ° Provides additional resources and recommendations ° Final approving body

• Engaging unlicensed staff • Staff-level leadership turnover • Identification of appropriate agenda items to implement • Leadership understanding of their roles in facilitation and provision of

° Role-based councils working independently with multiple

• Role-based councils

• Interdisciplinary Councils

governance

• Possible council structure revision due to remote work

1. Council structure developed

° Provide a voice for frontline staff ° Opportunity to directly affect workflow ° Build a healthy work environment

• Obtaining buy-in from non-nursing staff about benefits of shared

support and requested resources

• Implementation of shared governance utilized as solution with

rationale gathered from Swihart (2018) who proposed that in order to arrive at the most effective decision, those who perform the work within the organization must share in the decision-making process.

CHALLENGES

*Guidelines for interpreting difference in scores: Mercer | Sirota suggests that for a group of more than 100, +/- 5% is considered a notable difference. **Minor wording modifications due to change in survey provider

Scott, L., Caress, A. (2005). Shared governance and shared leadership: meeting the challenges of implementation. Journal of Nursing Management 13, 4-12. Blackwell Publishing Ltd. Hoboken, NJ Swihart, D. (2018). Shared Governance: A Practical Approach to Transforming Interprofessional Healthcare 4th edition. HCPro Inc. Middleton, MA

° Education Council ° Quality Assurance Council ° Epic Super User Council ° Preceptor Council

PHASE III

• Continuous improvement

° Identify challenges ° Generate ideas to address challenges

Project Summary Usually when we hear of transitions of care, we think of the admitted patient who is transitioning to a post-acute setting. However, care transitions refer to the movement of the patient between the healthcare systems. The patient with COVID-19 is the perfect example of care transitions. The patient with COVID-19 transitions from the primary care provider to inpatient hospital setting, and while in the hospital this patient may transition from the medical floor to the intensive care unit, back to the medical floor and then transition to home or a post-acute care facility. The need for transitional care management in the COVID-19 pandemic is pivotal. A holistic approach to care with collaboration of the interdisciplinary team is fundamental to achieve best practice outcomes. The hospital-based case manager has that responsibility to transition this patient to the post-acute care setting equipped with services and resources to facilitate optimal recovery.

Outcome Data: There is currently no outcome data as we are in the midst of the pandemic. Statistics have not been collected as this situation remains fluid with changing guidelines and protocols. However, below are some outcomes that we anticipate as we move forward, building a better foundation to change the trajectory of care transitions in future 1.Patients with COVID-19 whose discharge and transition of care services began at presentation were more informed, and were able to implement safety precaution, and self-monitoring steps in order to seek treatment in a timely manner. 2.Family involvement upon initiation of care improved post-acute care compliance and reduced readmission. 3.Discharge planning standardization increased. 4.The Interdisciplinary team expanded to include: MD, PA/NP, RN, LPN, CAN, PT, OT, Speech-Language, Activity Therapist, Dietary, Chaplains, pharmacy, 5. Increase in referral to case management of patient requiring care transitions at the time of their admission.

Nurseadvocates.com

Learning Objective 1. Attendees will understand when to initiate transition of care 2.Attendee will understand the benefits of transitions of care (TOC) for the patient and family 3. Attendees will understand the importance of the interdisciplinary team as it relates to TOC. 3. Attendees will understand the role of modern technology in TOC in acute care and post-acute setting.

COVID-19 Resources for Healthcare Workers https://www.aha.org/other-resources/2020-07-22-recovery-playbook-improves-follow-care-covid-19patients https://optionb.org/advice/how-to-support-others-during-the-covid-19pandemic?gclid=EAIaIQobChMIm_H4lvCE7AIVFz2tBh1wRwN0EAAYASAAEgJZ5PD_BwE https://www.pcdc.org/covid19/?creative=444418100293&keyword=covid19%20resources&matchtype=b&ne twork=g&device=c&gclid=EAIaIQobChMIm_H4lvCE7AIVFz2tBh1wRwN0EAMYAyAAEgJAxPD_BwE https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

Georgia Chapter ACMA Education Committee Care Transitions Management During the COVID-19 Pandemic Joseph Kamah-Kanu; Stephanie Kemp; Gauri Desai; Jacqueline Bushell RN MSN

CLOG BUSTER Reducing Emergency Department Visits and Hospital Admissions from Feeding Tube Malfunctions Beverly Bowell, RN, BSN, ACM

Background Every year approximately 250,000 patients receive enteral nutrition through feeding tubes. Feeding tubes are prone to clog for many reasons such as, formula composition, small feeding tube diameters, inadequate water flushes, and improper medication administration.1 Patients discharged with new feeding tubes are at high risk for return to the Emergency Department or Hospital within 30 days after hospitalization with feeding tube malfunction. Research supports the patient initially use lukewarm water for de-clogging efforts. Furthermore, ASPEN guidelines recommend activated pancreatic enzyme solutions as a secondline option.2,3 UPMC observed several patients per month presenting to the ED and often admitted with feeding tube obstructions. As a result, we developed several processes to manage clogged feeding tubes. Goals 1. Reduce avoidable Emergency Room (ER) visits and hospital readmissions. 2. Provide patient with necessary education and tools to proactively manage feeding tube clogs. 3. Provide care in the appropriate outpatient setting. 4. Improve the patient and family experience.

Methods: Development Phase • Engaged FEEDS (Feeding Education and Enteral Diet Support) Team, MD leadership and pharmacy to support sending patients home with prophylactic enzymes. • Pharmacy ran test scripts to determine cost of enzymes. These medications are not covered by most payers for this use. • Secured approval from hospital leadership to incur the expense of dispensing enzyme kits to all patients with new feeding tubes seen by the FEEDS Team. • Provide pancreatic enzyme kits, consisting of Viokase and Sodium Bicarbonate for use at home by patient, home care or skilled nursing home personnel to manage impending obstruction of tubes. • Consultation by FEEDS Team, a liaison service consisting of a PA and a dietician dedicated to helping patients discharged from the hospital on enteral nutrition / tube feedings. The team provides personalized inpatient education, discharge coordination, and outpatient follow-up to this group of patients with unique needs. The FEEDs team will ensure enzyme kits are delivered to the patient along with the proper instructions for use in de-clogging feeding tubes. • Identified service line (Otolaryngology) which utilizes most feeding tubes to partner with and pilot enzyme kit.

Methods: Implementation Phase • Created standard process for providing enzymes and instructions to patients going home or to skilled facilities. • Created automatic consult for FEEDs team in electronic record on patients who received a new feeding tube. • Partnered with home care and skilled facilities to support and monitor effectiveness of enzyme kit usage. • Provided home care nurses and post-acute facilities with enzymes in the event they encounter sluggish or clogged feeding tubes.

Methods: Assessment Phase • Home care tracking volume of patients receiving enzyme kit to identify trends and issues. • Patients with new feeding tube are now identified on initial referral to home care. • Identified issues with enzyme scripts on pilot units, engaged pharmacy and electronic medical record teams to streamline and simplify enzyme ordering.

Outcomes

Conclusions • Results show patient and home care staff ability to successfully address feeding tube malfunctions in an outpatient setting. • Process reduces unnecessary ER or hospital readmissions.

Next Steps • Spread enzyme kit distribution to other key service lines (Thoracic). • Develop after-hours feeding tube algorithm to provide live support and better manage patients with feeding tube issues in the outpatient setting.

References 1. Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN Journal Parenteral Enteral Nutrition. 2017;41(1):15-103. 2. Fisher C, Blalock B. Clogged Feeding Tubes: A Clinician’s Thorn. Practical Gastroenterology. March 2014:1622. 3. Hayes KD, Hayes DD. Best practices for unclogging feeding tubes in adults. Nursing2019. 2018; 48:1.

Decreasing Avoidable Utilization through an Emergency Department High Risk Coordination Program Peggy Blizzard, BSN, RN, ED High Risk Coordinator; Mary Zak, RN, ED High Risk Coordinator; Jacqueline Moore, RN, BSN, LCSW-C, ACM, Director Integrated Care Management University of Maryland St. Joseph Medical Center, Towson, MD INTRODUCTION

INTERVENTIONS

CUMULATIVE DATA

OUTCOMES

The Emergency Department (ED) High Risk Coordination program was developed by the Integrated Care Management Department at the University of Maryland St. Joseph Medical Center in 2015. The goal was to support patient care teams in decreasing the number of unnecessary ED visits and hospital admissions. These avoidable visits are commonly a result of an explicit group of multiple visit patients who impose an unreasonably high burden on the healthcare system through an elevated use of facility resources. The definition of a multiple visit or high utilizer patient differs from institution to institution. For this program, we define them as “patients presenting with 6 or more ED visits within a 12 month time period”. These patients often have unmet healthcare needs. Many have a secondary psychiatric component and/or complex social determinants such as homelessness and being underinsured or uninsured. Program exclusions are the pediatric population and those with a primary psychiatric component.

 Collaborate with ED providers on goals for patient dialogue and interventions.  Discuss ED visits with patient to determine drivers of multiple visits and alternatives for care.  Provide patient with community healthcare resources for non-emergent medical care such as Primary Care Providers (PCP) and Urgent Care centers and educate them on the appropriate use of these resources versus the ED.  Connect patients requiring disease-specific or new diagnosis care to Specialty, Transitional, Bridge or High Risk clinics as appropriate.  Assist with appointment scheduling, if needed.  Assess for social determinants and offer suitable resources for housing, food, financial assistance, medical insurance and transportation.  If warranted, author a Care Alert to inform the healthcare team of patients’ key health concerns, barriers to care, recommended actions and other patient information deemed relevant.  Review existing Care Alerts directly with providers, avoiding duplication of medical resources and preserving the message of the care plan upon patient arrival to the ED.

Data is compiled semi-annually on all patients with Care Alerts. These numbers measure ED patient utilization before and after the initiation of a Care Alert. They also demonstrate the impact of Care Alerts on Inpatient admissions and Observation stays. The expectation is that the data will reflect a decrease in avoidable utilization.

Increased awareness of Care Alerts by facility providers. Enhanced communication and treatment plan consistency among care team members across the continuum. Patients are able to make appropriate decisions in accessing care as evidenced by EMR review or Transitional Care program follow-up. Data demonstrates that our overall avoidable utilization decreased by more than 80% consistently over the last 3 years. Manpower expanded from 1.0 to 1.8 full-time equivalents based on program effectiveness and ED provider support.

The primary focus of the ED High Risk Coordinator is to:  reduce the number of ED visits.  work with ED staff to identify high utilizers and underlying determinants for visit frequency.  employ interventions that best match the needs of the patient.  encourage this patient cohort to utilize appropriate resources prior to visiting the ED.  create a Care Alert if necessary, to communicate pertinent information to the care team. What is a Care Alert?  tool used to improve communication among healthcare teams  offers “need-to-know-now” information  key function in the High Risk Coordinator role  facilitates consistency and coordination of care

OBJECTIVES Decrease avoidable utilization within the facility. Provide patients with connections to community resources. Promote the use of Care Alerts as a means to communicate the recommended plan of care. Improve access to medical treatment in the appropriate setting. Empower patients to take ownership of their health and well being.

www.PosterPresentations.com

A Care Coordination Committee convenes monthly to review patients posing the greatest challenges in altering their utilization patterns. The Committee consists of:  ED High Risk Coordinators  Integrated Care Management Director  Chief of Emergency Medicine  Chief of Hospital Medicine  Chief Medical Officer  Physician Advisor/Transitional Care Center Physician  ED Nurse Manager  Clinical Pharmacist Committee members discuss patient concerns and obstacles to change. Together, they develop a potential solution that is incorporated into the Care Alert. Pain management and behavioral contracts are written for some patients. These contracts are patient specific and detail the expectations of both the treatment team as well as the patient. The High Risk Coordinator familiarizes the patient with the contract when they present to the hospital.

HIGH RISK PATIENTS ED Utilization through December 2020 - Cumulative

# ED Visits Pre Care Alert: 0-3 months Post Care Alert: 0-3 months 4-6 months 7-9 months 10-12 months

% ∆ from Pre Care Alert ED Visits

3642 1210 841 622 609

BARRIERS

-66.8% -76.9% -82.9% -83.3%

* 1856 total Care Alert pts; 1670 with ED visits since Care Alert created

Motivation for change can be difficult to achieve for patients with long-standing behavior patterns. Chronic illness often involves complicated and expensive treatment regimens contributing to non-adherence. ED pace and workflow can lead to untimely acknowledgement of Care Alerts if High Risk Coordinator is not present. As the use of Care Alerts becomes more universal across the continuum, maintaining the original intent and design is arduous.

REFERENCES

HIGH RISK PATIENTS ED VISITS BY DISPOSITION Cumulative through December 2020

I/P ADMISSIONS Pre Care Alert: 0-3 months Post Care Alert: 0-3 months 4-6 months 7-9 months 10-12 months

% ∆ Pre # ED Alert OBSERVATION # ED Visits ED Visits STAYS Visits Pre Care Alert: 550 0-3 months 655 Post Care Alert: 200 -63.6% 0-3 months 204 103 -81.3% 4-6 months 141 73 -86.7% 7-9 months 117 75 -86.4% 10-12 months 114

% ∆ Pre Alert ED ED Visits DISCHARGES Pre Care Alert: 0-3 months Post Care Alert: -68.9% 0-3 months -78.5% 4-6 months -82.1% 7-9 months -82.6% 10-12 months

% ∆ Pre # ED Alert Visits ED Visits 2536 794 572 409 405

-68.7% -77.4% -83.9% -84.0%

1. Blumenthal, K. J., Chang, Y., Ferris, T. G., Spirt, J. C., Vogeli, C., Wagle, N., & Metlay, J. P. (2017). Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization. Journal of General Internal Medicine, 32(8), 877–882. https://doi.org/10.1007/s11606-017-4041-y 2. Hayward, J., Hagtvedt, R., Ma, W., Gauri, A., Vester, M., & Holroyd, B. (2018). Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department. Western Journal of Emergency Medicine, 19(6), 912–918. https://doi.org/10.5811/westjem.2018.8.38225 3. Soril, L., Leggett, L., Clement, F., & Noseworthy, T. (2015, February 21). Reducing Frequent Visits to the Emergency Department: A Systematic Review of Interventions. . https://www.ncbi.nih.gov/pmc/articles/PMC4395429/. 4. Wang, C.-L., Ding, S.-T., Hsieh, M.-J., Shu, C.-C., Hsu, N.-C., Lin, Y.-F., & Chen, J.-S. (2016). Factors associated with emergency department visit within 30 days after discharge. BMC Health Services Research, 16(1). https://doi.org/10.1186/s12913-016-1439-x Authors: Peggy Blizzard: Peggy.Blizzard@umm.edu Mary Zak: MaryZak@umm.edu Jacqueline Moore: JacquelineMoore@umm.edu

Reduction in Scheduled Out Trips for Medical Appointments:

Significant Clinical and Financial Results Realized via Process Improvement Aimed to Decrease Off-Site Medical Appointments Katherine Reilly, RN, MS, ACM-RN, Leigh Golembiewski, CTRS Affiliations: Gaylord Specialty Healthcare, Wallingford, CT 06492

INTRODUCTION Gaylord Hospital is a 137-bed non-profit, inpatient long-term acute care hospital (LTCH) for patients who need intensive medical rehabilitation following a critical illness, traumatic accident or other serious health event. The hospital is rehabilitation-focused and part of a non-profit health system that provides inpatient and outpatient care at every point in our patients’ journey from illness and injury to maximum recovery. Widely recognized for leadership in treating spinal cord and brain injuries, pulmonary and cardiac conditions, sports-related injuries and amputee and stroke patients, Gaylord is the only rehabilitation system in Connecticut accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) for both inpatient and outpatient programs. Gaylord Hospital is staffed around the clock with physician coverage and has a significant number of consultants on staff to see patients when indicated. However, there are times when patients need to go to an appointment with a physician that has treated them at the acute care hospital from which they were admitted. This project speaks to the need to identify just which of these appointments are medically appropriate while the patient is in the LTCH. These complex patients are admitted from short term acute care hospitals to continue with medical management at a hospital level of care. The discharging providers would order follow up appointments often without regard to the fact that patients were in a hospital setting being seen by a physician on a daily basis. It was as if the patient were going to a lower level of care (home, skilled nursing facility, assisted living).

LEAN TEAM INITIATIVE A lean team was created to look at consult appointments for patients at the LTCH. There were quality concerns for patients missing medical treatment, medications, as well as therapies. There are also significant increased costs associated with the trips for Medicare DRG patients and patients reimbursed on a case rate.

PROBLEM STATEMENT From October 1, 2018 through March 31, 2019, the total number of scheduled out trips for patients is 525, with an associated cost of $158,813. Projected cost for Gaylord if this out trip rate is maintained by the end of FY19 is $381,115.

GOAL STATEMENT Reduce the number and cost of scheduled trips by 10% by mapping the

current out trip process, measuring and identifying key steps in the process that can be modified and memorializing the process expectations.

OUTCOMES The following slides show the outcomes for FY19 and FY20. In 2019, there were 545 total appointments requested by physicians discharging patients from the short term acute care hospitals. After implementation of the new process, 292 appointments were deferred. At the end of FY20, there were a total of 1,855 appointments requested and 1,179 were appropriately deferred.

This resulted in significant cost avoidance for the hospital. In addition, continuity of care for patients was uninterrupted.

SCHEDULED OUT TRIP TOTALS

Patient arrives with multiple prescheduled appointments

Request for additional off-site consults after admission

Currently management of appointments managed differently on each of the units

292

DEFERRED

FY19 Transportation Costs Avoided : $175,200 FY20 Transportation Costs Avoided: $943,200

INITIAL PROCESS

545

REQUESTED

FY 2019 SCHEDULED OUT TRIP TOTALS

1,855 REQUESTED

1,179 DEFERRED

FY 2020

IMPROVED PROCESS Reduce the number of off-site appointments for those that are not medically necessary at this time

Utilize in-house consultants effectively

Create a consistent process throughout the hospital

In addition to reduction in number of trips and cost avoidance, workflow was improved significantly. The process went from a very manual, laborious, duplicative process to a streamlined, automated process using the hospital’s clinical IT system. This resulted in more consistent measurable data which contributed to the success of the Lean Project.

Striving to Engage Patients with Substance Use Disorders in Treatment Creation of an Addiction Medicine Consultation Service Mary Veihdeffer, LCSW THE OPIOID EPIDEMIC

ADDICTION MEDICINE CONSULT SERVICE – A RESPONSE TO THE EPIDEMIC

The Addiction Medicine Consult Service was developed in October 2018 with the goal to proactively manage withdrawal and medical comorbidity while promoting engagement and linkage to substance use treatment following hospital discharge. Bedside interventions include Motivation Interviewing (MI) and Screening Brief Intervention referral to treatment (SBIRT). Medical complications related to Substance Use Disorders are addressed including medically managing intoxication and withdrawal. Linkage to outpatient services can include MAT (Medication Assisted Treatment), Dual Diagnosis services and other treatment facilities. The opioid crisis was declared to be a public health emergency by the U.S. Department of Health and Human Services in 2017 and has brought national attention to those suffering from substance use disorders1. Evidence has shown that with treatment, recurrence rates for those with substance use disorders are no higher than those with other chronic medical conditions2. According to the U.S. Department of Health and Human Services, 2 million people had an opioid use disorder in 2018 and on average, 130 Americans die every day from an opioid overdose3. A 2014 SAMSHA survey (National Survey on Drug Use and Health) estimates the cost of illicit drugs to the US health care system at over $600 billion4. According to the National Institute on Drug Abuse, 70,200 drug overdose deaths were reported in the US and 47, 600 of these involved opioids5.

OUTCOMES TO DATE

In review of years 2019 and 2020, the Addiction Medicine Consult service saw 1,376 patients. 508 patients were seen in 2019 with an average age of 45.2. Of these patients, 42.2% were female and 57.8% were male. In 2020, 868 patients were seen with 39.2% female and 60.8% males. The average age of patients seen in 2020 was 44.4. Prior to the creation of the Addiction Medicine Consult Service, patients with substance use disorders had a 9.33% mortality rate at 6 months. Data for 2019 and 2020 show a decrease in mortality at 6 months. For 2019, this rate was 7.28%. For 2020, the rate was 5.68%. At 1 year, the mortality rate in 2019 was 9.44% while in 2020, the rate dropped to 7.17%. Additional positive outcomes from the Addiction Medicine Consult Service can be seen with AMA (Against Medical Advice) discharges. In 2019 there were 40 patients (7.87%) who left AMA while in 2020 there were 60 patients (6.91%) STRIVING FOR EXCELLENCE

While the Addiction Medicine Consult Service strives to connect patients to treatment, the impact of the team can be seen over the previous 2 years in a reduction in mortality and AMA discharges. There is still much work to do. Goals for the future include: • Expand the service to the sister campus • Expand the social work role to allow more time to engage in counseling and therapeutic process for patients who have prolonged hospitalizations. • Connect with community programs for seamless, warm hand off transitions of care.

ADDICTION MEDICINE CONSULT SERVICE – ROLES OF THE TEAM

The Addiction Medicine Consult Service is a multidisciplinary team consisting of a physician, nurse, social worker and peer navigator. • Physicians focus on the medical management of the patient with substance use disorders including recommendations for medications for opioid use disorders (MOUD). • The nurse has a primary role of providing assessments for patients and communicating with physicians regarding urgent patient needs. A large emphasis is also placed on education of incoming nurses and training of floor staff regarding best practices. • The social work focus is to engage the patient to talk about their addiction and connect the patient with treatment upon discharge. The social worker closely collaborates with floor case management teams to provide the safest transition possible to the next level of care. • The Peer Navigator (PN) focus is to provide ongoing support and companionship throughout the inpatient stay. PN’s also assist with connection to treatment in the outpatient setting. Acknowledgements We would like to acknowledge the work done by the entire Addiction Medicine Consult Service of UPMC Presbyterian Shadyside, whose focus has been on making an impact on the lives of patients with substance use disorders References “What is the U.S. Opioid Epidemic?” https://www.hhs.gov/opioids/about-the-epidemic/index.html , last reviewed September 4, 2019 “Early Intervention, Treatment, and Management of Substance Use Disorders”, https://addiction.surgeongeneral.gov/sites/default/files/chapter-4-treatment.pdf “Help, Resources and Information, National Opioids Crisis”, https://www.hhs.gov/opioids/ Substance Abuse and Mental Health Services Administration. “Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health” https://www.samhsa.gov/data/sites/default/files/NSDUHFRR1-2014/NSDUH-FRR1-2014.pdf Drug Overdose Death, Pennsylvania Opioid Summary, https://www.drugabuse.gov/opioid-summaries-bystate/pennsylvania-opioid-summary

Grief Shared is Grief Diminished: COVID-19 Bereavement Outreach Linda Caurdy-Bess, LMSW, ACSW, ACM-SW & Sara Damiano, LMSW,CCM Advance Care Planning ■ Palliative Care Department ■ Beaumont Health, Southfield, MI Special Thanks to the Beaumont Community Health and School Clinic Social Workers

BACKGROUND Beaumont Health is Michigan’s largest health care system and provides patients with compassionate, extraordinary care. With eight hospitals and 167 outpatient locations, Beaumont Health cared for the majority of COVID-19 patients in Southeast Michigan during the coronavirus pandemic. In March 2020, the Governor of Michigan issued an emergency executive order that restricted and limited family and visitor access to patients in the hospital to stop the spread of the virus. At the height of the pandemic an urgent need was identified by the frontline staff--the need to support patient’s families and one another. We mobilized a team of licensed clinical social workers and developed a bereavement support program.

METHODS It was recognized that families who experienced the death of a loved one were not consistently receiving bereavement support. Some inpatient sites had an established process to follow up with families following a death, but there were no consistent processes. Additionally, due to restrictions on family presence many patients were dying without their family present and families were often left with unanswered questions about their loved one’s final moments. A proposal to provide bereavement support to affected families was created and approved by executive leadership. In assessment of available staff and resources, the school-based clinic licensed clinical social workers (LMSW) were able to lend their time and expertise to support the bereavement outreach efforts. The match fit perfectly, as the school social work staff were able to support the program from mid-April through August when they would need to return to their regular work. The school based social workers were poised to take on this role due to their education, training and experience working with individuals and families. The focus of the intervention was on families who were experiencing a grief response related to any death, apart from hospice, pediatric, and perinatal losses, that occurred at a Beaumont Health facility during the COVID-19 pandemic (March-August 2020). Staffing Model and Patient Identification

RECOMMENDATIONS The findings in the COVID-19 bereavement support intervention offers guidance and recommendations for health systems. • First, it is recommended to offer telephonic bereavement outreach support. The ideal time for follow up seems to be within 2-3 weeks following the death. Based on the feedback provided by families it is imperative to support the care of families who have lost loved ones by offering a person-centered approach. Ideally it is best to draw on existing social work, nursing, spiritual care, or palliative care resources at your site to support the bereavement outreach intervention. • Furthermore, it is essential to have a key champion overseeing the efforts, navigating interactions with stakeholders, and ensuring sustainability of the model so the clinical staff can focus on supporting the family members. • Additionally, we recognized the need to support our team members and offered a moment of reflection, a pause to encourage staff to reflect on our experiences and losses and a virtual Service of Remembrance.

Nine social workers were given formal training including a script for phone calls, workflows and resources.

Social Work Intervention Social workers reviewed medical records prior to the bereavement call for information that could be helpful for the intervention. The outreach attempts included leaving up to 2 voice mail messages stating the purpose of phone call and contact information.

PURPOSE The purpose of the bereavement support model was to provide psychosocial support and initial crisis counseling to Beaumont Health families who experienced grief and loss related to the death of a loved one who was hospitalized at a Beaumont hospital during the pandemic and linking those in need to community resources.

Objectives: • To provide psychosocial support and initial crisis counseling to Beaumont Health families who experienced a death during the pandemic. • To connect bereaved families with community resources as appropriate. • To provide person centered and holistic care to our Beaumont community Grief shared is grief diminished. It is important for survivors to receive support at the time of loss, when those painful feelings are particularly acute. Disenfranchised grief is a term coined by grief researcher, Ken Doka, about twenty years ago. This term sheds light on this particular pandemic grief experience that resulted in complicating factors that worsened the grief experience such as limitations to funerals, memorial services, or family gatherings after the loss.

Bereavement Support Outreach The follow up by the social worker varied based on the person’s need and clinical assessment with the goal of transitioning the person to long tern clinical support or natural community resources.

RESULTS The bereavement support team made 573 outreach calls to families from April-August 2020. Of the outreach attempts, over 390 families were successfully contacted. Approximately 96 % (374) of the families contacted were receptive to the intervention and 63% (245) of those contacted indicated interest in a Beaumont sponsored Memorial Service. Key themes and numerous challenges that families were experiencing following the death of their loved one emerged. The main areas of concern are categorized below: • Logistic issues in navigating systems to obtain a death certificate or a copy of the medical record • Lack of details about the death and corresponding distress • Service issues including limited communication and ability to be present at bedside • Generalized grief and need for support groups or counseling • Financial concerns Based on the needs, the most common interventions provided by the social workers included psychosocial support, offering of written educational materials, and connection to another Beaumont staff member. A committee was formed to revise an existing booklet When Someone You Love Dies and a Bereavement webpage with resources was created.

“I am very impressed with Beaumont. My dad was given great care and we (my sister and I) appreciate the follow up calls and the card we received. We are so thankful for everyone who helped my family during this time.” (Patient’s Daughter)

“I am so thankful for the doctors and nurses who cared for my mother they called every day and Melissa, the nurse taught me how to video chat and waited 1 hour so I could also include my brother.” (Patient’s Son)

“I don't know what miracle happened for my phone to ring but I'm glad it did.” Spouse then reminisced about her husband. (Patient’s Spouse)

https://www.beaumont.org/patients-families/service-of-remembrance

Disenfranchised Grief “Grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, socially sanctioned or publicly mourned.” Ken Doka

65 & Thrive: Improving Patient Length of Stay, Readmission, and Quality of Care by Becoming an Age-Friendly Hospital Tracey Vien BSN, RN, PHN, ACM-RN, Stella Bobroff MSHCA, and Ricardo De Ocampo MSN, RN, NP-BC Introduction/Purpose The United States geriatric population projected growth: • Double from 43.1 million in 2012 to 83.7 million in 2050 due to aging baby boomers that began turning 65 in 2011 • Life expectancy of the aging will increase

What are we doing? KP Los Angeles Medical Center’s Utilization Management (UM) Department developed “65 and Thrive”, an age-specialized initiative that: • Preserves independence and quality of life • Prevents functional and cognitive decline • Promotes both patients and their families to thrive • Reduces average length of stay (ALOS) and readmissions • Improves HCAHPS scores and patient satisfaction

Readmission % Rates

Data and Results Age 65+ Readmission Rates: 2019 - 2020 30 25 20 15

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec Total

2019 19.5 23.9 22.3 21.7 22.8 23.1 23.1 22.7 24.8 28.6 26.2 24.9 23.6 2020 21.8 19.5 18.1 17.5 21.2 20.5 23.3 20.1 24.2 21.8 22.1 15.8 20.5

# of Days

Age 65+ ALOS: 2019 - 2020 8.00 6.00 4.00 2.00 0.00

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec

LOS ANGELES MEDICAL CNTR 2019 4.35 4.00 4.08 4.13 4.10 3.61 3.66 4.22 3.92 3.99 4.18 4.25 2020 4.44 3.73 4.66 5.13 4.54 4.60 5.17 4.79 4.63 4.45 4.59 7.20

Implications, Conclusions & Outcomes

Areas of Focus 5 M’s: Mobility, Medication, Mentation, Multi-Morbidity, What Matters Collaboration

Real-Time Escalations

Holistic Care

Workflows

UM Geriatric Team • UM Manager • Geriatric RN Case Managers (CM) • Discharge Planners (DCP) Age Sensitivity Training • Completed with 7 West RNs and UM Department • Ongoing training with Silver Angel volunteers RN Case Managers (CMs): • Initial assessment within 24 hours of admission • Nutrition, exercise, caregivers, transportation, advance directives, and resources (NECTAR) 2.0 training Geriatric RN CM • Chart review for completion and quality UM Geriatric Smart phrase • Identify patient barriers & interventions completed Staffing on each Nursing Unit • RN Case Managers • Case Manager Assistants (CMA) • Discharge Planners

CM-CMA-DCP-Bedside RN Communication • Digital whiteboard • UM/CM Navigator in Health Connect (EPIC EHR) • UM CM comments in Health Connect Silver Angels (SA) Volunteers • Specially trained healthcare students • Interaction with patients to maintain 5 M’s • Conduct readiness for hospital discharge surveys for patients and families • Assist with activities of daily living Discharge Planning Workflows & Process Improvements • In-service and workflow updates

Right Time

External Strategy

Project Summary & Methods Infrastructure / Training

Transitions of Care

•Home Based Palliative •Home Health •Discharge phone calls •Complex case management •SNF Community •Hospice

Inpatient •Comprehensive NECTAR/ Initial Assessment •Continuation of discussion and securement of LVOC •Partnership with bedside nurse for d/c planning process •Rounds with MD •Escalation of complex cases to prevent delays and avoidable hospital stays •Timely inpatient consults for Inpatient Palliative Care, Hospice, and Geriatrics

•Geriatric Medicine •Primary Care MD followup visit •Outpatient Palliative Care Outpatient •Rehab Ambulatory

Emergency Department •Comprehensive NECTAR/Initial Assessment •Case discussion on ED rounds •Assess observation admit status for readmitted patients •Focus on home first • Focus on geriatric population on Care Without Delay rounds •Palliative and hospice care referrals •Interventions: 5 M’s and Silver Angels volunteers

Future Applications • • • •

Initiate 65 & Thrive Program to other nursing units and KP hospitals in the Southern California region Develop Geriatric Support Groups Partnership with Pharmacy Annual Hospital Geriatrics Day for awareness

•

Piloted on the stroke telemetry unit with a focus on 5 M’s interventions by 65 & Thrive team and SA volunteers Hospital Geriatric Day created hospitalwide awareness regarding 5 M’s

•

• •

2019 vs. 2020 Data Comparisons ALOS: Increased from 4.05 days to 4.83 Readmissions: Decreased from 23.6% to 20.5% Recognized by the Institute of Healthcare Improvement (IHI) as a Level 1 Age-Friendly Hospital, in process for Level 2

•

Barriers

•

COVID-19 pandemic leading to limited staff & higher acuity patients on floors Initiative on hold during surge Online training vs. in-person Workflows not finalized Receiving timely data updates Incomplete trackers & surveys Restricted visitation access by families/caregivers due to pandemic

• • • • • •

References 1.

Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. Am J Geriatr Psychiatry. 2018 Oct;26(10):1015-1033. doi: 10.1016/j.jagp.2018.06.007. Epub 2018 Jun 26. PMID: 30076080; PMCID: PMC6362826. Kuo Y-L, Chen I-J (2019). Facilitating a Change Model in Age-Friendly Hospital Certification: Strategies and Effects. PLoS ONE 14(4): e0213496. https://doi.org/10.1371/journal.pone.0213496 Lundy, J., Hayden, D., Pyland, S., Berg‐Weger, M., Malmstrom, T. K., & Morley, J. E. (2020). An Age‐Friendly Health System. Journal of the American Geriatrics Society. https://doi.org/10.1111/jgs.16959 Palmer R. M. (2018). The Acute Care for Elders Unit Model of Care. Geriatrics (Basel, Switzerland), 3(3), 59. https://doi.org/10.3390/geriatrics3030059 US Census Bureau. (2017, May 30). An Aging Nation: The Older Population in the United States. The United States Census Bureau. https://www.census.gov/library/publications/2014/demo/p251140.html

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The Necessity for Care Management Services for Children with Complex Needs Andrea Myer, LMSW, CASAC Material and Methods

Abstract Care Management for patients with complex medical and/or mental health needs and social determinants of health is a challenge. Patients need assistance to overcome barriers to care, and health home care management is a way to achieve that. The Golisano Children’s Hospital has implemented their health home care management program to work together with primary care and specialists to establish work flows, referral management, barrier resolution, and outcome tracking.

• • • • • • • • •

Objectives

• Reduce hospital admission rates • Reduce hospital length of stay and admission cost • Close in Gaps In Care • Reduce the workload for social work and other healthcare staff • Increase of preventative care and specialty appointment visits

•

Conclusions

Provide care coordination and planning that is family-and-youth driven, and supports a system of care that builds upon the strengths of the child and family/caregiver. Ensure care managers are trained in working with families and children with unique, complex health needs. Ensure continuity of care and comprehensive transitional care from service to service and across and within systems (education, foster care, juvenile justice, child to adult). Track clinical and functional outcomes using proprietary developed standardized tools that are created to validate for the screening and assessment of children. Adopt child-specific and nationally recognized measures to monitor quality and outcomes. Ensure smooth transition from current care management programs Methods used: face to face visits, telephonic communication, email, text messages, letters Care Managers meet with children and families at their medical appointments, provide them transportation to and from appointments, deliver their medications, food, clothing etc. Families prefer to visit with their care manager face to face within their home. Families find the convenience of having someone come out to them as being a barrier that can be overcome with this program. Children are been able to attend more ADHD, Asthma, behavioral health, medication and other follow up appointments due to the work of the care managers.

Outcomes

• A review of 12 leading studies in 2016 estimated that better care coordination and the utilization of care management services for children with complex medical needs could reduce utilization of inpatient and ED visits by 20%-40% • In 2011 a study showed that by implementing a comprehensive care team, with a care manager the facility was able to show: • Reduced costs of hospital stays by 29% and shortened stays by 2.9 days • Savings of $14148, per patient per year for Medicaid • Increase in preventative care appointments and medication costs (which then made for savings in other areas) • Golisano Children’s Hospital entered into a study with our largest payer to study care coordination models for medically complex children. Between 1984 and 1995 • Findings included decrease length of stay in hospital, adjusted inpatient charges decreased, overall inpatient savings 500

450

Referrals Per Year

400

350

300

Total Referred

Accepted

Antonelli, R. C., & Antonelli, D. M. (2004). Providing a Medical Home: The Cost of Care Coordination Services in a Community -Based, General Pediatric Practice. Pediatrics, 113(5), 1522-1528. Gupta, V. B., O'Connor, K. G., & Quezada-Gomez, C. (2004, May). Care Coordination Services in Pediatric Practices. Pediatrics, 113(5), 1517-1521. Hamblin, A., Davis, R., & Hunt, K. (2014). Outreach to High-Need, High-Cost Individuals: Best Practices for New York Health Homes. NYS Health Foundation. Liptak, G., Burns, C. M., Davidson, P. W., & McAnarney, E. R. (1998, October). Effects of Providing Comprehensive Ambulatory Services to Children with Chronic Conditions. Archives of Pediatric Adolescent Medicine, 152, 1003-1008. National Committee for Quality Assurance. (n.d.). Patient-Centered Medical Home (PCMH) Recognition. Retrieved from NCQA: http://www.ncqa.org/programs/recognition/practices/patient-centeredmedical-home-pcmh Sia, C., Tonniges, T. F., Osterhus, E., & Taba, S. (2004, May). History of the Medical Home Concept. Pediatrics, 113(5), 1473-1484. Starfield, B., & Shi, L. (2004, May). The Medical Home, Access to Care, and Insurance: A Review of Evidence. Pediatrics, 113(5), 14931498. 2013 NYS Data Children Potentially Eligible for Health Home by Health Home Population NYS Medicaid Fact Sheet http://files.kff.org/attachment/fact-sheetmedicaid-state-NY

Andrea Myer, LMSW, CASAC Golisano Children’s Hospital Christine M. Burns CARES Center 601 Elmwood Ave. Rochester, NY 14618 Phone: (585) 472-3742 Fax: (585) 341-9430

-- Successful Discharges

200

150

100

2016-2017

References

Contact

250

The number of children with complex medical needs in the United States is expected to double in the next decade

• In 1978, the Presidents of American Academy of Pediatrics were asked to create a child health plan for their respective chapters. In North Carolina, the proposed plan which was the beginnings of a medical home (similar to that of the Children’s Health Home Program), was shot down by state legislators, citing “concern that pediatricians were taking over too much of the parent’s responsibility”. • The idea of Care Management Services has been developing for over 40 years. • New York State has developed a program to meet the needs of children and families, providers, insurance companies, hospitals and other service agencies. Parents can be overwhelmed with their child’s needs and having this type of support allows for them to be able to meet their child’s needs and to be successful in all aspects of their lives.

2017-2018

2018-2019

2019-2020

Successful Respiratory Therapist Driven Team Approach to Reducing COPD Readmissions Thomas Rhodes, MHA, RRT, Director Respiratory Care Alma Villanueva, MSN, RN, Director Case Management

Volunteer Program Key Components

Background • Chronic obstructive pulmonary disease (COPD) is the third leading cause of 30-day readmissions that affects over 12 million adults in the United States and accounts for over $15 billion annually in healthcare costs (Press, Konetzka, & White, 2018).

• In 2016 our Readmission Reduction Committee identified a higher than the national average readmission rate for our COPD patients of 23.4%. • A collaborative multidisciplinary workgroup was formed and discovered opportunities to decrease readmissions by accurately diagnosing COPD patients in the ED, developing more standardized COPD treatment protocols and educational tools. In addition, discharge processes were enhanced by utilizing community volunteers to assist with scheduling follow-up appointments and the in-house respiratory therapists make wellness calls to the discharged patients.

2017 COPD Readmission (Vizient Data)

• Of 210 total volunteers at our hospital, five were chosen for the COPD program. They were trained in aspects of service quality and were given specific scripting regarding how to assist patients with scheduling their outpatient follow up visits. • Volunteers utilized a daily work list of admitted and observation COPD patients identified by the Lead Respiratory Therapist and generated through the electronic health record. • A volunteer visited each COPD patient to offer assistance with making follow up appointments with Pulmonology and/or Primary Care. • The volunteer made the appointment call from the patient’s room in order to include the patient in the process. The patient/caregiver was physically present to be part of the dialogue with the physician’s office. All necessary appointments were made. • Patients were assisted in obtaining follow up appointments with both affiliated and non-affiliated Pulmonologists and Primary Care Physicians.

Goals

Results: Volunteer Assisting with Follow-Up Appts

• Improve clinical outcomes and quality of life for our COPD population while reducing overall costs.

Outcomes: Patients Educated by the Respiratory Therapist

2018 COPD Readmission (Vizient Data)

• Meet the Vizient top quartile for COPD readmission rate for complex teaching • Form a comprehensive multidisciplinary team approach to address COPD readmissions • Create a sustainable COPD program

Methods Lessons Learned

• • • •

Biweekly COPD Workgroup meetings Implemented ED process map Implemented COPD clinical pathway Created dedicated respiratory therapists to educate COPD patients utilizing an educational booklet. • Partnered with community volunteers to assist with scheduling follow-up appointments • Integrated respiratory therapists to perform follow up phone calls to assess the transition of care after discharge from the hospital.

Special Acknowledgments • • • • • • • • • •

Dr. Maturza Ahmed, Pulmonologist Dr. Ming Wang, Emergency Physician Laurie Dupre, RRT, CPFT Maisee Thao, RRT, NPS Christina Ramirez, RRT, RCP, Maribel De Jesus RRT, NPS Debra Welch, RN, Case Management Department Tere Jackson, Manager, Volunteer Services Volunteers: Linley Wilkins and Fred Quell Case Management and Nursing Staff

Process for Assisting COPD Patients with Follow-up COPD Follow-up Appointment Process Map Lead Respirat ory Therapist emails HMW CO PD distr ibut ion list members a list of all COPD patients on the COPD Clinical Pathway. This includes OBS and Inpatients with active hospital problem list diagnosis of CO PD (exclude ICU pts)

Volunteer offers to provide pt with list of pulmonologists and offers to ass ist the pt to make a f/u appointment.

Volunteer Dept Secretary prints list of identified pts for volunteer

Volunt eer int roduces se lf to the charge nur se as t he COPD Follow Up Appointment Volunt eer. If CN not available call CM or SW

COPD patient discharging to HOME within 1 - 2 Days? No appt will be made for pts on hospice or considering hospice, or if discharging to SNF, LTAC or Rehab.

Follow up later by checking the anticipated discharge date in Epic

Volunteer asks the patient if they have a pulmonologist.

Does patient have a Pulmonology Consult?

Yes

Refer to the Networ k of Car e Pr ogram via the Social Worker

Yes

If patient continues to decline, communicate to charge nurse to manage up the program

R.T. visit s pt w/ or s/ volunteer to educate about follow up care. If pt agrees t o app, RT will notify vol at Ext 29554.

If patient declines volunteer contacts Lead Respiratory Ther apist at Ext. 29660

Patient agrees to volunteer help: Yes

After 1 week, the volunte er will call the clinic to see if the patient attended their appointment. Recor d on spre adsheet.

Yes

Complete pink appointment reminder page. Make 4 copies. Provide 1 copy to the patient and place 1 copy in the patients chart in fr ont of the Rx form, 1 copy to discharge nurse (or if unavailable to charge nurse or patient s nurse) and1 copy to volunteer clipboard. Ask Pt if they would like their appt info emailed to them or help them add the appointment to their cellphone calendar app

From the patient s r oom: Offer assistance to pt to help call MD s office with Cisco phone. Verify that pt has been seen by this M D in the past. If they have, assist pt with making an appt. for with in 3-5 days after discharge. If they have not been seen by this pulmonologist, confirm that they c an accept a new patient.

Has insurance?

Yes

Go to the patient s room: Offer to assist the pt in making a follow up appointment. Confir m with the pt which pulmonologist they usually see. If they would like to continue with the consulted pulmonologist instead, offer to assist with making an appointment.

Verify which d ates and times they can attend appointment. Rev. Date: 4/30/2019 V7 Orig. Date: 2/28/17 Target Rev: 2/28/20 Owner: CO PD Vol/ CM

• This Respiratory Therapist lead initiative to reduce readmissions for COPD patients was very successful and sustainable because of the close relationship formed with the patient and caregivers throughout their treatment and education during the hospital stay and the transition home. • A pulmonologist physician champion contributed expertise and buy in from medical staff, nursing and administration. • A critical component of the initiative is the direct involvement of a community volunteer with the patient or family member during appointment creation and the volunteers’ modeling of appropriate self-advocacy skills. • Phone calls made by the respiratory therapists to the discharged patients/caregivers reinforced education, addressed concerns, verified appropriate follow up care and helped to prevent unnecessary return visits to the hospital. • Multidisciplinary COPD Workgroup collaboration was essential to the reduction of readmission rates from 23.4% to 10.6% in just 2 years.

COPD Workgroup

Centralized Case Management (CCMx): A Focused Approach to Improve Care Transitions Within Skilled Nursing Facilities Karine Shnorhokian, MSN, RN & Carol Kulkens, MHA, MSW, LCSW, ACM-SW

www.PosterPresentations.com

Implementation of Risk Model-Related Interventions to Reduce Inpatient Oncology Readmissions Jennifer Bruno BSN, RN, ACM-RN, Angela Wolf-Erdlitz BS, RN, MGS Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at The Ohio State University Wexner Medical Center

Background • Reducing 30 day unplanned hospital readmissions is a national policy priority 3 • A goal of the Centers for Medicare and Medicaid Services is to reduce unplanned hospital readmissions by 20% through programs that improve care transitions 3 • Preventing avoidable readmissions can improve a patient’s quality of life and the financial wellbeing of health care systems 2 • Patients with localized and metastatic cancers are at increased risk for readmission 1 • One third of oncology hospitalizations may be potentially avoidable 4 • Patient readmission risk screening tools are available, however, none are specific for oncology patients 2, 4 • Cancer readmission studies in the United States are needed to ascertain the extent of this population’s risk for readmission 5

Purpose • Reducing readmissions is a James Cancer Hospital goal • Case managers collected reasons for readmission and data was used to identify specific elements that placed oncology patients at risk • An internal cancer readmission risk model was developed using 2 years of data • The statistical algorithmic model was embedded in the EMR predicting a patient’s readmission risk • The readmission risk score is intended to guide the discharge planning process • A multidisciplinary process improvement work group was formed to standardize risk related interventions • Evidence-based interventions applied to 4 levels of readmission risk

Risk Interventions Medical Oncology Services: Readmission Risk Score Interventions

Methods • Readmission data for Medical Oncology population was reviewed from April 2018-June 2018

• Utilizing evidence-based discharge planning interventions can prevent readmissions

• Education to multi-disciplinary team members provided

• A multi-disciplinary team approach is critical to success of readmission reduction

• Interventions for each level implemented in July 2018

• Case managers play a pivotal role in engaging team members in initiatives to reduce readmissions and improve patient outcomes

• Readmission data analyzed following intervention period September 2018 High Risk Moderate Risk Minimal Risk

+ Referral to

Ambulatory PCRM/Primary Nurse/Social Work

+ Discharge

patient per normal policies and discharge standard of practice + Consider ambulatory referral to social work + Consider referral to Ambulatory PCRM/Primary Nurse/Social Work + Post discharge call within 48 hours*

+ Post discharge call within 48 hours*

Referral to Ambulatory PCRM/Primary Nurse/ Social Work

+ Post discharge call within 48 hours*

+ RN to complete discharge teaching with patient and family using teach back methodology

+ Pharmacy to detailed medication reconciliation

+ Partner with payer case managers regarding discharge plan

+ Post dc appointment within 3 days

Unplanned Readmission Rate by Month

+ Bedside multi-disciplinary discharge rounds (PCRM, SW, APP, RN, and physician) when available

+ Ensure patient-specific ambulatory consults, as needed (i.e.- infectious disease, dietitian)

+ Ensure patient-specific ambulatory consults, as needed (i.e.- infectious disease, dietitian) plan

+ If inpatient consulting teams are involved, communicate with them on day of discharge and document final recommendations

+ If inpatient consulting teams are involved, communicate with them on day of discharge and document final recommendations + RN to complete discharge teaching with patient and family using teach back methodology

• Interventions can be utilized using any model

References 1-Shapiro, J. S., Humeniuk, M. S., Siddiqui, M. A., Bonthu, N. R., Schroeder, D. T., & Kashiwagi, D. undefined. (2017). Risk Factors for Readmission in Patients With Cancer Comanaged by Hospitalists. American Journal of Medical Quality, 32(5), 526–531. doi: 10.1177/1062860616665904

+ Consider additional post-acute services (i.e.- home health, SNF.) Ensure strong handoff and follow up to postacute care provider

+ Bedside multi-disciplinary discharge rounds (PCRM, SW, APP, RN, and physician) when available

• A service-line cancer specific readmission risk model takes substantial IT support and maintenance • Other models are available for use

Timeframe: February 2018 – February 2019 + Post discharge call within 48 hours*

+ RN to complete discharge teaching with patient and family using teach back methodology

Results

PCRM/Primary Nurse/ Social Work

+ Post dc appointment within 7 days

+ Consider addl. post-acute services + Consider additional (i.e.- home health, post-acute services SNF.) Ensure (i.e.- home health, SNF.) strong handoff and Ensure strong handoff follow and follow up to postup to post-acute acute care provider care provider + Ensure patientspecific ambulatory consults, as needed (i.e.infectious disease, dietitian)

Highest Risk + Referral to Ambulatory

Implications

2-Alper, E., O'Malley, T. A., & Greenwald, J. (2020, January 14). Hospital discharge and readmission. Retrieved February 24, 2020, from https://www.uptodate.com/contents/hospitaldischarge-and-readmission

Outcomes • 5.7% readmission reduction after 3 month pilot intervention period in September 2018 • Use of interventions continued following the pilot • Data re-analyzed in February 2019 showed a continued downtrend • 23.4% readmission reduction from February 2018 to February 2019 • Readmission risk interventions initiated hospital wide in August 2019

3-Montero, A. J., Stevenson, J., Guthrie, A. E., Best, C., Goodman, L. M., Shrotriya, S., … Khorana, A. A. (2016). Reducing Unplanned Medical Oncology Readmissions by Improving Outpatient Care Transitions: A Process Improvement Project at the Cleveland Clinic. Journal of Oncology Practice, 12(5). doi: 10.1200/jop.2015.007880 4-Johnson, P. C., Xiao, Y., Wong, R. L., Darpino, S., Moran, S. M., Lage, D. E., … Nipp, R. D. (2019). Potentially Avoidable Hospital Readmissions in Patients With Advanced Cancer. Journal of Oncology Practice, 15(5). doi: 10.1200/jop.18.00595 5-Bell, J. F., Whitney, R. L., Reed, S. C., Poghosyan, H., Lash, R. S., Kim, K. K., ... & Joseph, J. G. (2017, March). Systematic Review of Hospital Readmissions Among Patients With Cancer in the United States. In Oncology nursing forum (Vol. 44, No. 2).

Case Management Work in Preventing

UNNECESSARY READMISSIONS from the Emergency Department Amy A. Gustafson, MSW ACM & Murolyn Schmidt, RN BSN ACM Bon Secours Health System, St. Mary’s Hospital Case Management Team ABSTRACT TITLE: Preventing Unnecessary Readmissions in the Emergency Department by the Case Manager BACKGROUND: St. Mary’s Hospital (SMH) is a suburban acute care facility. The 36 bed Adult ED treats approximately 200 patients daily. Nationally, 50 % of Medicare hospital discharges return to the ED within 30 days. We aim to provide care in the least restrictive care setting to control costs while improving patient outcomes.

METHODS: Case Managers (CM) utilize tools to identify and evaluate potential readmissions in real time during emergency department visits. Tools include EMR indicators of patients returning within 30 days of discharge and EDIE notifications for State of Virginia communication across healthcare systems.

RECOGNIZE • Readmissions EARLY during Emergency Room Visit • Tracking Board Icons/EDIE Notifications • Importance of communication/handoff from SNF, Acute Rehab, Home Health, MD/Specialty office, and Nurse Navigators • Importance of ongoing communication during ED encounter with Triage Staff, RN, and ED provider • Review previous discharge plan, recognize opportunities

EDUCATE • Talk with patient and family, education of available resources • Discuss alternatives to admission and give examples • Involve MD and discuss clinical capabilities of SNF and Inpatient Rehab • Discuss opportunities and challenges, strength based approach • Engage ED staff to alert CM staff with updates and involve them in plan

ASSESS/ADVANCE CARE PLAN/ADVOCATE • Thorough assessment of patient, family, social situation, and needs in the home (Review previous notes) • Identify resources (Financial, Support system, Living arrangements, and complexity of comorbidities) • Hospice? Palliative? Advance Care Planning – DNR? HUG? • Patient’s needs and preferences , ADVOCATE • Ask hard questions

DOCTORS/Discussions/Develop Plan RESULTS:

OBJECTIVES:

This focused effort began in summer 2017. At the time, St. Mary’s readmission rate was 9.68%; currently it is 9.15%. As a result of this success, SMH ED team trained 2 other ED teams within the Bon Secours system in the above to expand results in the Richmond market. This included standardized CM processes and expanded Point of Entry (POE) Care Management hours.

• Identify and involve ALL readmissions to ED Providers • Discuss medical workup/medical needs, and plan of care • Discuss options for Discharge with additional services, higher level of care – Medical Stability? Involve patient in discussion • Senior Services – NP/SW/PT/NN (Specialize in Geriatrics)

MANAGING, MONITOR, AND MEDICATIONS • Managing care safely in a lower level of care – GOAL • Did meds get filled? Barriers? Pharmacy Med Reconciliation? • Follow up with Dispatch Health, Home Based Primary Care, timely TOC, appointment with PCP • Transportation barriers and resources • Managing symptoms from home that brought patient to ED • Mental Health Component and are we addressing?

INTERVENTIONS/IMPLEMENTATION

CM’s reduce number of medically unnecessary readmissions to SMH by: interviewing patient and family; conducting interdisciplinary planning; communicating with Home Health or SNF providers regarding care; re-evaluating previously established discharge plans for safety and effectiveness in current situation

• Can patient be discharged with additional services – Home health, Dispatch Health, Personal Care/Private Duty, Hospice? • Can patient be discharged to SNF? Acute inpatient rehab? Acute hospital - many services CAN be performed in this setting • Respite Care? Caregiver Fatigue? Discuss all alternatives • Assisted Living Facility, Memory Care Unit? ALF with private duty? Independent Living/ALF – Health Care Unit options?

TRANSITIONS OF CARE

CONCLUSIONS:

Dedicated POE Case Management is an effective driver of reducing unnecessary hospital admissions and providing patients cost effective care in the safest & least restrictive environment

• Verbal handoffs to PCP, SNF, NN, Acute Inpatient, and HH • Schedule Dispatch Health follow up for next day • Give CM/NN contact information to family/patient, update AVS • Palliative Consults/Home Based Primary Care options • Telephonic Follow up with Patients • Develop relationships with SNF/Inpatient Rehab/HH/Personal Care Agencies **Preferred Providers** • Community Resources – Senior Connections, Meals on Wheels, Alzheimer Association, and DSS • Accountability

SUCCESS - Systemic Review of processes • RN/SW collaboration with MD/Hospitalist during ED visit • Push back, ask questions, advocate for patient • Culture change can be hard and work needs to be consistent • Share successful avoided readmissions with all staff and engage staff to openly discuss opportunities for improvement

Meds to Beds Collaboration Between Outpatient Pharmacy and Inpatient Case Management to Improve Discharge Safety and Satisfaction

UVMHealth.org/MedCenter

Douglas Franzoni PharmD, BCGP, RPh

Jennifer Hauptman, MSW, LICSW, ACM-SW, CCTP

Meds to Beds Place in Healthcare

Meds to Beds is a hospital- based initiative to enhance the patient satisfaction around the discharge process, to improve efficiency and collaborative nature of care transitions, and to create a culture of safety around discharge medications.

Barriers to a Safe Discharge

• Historically, at the time of discharge less than 50% of patients are able to state what medications they are to be taking once back in the community setting, and that percentage drops with any newly added medication during the hospital stay. [1]

• Once discharged, less than 50% of the population will take their medication as-prescribed.

• Commonly associated factors for medication non-adherence are poor health literacy, lack of involvement in the treatment decision process and patient understating of the medications role and benefit in therapy. [2]

• Fiscal burden of a therapeutic regimen has been noted to be a significant barrier to patient adherence and thus success of a medication regimen. [3]

• Translation of inpatient orders to outpatient pharmacies and what is available commercially and covered by the PBM

Who can Break Down the Barriers?

• Pharmacists and Case Managers specialize in translating the therapeutic plan into the reality of day-to-day life of the patient.

• Not only can they help to develop a plan that helps the patient to understand the medication and why they are taking it, but how it will fit into their home life, and can identify any financial barriers to the medication.

The 3 Cornerstones of the Program

Data and Discussion

1. Thorough DUR of the Discharging medication regimen.

2. Patient education at the time of discharge [4]

3. Identifying and decreasing any financial barriers by utilizing UVMMC’s Health Assistance Program, submitting for prior authorizations proactively ahead of discharge, referring patient to pharmaceutical copay assistance programs, or as a last resort when absolutely necessary, utilizing case management funds on a one-time basis in order to allow patients to discharge with the new medications until other long term solutions have been identified.

Below is the graph depicting the 41 day study period where interventions were closely documented by the pharmacy team and were depicted as a percentage of interventions per number of patients discharged on any given day.

• The percentage of interventions per patient averaged 19%. Intervention rates decreased over the time of the study period, inversely proportional to the number of patients served. This could possibly be attributed to an increased awareness by pharmacists and case managers of common barriers, and increased communication.

Methods

The following are the most common interventions that were identified in the process of the study data collection period and appear in no particular order:

1. Therapy change recommended due to PBM formulary 2. Necessary Rx not ordered 3. Incorrect Directions on Rx

4. Incorrect supply of medication ordered

5. Duplication of therapy

• Program was rolled out progressively beginning in October 2019.

• Data was initially tracking number of Rxs and by what means they were paid for (case management dept vs health assistance program)

• Once workflow had been adapted to the specific unit, we dove into evaluating and identifying interventions that the pharmacy and case management department were making and the rationale behind them.

• A specific time period was identified prospectively from the end of April 2020 through mid-June 2020.

• Interventions were broken down into predefined categories that specified the intervention.

• Interventions were documented only if they were deemed clinically significant (defined by if the intervention would have prevented a negative outcome for the patient).

Conclusion

• Of the 1004 patients served, 19% of patients required some type of intervention from the pharmacy department or case management.

• It is important to note that if these prescriptions had been sent to a community pharmacy, they quite likely would not have had the resources to rectify the issue leading to a likely negative outcome for our patients, including, but not limited to, a costly readmission.

• 12% of all prescriptions required intervention from case management to help with either covering some or all of the cost of a medication for a patient due to a pending prior authorization or personal financial complication, thus ensuring no delay at time of discharge, and reducing the risk associated with a prolonged/unnecessary hospital stay.

Development and Focus of the Program

• Case Manager is responsible for identifying a patient that qualifies for the program during the initial assessment.

• Any patient that is to discharge home will qualify for the program regardless of the medication regimen to be initiated or the diagnosis for admission.

• The outpatient pharmacy will then follow the patient over the course of their admission through discharge.

• Pharmacy will then perform a thorough drug utilization review, evaluating therapeutic efficacy and its appropriateness for the patient.

• The pharmacy team will also coordinate with the case manager on the financial component of discharge. The goal is to identify any barriers the patient may have with obtaining the medication once out in the community.

Above is the graph depicting the 12 month period and the corresponding number of deliveries, prescriptions filled, and number of Rxs paid for by the case management department or the Health Assistance Program.

References:

1. Freyer J, Greißing C, Buchal P, Kabitz HJ, Kasprick L, Schuchmann M, Sultzer R, Schiek S, Bertsche T. Entlassungsmedikation - Was weiß der Patient bei Entlassung über seine Arzneimittel? [Discharge medication - what do patients know about their medication on discharge?]. Dtsch Med Wochenschr. 2016 Jul;141(15):e150-6. German. doi: 10.1055/ s-0042-108618. Epub 2016 Jul 27. PMID: 27464288.

2. Brown MT, Bussell JK. Medication adherence: WHO cares?. Mayo Clin Proc. 2011;86(4):304-314. Doe:10.4065/Jia-Rong Wu, Debra K. Moser, Misook L. Chung, Terry A. Lennie,

3. Predictors of Medication Adherence Using a Multidimensional Adherence Model in Patients With Heart Failure, Journal of Cardiac Failure, Volume 14, Issue 7, 2008, Pages 603-614, ISSN 1071-9164,

4. Sander D. Borgsteede, Fatma Karapinar-Çarkit, Emmy Hoffmann, Jan Zoer, Patricia M.L.A. van den Bemt, Information needs about medication according to patients discharged from a general hospital, Patient Education and Counseling, Volume 83, Issue 1, 2011, Pages 22-28, ISSN 0738-3991,

June, 2021

MEDS TO BEDS

Collaboration Between Outpatient Pharmacy and Inpatient Case Management to Improve Discharge Safety and Satisfaction

Authors:

Douglas Franzoni PharmD, BCGP, RPh

Jennifer Hauptman MSW, LICSW, ACM-SW, CCTP

About UVMMC

The University of Vermont Medical Center is a 499-bed tertiary care regional referral center providing advanced care to approximately 1 million residents in Vermont and northern New York. Together with our partners at the Larner College of Medicine at the University of Vermont and the College of Nursing and Health Sciences, we are Vermont’s academic medical center. The University of Vermont Medical Center also serves as a community hospital for approximately 150,000 residents in Chittenden and Grand Isle counties.

The Meds to Beds program is a hospital wide initiative that was implemented in October of 2019 on our HematologyOncology unit and has since been initiated on 7 different services at UVMMC.

Rational for Development

Adaptation of a Meds to Beds program has become commonplace at academic medical institutions around the country, given the growing importance of a patient’s understanding of their discharge medication regimen. Historically, at the time of discharge less than 50% of patients are able to state what medications they are to be taking once back in the community setting, and that percentage drops with any newly added medication during the hospital stay. [1] Once discharged, less than 50% of the population will take their medication as-prescribed. Herein lies the role of a pharmacist; a PharmD can help supplement discharge teaching with additional bedside education at the point of discharge. Pharmacists and Case Managers specialize in translating the therapeutic plan into the reality of day-to-day life of the patient. Not only can they help to develop a plan that helps the patient to understand the medication and why they are taking it, but how it will fit into their home life and can help identify any financial barriers to the medication.

Operational Workflow

The Case Manager is the spearhead of the program and is responsible for identifying a patient that qualifies for the program during their initial assessment. Any patient that is to discharge home will qualify for the program regardless of the medication regimen to be initiated or the diagnosis for admission. The outpatient pharmacy will then follow the patient over the course of their admission until the day of discharge, which is when the medications will be sent to the outpatient pharmacy by the discharging team. The pharmacy will then perform a thorough drug utilization review, evaluating therapeutic efficacy and its appropriateness for the patient. The pharmacy team will also coordinate with the case manager on the financial component of discharge; the goal is to identify any barriers the patient may have with obtaining the medication once out in the community. This process has been our focus for the last 12 months. Fiscal burden of a therapeutic regimen has been noted to be a significant barrier to patient adherence and thus success of a medication regimen. [3]

June, 2021

Evaluation fo Efficacy

Thus, the focus of the program has culminated to rely on 3 cornerstones:

Once the program was initiated on all floors and the operations workflow had been adapted to the specific unit, we dove into evaluating and identifying interventions that the pharmacy and case management department were making and the rationale behind them. A specific time period was identified prospectively from the end of April 2020 through mid-June 2020, and we tracked the interventions using the “safe system”. We broke down the interventions into predefined categories that specified the intervention, and interventions were documented only if they were deemed clinically significant (defined by if the intervention would have prevented a negative outcome for the patient). The interventions were tracked Monday through Friday.

1. Thorough DUR of the discharging medication regimen 2. Patient education at the time of discharge [4] 3. Identifying and decreasing any financial barriers by utilizing UVMMC’s Health Assistance

Results

The Below is the graph depicting the 41 day study period where interventions were closely documented by the pharmacy team and were depicted as a percentage of interventions per number of patients discharged on any given day. As you can see the percentage of interventions per patient averaged 19%. Intervention rates decreased over the time of the study period, inversely proportional to the number of patients served. This could possibly be attributed to an increased awareness by pharmacists and case managers of common barriers, and increased communication with the medical teams.

References

1. Freyer J, Greißing C, Buchal P, Kabitz HJ, Kasprick L, Schuchmann M, Sultzer R, Schiek S, Bertsche T. Entlassungsmedikation - Was weiß der Patient bei Entlassung über seine Arzneimittel? [Discharge medication what do patients know about their medication on discharge?]. Dtsch Med Wochenschr. 2016 Jul;141(15):e150-6. German. doi: 10.1055/s-0042-108618. Epub 2016 Jul 27. PMID: 27464288.

2. Brown MT, Bussell JK. Medication adherence: WHO cares?. Mayo Clin Proc. 2011;86(4):304-314. Doe:10.4065/ Jia-Rong Wu, Debra K. Moser, Misook L. Chung, Terry A. Lennie,

3. Predictors of Medication Adherence Using a Multidimensional Adherence Model in Patients With Heart Failure, Journal of Cardiac Failure, Volume 14, Issue 7, 2008, Pages 603-614, ISSN 1071-9164,

The following are the most common interventions that were identified in the process of the study data collection period and appear in no particular order:

1. Therapy change recommended due to PBM formulary 2. Necessary Rx not ordered 3. Incorrect Directions on Rx 4. Incorrect supply of medication ordered 5. Duplication of therapy

Conclusion: Data collection is in its infancy, but has been able to show that of the 1004 patients served, 19% of patients required some type of intervention from the pharmacy department or case management. It is important to note that if these prescriptions had been sent to a community pharmacy, they quite likely would not have had the resources to rectify the issue leading to a likely negative outcome for our patients, including, but not limited to, a costly readmission.