1 Bethany Model of Care Sister Jacquelyn McCarthy, CSJ, RN CEO/Administrator Bethany Health Care Center

2 Faculty Disclosures Sister Jacquelyn has disclosed that she has no relevant financial relationships.

3 Learning Objectives By the end of the session, participants will be able to: Understand the importance of daily collaboration of interdisciplinary nursing and support teams who provide timely intervention and implementation of medical care. Understand the importance of adherence to institution organizational improvement plans. Understand that providing a comprehensive array of in-house medical services and an in-house education program tailored to enhance the delivery of quality care requires a willingness of the staff to change from the traditional way of caring for our residents to a resident-oriented approach. Understand the impact of low employee turnover on care given to residents.

4 Facility Demographics Bethany Health Care Center Framingham, Massachusetts Total # of Beds = 101 A Non-profit Facility Sponsored by the Sisters of St. Joseph of Boston

5 Bethany Model of Care Program Initiated formal study beginning January, 2003 – program was in place to a degree prior to this date. We wanted to have a “treat in place” modality of care. We believe we could reduce the number of unnecessary admissions to the acute care setting. We had historically followed this mode of care, but had not studied outcomes. Our objective was to verify that “treat in place” philosophy could be an option for residents who reside in long term care facilities and have positive outcomes. Efficacy - the degree to which a test, procedure or service meets the individual’s needs, desired or projected outcome(s). Appropriateness - the degree to which care and services are relevant to the individual’s needs, given the current state of knowledge.

6 Bethany Model of Care Program (Continued) Availability - the degree to which appropriate care and services are available to meet the individual’s needs. Timeliness - the degree to which the care and services provided to the individual are at the most beneficial or necessary time. Effectiveness - the degree to which care and services are provided in the correct manner, given the current state of knowledge, to achieve the desired or projected outcome. Continuity - the degree to which the individual’s care and services are coordinated among practitioners, among organizations and over time.

7 Project Timeline Study was conducted over 5 years 2003 – 2007 Planning and Research Data compiled included: 1.Age of Residents – Currently Bethany residents 85 years old and over is 73%. Compared to Massachusetts state average of 45% and national average of 41%. 2.Number of hospitalizations: 29 in 2003 to 8 in Number of infections: 129 in 2003 to 74 in Number of deaths: 33 in 2003 to 21 in Average number of medications residents receive: 40% - 9 medications or less 6.Positive contributing factors: a.Low turnover of direct caregivers RNs:31% in % in 2007 LPNs: 7% in % in 2007 CNAs:15% in 2003 – 21% in 2007 b.Care hours provided 3.5 to 3.8 hours per resident; Massachusetts standard is Reviewed Contracted Vendor use looked for ways to improve in- house service to residents.

8 Project Timeline (Continued) Issues encountered: How do we bring as many services to the facility as possible so that residents do not have to leave the building. –Added Mobile Barium Swallow Capability. –Added Psychiatrist to Bethany Staff. –Added INR Testing On Site. This is an on-going study monitored by our QI team that meet monthly.

9 QI Planning & Implementation Committee Members meet monthly: CEO/AdministratorPharmacy Assistant Directors of NursingLab Director of NursingX-Ray Medical DirectorRehabilitation Department HeadsHuman Resources Nurse ManagersPastoral Care Social Services Interdisciplinary members meet daily. Meetings: Results communicated to Staff at QI meeting Collaboration with committee to look at best practice. Identify high risk issues such as falls, weight loss, infections, change of condition promptly at daily interdisciplinary meetings. Continue to monitor to see if factors changed and effect on resident care. Plan Review Staff Quality Assurance Committee In addition: Each month the information regarding fall, weight loss, infections is communicated to Staff. Each day information regarding changes in condition is shared with Nursing Staff, Social Service and Administration.

10 Issues Found/Communicated Residents preferred to be treated in their own home at Bethany. Families/Health Care Proxies are in agreement with resident’s preference to be treated at our facility. Longevity of staff builds relationships with residents. Consistent care assignments of CNAs; Medical Director at Bethany more than 20 years; NP more than 5 years; DON 19 years; ADON 15 years; Administrator 12 years. Quick assessment of health issue and intervention reduced need for hospitalization. Staff recognizes subtle changes in resident’s condition allowing for quick assessment of health issues. Five days per week visit by facility Physician and Nurse Practitioners. 24 hour availability of Primary Medical Director and Nurse Practitioners allows for immediate intervention and implementation of care to reduce need for hospitalization.

11 Tools Used to Affect Change Tools used –In the beginning Committed Medical Director whose philosophy is to treat in place when at all possible and who practices evidenced-based medicine. Five day per week visits by on-site Primary Nurse Practitioners. Five days per week visits to the facility by Medical Director to those who are experiencing health decline. –As time progressed Round table discussions with contracted psychiatrist to discuss behavior modification. On-going training of nurses on physical assessment of residents by Education Coordinator, NPs, Pharmacy, Rehabilitation, and Audiologist. Monitoring of turnover rate of staff at facility and compare with State average. On-site monitoring of necessary hospitalization and number of MLOA days. Proactive fall reduction program to reduce unnecessary hospitalizations. –Rehab rounds weekly. –Daily discussion of falls and high risk residents with interdisciplinary team. –Walking club. –Daily exercise classes. –Daily activities on each unit to keep residents engaged.

12 Tools Used to Affect Change (Continued) Tools used –As time progressed (continued) Monitoring of meal consumption. Adequate nutrition reduces skin breakdown and reduces admissions for those who are diabetic. –Watch your weight group (for residents who are trying to lose weight) –Food group meetings (for all residents to discuss menu choices and favorite foods) –Monthly weight management meetings. –Weight changes discussed at weekly interdisciplinary meeting. Prevention of infections through vaccinations of staff and residents, education of staff and residents. Tools created –Use of on-site Barium Swallow –INR testing in-house

13 Facility Expenses No additional costs were incurred because planning and execution were done during normal work hours. However, the cost of on-call psychiatrist was $1500 per month and use of coagucheck was $ per month. Supplies for the coagucheck were about $250 per month. Facility receives reimbursement of about $5.95 per INR. Average number of INR tests done: 105 per month. The BMCP "treat in place" modality of care has resulted in cost savings associated with decreased hospitalizations, testing, medication costs and transportation services.

14 Outcomes Reduction in hospitalization and infection: –29 residents hospitalized in 2003; 7 residents hospitalized in –Decreased days in hospital: 102 in 2003 to 34 in –Reduction in infections from 129 in 2003 to 74 in 2007, with the most notable reduction in urinary track infections: 53 in 2003 to 26 in –A fall reduction program that included weekly rehab rounds that reduced the number of hospitalizations. –Average number of medications prescribed decreased. –40% of Bethany residents take fewer that 9 medications. –Deficiency free DPH survey rating 11 consecutive years. –One of 33 homes in the United States to receive a 5-Star rating from the Federal Government. –100% referral recommendation from residents and families who responded to a Massachusetts Department of Public Health Survey. –Reduction in turnover rate of employees: RN 31% 7% LPN 7% 0% NA 15%21% –Reduced recruitment and training costs. –Consistent resident care assignments have brought benefit to residents who have their issues addressed quickly and staff who have strong relationships with residents. –Staff satisfaction with job improved.

15 Closing Thoughts This model of care can be easily replicated. Essential Elements Needed: 1.Dedicated Medical Director. 2.Nursing Department with strong assessment and collaborative skills. 3.Quality Improvement Program that meets regularly and resolves issues across departments. 4.Salary and benefit package that will keep turnover rate low. 5.Common understanding and acceptance among employees and families that “treating in place” can prevent hospital acquired conditions. 6.“Treating in place” can and does improve quality of life!