Improving the Transition from Tertiary Care Hospitals into Various Post Acute Environments Gerda Maissel, MD Medical Director, PAC Susana Hall, RN, BSN,

Improving the TransitionImproving the Transition from Tertiary Care Hospitals into from Tertiary Care Hospitals into

VariousVarious Post Acute Environments Post Acute Environments

Gerda Maissel, MDGerda Maissel, MDMedical Director, PACMedical Director, PAC

Susana Hall, RN, BSN, MBA, ACMSusana Hall, RN, BSN, MBA, ACMClinical Business Consultant to PACClinical Business Consultant to PAC

Baystate Health, Springfield, MABaystate Health, Springfield, MA

Baystate Medical CenterBaystate Medical Center 33 Flagship of Baystate Health Flagship of Baystate Health

650+ beds 650+ beds Level 1 Trauma / Level 3 Nursery Level 1 Trauma / Level 3 Nursery Tufts Med School Teaching Facility Tufts Med School Teaching Facility 293 residents and fellows293 residents and fellows 37,940 Discharges FY0637,940 Discharges FY06 ED >105,000 per yearED >105,000 per year Solucient Top 100 HospitalSolucient Top 100 Hospital Magnet Hospital - NursingMagnet Hospital - Nursing EMR CIS EMR CIS

ObjectivesObjectives

Literature ReviewLiterature Review Overview of Post Acute Levels Overview of Post Acute Levels

of Careof Care Review of strategies, specific Review of strategies, specific

tactics & datatactics & data Lessons Learned / Next StepsLessons Learned / Next Steps

Literature Review –Literature Review –PAC Transition IssuesPAC Transition Issues

Christopher L. Roy, MD et al., “Patient Safety concerns Arising from Test Christopher L. Roy, MD et al., “Patient Safety concerns Arising from Test Results that Return after Hospital Discharge,”Results that Return after Hospital Discharge,” Ann Intern Med., 2005 Ann Intern Med., 2005

Schoen C et al., “ Taking the Pulse of Health Care Systems: Experiences Schoen C et al., “ Taking the Pulse of Health Care Systems: Experiences of Patients with Heart Problems in Six Countries.”of Patients with Heart Problems in Six Countries.” Commonwealth Fund, Commonwealth Fund, 2006 2006

Naylor MD, McCauley KM, “The effects of discharge planning and home Naylor MD, McCauley KM, “The effects of discharge planning and home follow-up intervention on elders hospitalized with common medical and follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions,”surgical cardiac conditions,” J Cardiovasc Nurs, 1999. J Cardiovasc Nurs, 1999.

Stewart, S. et al., “Effects of home-based intervention on unplanned Stewart, S. et al., “Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths,”readmissions and out-of-hospital deaths,” J Am Geriartr Soc. 1998 J Am Geriartr Soc. 1998

Myer JS, et al., Are Discharge summaries teachable? The effects of a Myer JS, et al., Are Discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program,”in an internal medicine residency program,” Acad Med., 2006 Acad Med., 2006

O’Leary,KJ, et al., “Outpatient physicians’ satisfaction with discharge O’Leary,KJ, et al., “Outpatient physicians’ satisfaction with discharge summaries and perceived need for an electronic discharge summarysummaries and perceived need for an electronic discharge summary

Literature Review –Literature Review –PAC Transition IssuesPAC Transition Issues

Kripalani S., et al., “Deficits in communication and information transfer Kripalani S., et al., “Deficits in communication and information transfer between hospital-based and primary care physicians: “Implications between hospital-based and primary care physicians: “Implications for patient safety and continuity of care,”for patient safety and continuity of care,” JAMA 2007 JAMA 2007

Foster DS, et al., Evaluation of immediate discharge documents – room Foster DS, et al., Evaluation of immediate discharge documents – room for improvement,”for improvement,” Scott Med J, 2002 Scott Med J, 2002

Moore C., et al., Tying up Loose ends; discharging patients with Moore C., et al., Tying up Loose ends; discharging patients with unresolved medical issues,”unresolved medical issues,” Arch Intern Med, 2007. Arch Intern Med, 2007.

van Walraven C, Rokosh E, “What is necessary for a high-quality van Walraven C, Rokosh E, “What is necessary for a high-quality discharge summary’”discharge summary’” Am J Med Qual, 1999 Am J Med Qual, 1999

O’Leary, KJ, et al., “Outpatient physicians’ satisfaction with discharge O’Leary, KJ, et al., “Outpatient physicians’ satisfaction with discharge summaries and perceived need for electronic discharge summaries and perceived need for electronic discharge summaries,”summaries,” J Hosp Med, 2006 J Hosp Med, 2006

Williams, Mark, “Hospital Patient Safe-D(ischarge): Discharge bundle Williams, Mark, “Hospital Patient Safe-D(ischarge): Discharge bundle for,”for,” Emory University, 2005 Emory University, 2005

Post Acute Care Levels of Care Post Acute Care Levels of Care ABC’sABC’s

In-patient settingsIn-patient settings:: LTAC:LTAC: Long Term Acute Long Term Acute

CareCare IRF :IRF : Inpt Rehabilitation Inpt Rehabilitation

FacilityFacility Sub- AcuteSub- Acute or Short or Short

Term or TCU Term or TCU SNF:SNF: Skilled Nursing Skilled Nursing

FacilityFacility LTC: LTC: Long Term Care Long Term Care

Home SettingHome Setting:: VNA:VNA: Visiting Nurse Visiting Nurse

AssociationAssociation Medical House CallsMedical House Calls Palliative CarePalliative Care HospiceHospice

Initial PAC Strategy Initial PAC Strategy

1996 started with belief:1996 started with belief:

BMC had a responsibility to BMC had a responsibility to ensure our patients had the ensure our patients had the highest quality of PAC that highest quality of PAC that would provide the optimal would provide the optimal potential for return to prior potential for return to prior functional status.functional status.

Post Acute Strategies OverviewPost Acute Strategies Overview

Developed key relationships with Developed key relationships with each major type of post acute care each major type of post acute care

• Home Health - 1995Home Health - 1995• Sub Acute - 1996Sub Acute - 1996• LTAC - 2004LTAC - 2004• IRF - 2007IRF - 2007

Excluded PAC levels that had less Excluded PAC levels that had less impact on the hospitalimpact on the hospital

• Long Term Residential CareLong Term Residential Care• Assisted LivingAssisted Living

Post Acute StrategiesPost Acute Strategies Mutual wins & goal setting Mutual wins & goal setting Collaborate, don’t ownCollaborate, don’t own

• Collegial partnershipsCollegial partnerships• Allows each to focus on their core businessAllows each to focus on their core business

Imbed medical leadershipImbed medical leadership• Ability to influence standards of careAbility to influence standards of care• Clinical championsClinical champions

Regular, formal and informal Regular, formal and informal communicationcommunication

Program based approachProgram based approach Pull not push patients to post acutePull not push patients to post acute Not financially basedNot financially based

Post Acute TacticsPost Acute Tactics

Oversight committeesOversight committees SteeringSteering OperationsOperations

Medical leadership positionsMedical leadership positions Selected medical staffingSelected medical staffing Internal and External Internal and External

Education Education PAC PIPAC PI

Key Success FactorsKey Success Factors Shared GoalsShared Goals

Mission and Vision Mission and Vision Involved broad groups of staff, both sides Involved broad groups of staff, both sides

Case managers, physicians, nursing, therapy, Case managers, physicians, nursing, therapy, program mangers, administratorsprogram mangers, administrators

Influential stakeholdersInfluential stakeholders Embraced quality and safety as core driversEmbraced quality and safety as core drivers

Not heads in bedsNot heads in beds TransparencyTransparency

Data sharingData sharing

Similar Cultural ValuesSimilar Cultural Values

Medicare Readmission Analysis Medicare Readmission Analysis Discharges with and w/o PAC Discharges with and w/o PAC

FY06 Medicare PAC - Readmission AnalysisFY06 Medicare PAC - Readmission Analysis

Medicare Discharges Medicare Discharges WITHWITH PAC PAC No. of CasesNo. of Cases % of Medicare Discharges FY06% of Medicare Discharges FY06

FY06 Medicare DischargesFY06 Medicare Discharges 1166111661   

Total Discharged With PAC ServicesTotal Discharged With PAC Services 45344534 38.88%38.88%

Total Readmitted within 15 daysTotal Readmitted within 15 days 520520 11.47%11.47%

Top 20 DRGs Readmits within 15 daysTop 20 DRGs Readmits within 15 days 205205 1.76%1.76%

Medicare Discharges Medicare Discharges WITHOUTWITHOUT PAC PAC No. of CasesNo. of Cases % of Medicare Discharges FY06% of Medicare Discharges FY06

FY06 Medicare Discharges FY06 Medicare Discharges 1166111661   

Total Discharged Without PAC ServicesTotal Discharged Without PAC Services 71277127 61.12%61.12%

Total Readmits w/in 15daysTotal Readmits w/in 15days 10821082 15.18%15.18%

Top 20 DRGs Readmits within 15 days Top 20 DRGs Readmits within 15 days 248248 2.13%2.13%

Post Acute DataPost Acute Data

Discharge patterns from Discharge patterns from Baystate by level of care and or Baystate by level of care and or diagnosisdiagnosis

Bounce back rates from post Bounce back rates from post acute providersacute providers

Key quality & safety initiatives Key quality & safety initiatives both organizationsboth organizations

Post acute program outcomesPost acute program outcomes Key staffing / leadership Key staffing / leadership

changeschanges Readmission ratesReadmission rates

Comparative of Transtions to PAC and PAC Readmission Rates

229 281 268

0

10002000

30004000

50006000

70008000

9000

FY05 FY06 FY07 YTD

Numb

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AC

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

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ases

Re

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Total To PAC PAC Cases Readmitted % of PAC ReAdmitted Linear (Total To PAC)

PAC – Performance Improvement PAC – Performance Improvement Team at Baystate Medical CenterTeam at Baystate Medical Center

Subset of Medical Services Subset of Medical Services Performance Improvement (MSPIT)Performance Improvement (MSPIT)

Multi Organizational Team, various Multi Organizational Team, various backgroundsbackgrounds

Program DirectorsProgram Directors PhysiciansPhysicians Nursing Nursing Therapy Therapy Case ManagementCase Management Risk Management Risk Management (to assist in initial (to assist in initial

development)development)

PAC – PI EvolutionPAC – PI Evolution Blinded shared case discussion Blinded shared case discussion (still on going)(still on going)

Bounce backs, complaints, challenging patient careBounce backs, complaints, challenging patient care Reduced “noise”Reduced “noise” Ideas for operational improvementIdeas for operational improvement

Programs and Services DocumentPrograms and Services Document Education to Baystate AudiencesEducation to Baystate Audiences

Post acute levels of care specificsPost acute levels of care specifics Discharge summary importance and contentDischarge summary importance and content Expectation managementExpectation management

Modification of Baystate’s discharge reportModification of Baystate’s discharge report Formally surveyed post acute providers Formally surveyed post acute providers Used feedback to change hospital process and DC summary organization Used feedback to change hospital process and DC summary organization

and contentand content Developing the “Hand off” of care for pts treatedDeveloping the “Hand off” of care for pts treated and returned from and returned from

the EDthe ED

Electronic PAC Discharge ReportElectronic PAC Discharge Report Key Hand off informationKey Hand off information

Current informationCurrent information Reason for acute admissionReason for acute admission Advanced DirectiveAdvanced Directive AllergiesAllergies Infection Control ConcernsInfection Control Concerns Emergency contactsEmergency contacts Physician and Nursing Discharge SummaryPhysician and Nursing Discharge Summary Scheduled Meds at time of transition w/ time Scheduled Meds at time of transition w/ time

of next doseof next dose

Last 7 daysLast 7 days Discontinued scheduled and PRN Meds w/ Discontinued scheduled and PRN Meds w/

date/time of last dosedate/time of last dose Completed / Discontinued IV InfusionsCompleted / Discontinued IV Infusions

History and PhysicalHistory and PhysicalClinical Summary of last 7 daysClinical Summary of last 7 days

Lab Lab TherapiesTherapies

Vaccines (pneumoncoccal / Vaccines (pneumoncoccal / influenza)influenza)

Consult orders and dictationsConsult orders and dictations Vitals for last 24 hrsVitals for last 24 hrs Radiology ReportsRadiology Reports Ancillary AssessmentsAncillary Assessments

NutritionNutrition TherapiesTherapies Case ManagementCase Management

Case Review Case Review <72 hour Re-Admits / Unplanned Transfer<72 hour Re-Admits / Unplanned Transfer

Protected by peer review lawsProtected by peer review laws HIPPA – sharing of PHI by entities HIPPA – sharing of PHI by entities

providing care to the patientproviding care to the patient Medical Staff Bylaws Medical Staff Bylaws Baystate policiesBaystate policies All corporate entities recognize process as All corporate entities recognize process as

peer review and abide by confidentiality peer review and abide by confidentiality status. status.

Lessons Learned / Next StepsLessons Learned / Next Steps

Patients who have some level of PAC are less Patients who have some level of PAC are less likely to be readmitted.likely to be readmitted.

If readmitted the subsequent LOS is as much as If readmitted the subsequent LOS is as much as 1 – 1.5 days longer than initial LOS 1 – 1.5 days longer than initial LOS

• Raised awareness of the need for PACRaised awareness of the need for PAC• Identification and screening of patients with risk factors for Identification and screening of patients with risk factors for

readmission if sent home.readmission if sent home.

End of week discharges have a slightly higher End of week discharges have a slightly higher rate of return within 72 hours. rate of return within 72 hours.

Lessons Learned / Next StepsLessons Learned / Next Steps

High percentage of discharges to PAC High percentage of discharges to PAC occur between 3pm and 5pm. occur between 3pm and 5pm.

• Working to establish mid-level provider coverage in Working to establish mid-level provider coverage in evenings evenings

Home healthcare readmissions - Home healthcare readmissions - opportunity for greater understanding of opportunity for greater understanding of readmissions within 72 hrs. readmissions within 72 hrs.