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Improving Communication at Transition from NH to ED Suzanne Gillespie, MD RD Division of Geriatrics/Aging March 6, 2009 2008 AMDA Foundation/Pfizer Quality Improvement Award: One Year Update Suzanne Gillespie, MD RD Division of Geriatrics/Aging March 6, 2009 2008 AMDA Foundation/Pfizer Quality Improvement Award: One Year Update
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Background University of Rochester Div of Geriatrics Primary care for > 3,000 LTC residents 34 NH and ALF facilities Monroe Community Hospital (MCH) 566-bed county-owned NH with an academic medical staff Frequently send and receive patients to/from a variety of other medical settings in the region. Routine Emergently University of Rochester Div of Geriatrics Primary care for > 3,000 LTC residents 34 NH and ALF facilities Monroe Community Hospital (MCH) 566-bed county-owned NH with an academic medical staff Frequently send and receive patients to/from a variety of other medical settings in the region. Routine Emergently
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Transitions of Care from NH Frequently involve multiple people Patient, Families, Nurses, SW, EMS, Doctors…. LTC (& EM providers) expressing frustrations about care communication on a daily basis. Grant Award: opportunity to translate frustrations into QI Frequently involve multiple people Patient, Families, Nurses, SW, EMS, Doctors…. LTC (& EM providers) expressing frustrations about care communication on a daily basis. Grant Award: opportunity to translate frustrations into QI
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“LTC Quality Council” Focused on improving transitional care between organizations Bi-Monthly Meetings Representatives Medical Center, NH/ALF, home care Emergency Medicine & Geriatric Medicine Nursing, social work, physicians Quality Management Leaders Focused on improving transitional care between organizations Bi-Monthly Meetings Representatives Medical Center, NH/ALF, home care Emergency Medicine & Geriatric Medicine Nursing, social work, physicians Quality Management Leaders
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NH to ED Transitions: Perceptions ED and LTC teams expressed different perceptions of transitions of care “doing a great job” “issues on a daily basis” “incomplete” “inaccurate” “disorganized” “variable” Variability in what each of the homes provided Variability in how providers define good communication Neither sending nor receiving caregivers know what to expect when a resident is transferred to the ED. ED and LTC teams expressed different perceptions of transitions of care “doing a great job” “issues on a daily basis” “incomplete” “inaccurate” “disorganized” “variable” Variability in what each of the homes provided Variability in how providers define good communication Neither sending nor receiving caregivers know what to expect when a resident is transferred to the ED.
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Survey of ED and LTC Providers Respondents, n=155 Physicians (23%; n=36) NPs/PAs (14%; n=21) Nursing (63%; n=98) Comparable #LTC and ED respondents Experience in their field 41% reported >11 yr Response rate = 32% Respondents, n=155 Physicians (23%; n=36) NPs/PAs (14%; n=21) Nursing (63%; n=98) Comparable #LTC and ED respondents Experience in their field 41% reported >11 yr Response rate = 32%
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There is good communication between EDs & NHs in this community Impressions of Nursing Home Care Transitions Percent who agree/disagree with the following statements… Somewhat agree Strongly agree NeutralSomewhat disagree Strongly Disagree Important information is lost during transitions of care between NHs & EDs
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how often you believe the following occurs when a NH resident is transferred TO the ED for care? (1=NEVER, 7=ALWAYS) p<.01 ALWAYS NEVER * *
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how often you believe the following occurs when a NH resident is transferred TO the ED for care? (1=NEVER, 7=ALWAYS) always never
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How often you believe the following should occur, when a NH resident is transferred FROM the NH TO the ED,
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a verbal communication at my position/level should occur (doctor/NP/PA)
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a verbal communication at my position/level should occur (nursing)
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Transfer Form Focus group Feedback Survey input Pilot Revisions Focus group Feedback Survey input Pilot Revisions
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PRIMARY INFORMATION Extended Care Facility: Monroe Community HospitalPhone:(585) 760 - 6500 Code Status: FULL DNR MOLST (Include a copy) Transferred to: Allergies: Precautions: NONE VRE C-difficile Respiratory (type) ORSA Fall Seizure Wanders Reason for Transfer: Altered mental status (describe): Acute neuro change (describe): Fever Shortness of Breath Chest Pain Abdominal Pain Fall Injury-Site (describe): Weakness Blood sugar abnormality Other / further comments: Usual Mental Status: Alert, Oriented x Confused Verbal Non-verbal Vital Signs: TempHRR BPO2 sat % On lpm Last Weight: Provider to Contact: Name: Pager: Nurse to Contact: Name: Number: 760 - _ _ _ _ Medication changes in last 14 days: Lab studies done in last 72 hours? Yes No Unknown Skin Integrity: Intact Wounds—location & type:
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SECONDARY INFORMATION Advanced Care Plans (Send Copies): MOLST DNR HCP POA Living Will Guardianship Language: English Other: Patient Adaptive Equipment: Dentures Glasses Hearing aid Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Other: Usual Respiratory Care: None Oxygen ___ lpm ATC HS BiPapSetting: CPAPSetting: VentSetting: Transfers Independent 1 assist 2 assist Lift Mobility Independent 1 assist 2 assist Non-ambulatory Bedfast Mobility Equipment Cane Wheel Chair Walker—type: Sent with Patient: Dentures: Upper Lower Glasses Hearing Aide Other: Patient Diet: Resident Eats: Independently with set-up total assist/fed Resident Drinks: Regular Thin Liquids Modified Liquids Consistency: Nectar, Honey, Pudding Smoking Status: Current Former Unknown Type of Residence: SNF Rehabilitation SNF Long-term care Assisted Living Home with Home Care Hospice House Other (describe): Dialysis (if applicable) Schedule (days/time): Center:Access: Immunizations Influenza Yes No Date:Pneumovax Yes No Date: COPIES TO SEND WITH RESIDENT: Facility Face SheetIf available: MOLST Last History & Physical Health Care Proxy Acute visits prompting transfer Living Will Last routine provider 30/60-d note POA Last 3 days of progress notes Guardianship Medical administration record Last EKG
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Pilot 45 residents’ transitions audited 17 (38%) nothing- no information 16 (36%) used an old form 12 (27%) new form 100% code status 100% reason sent; often with extra detail 100% usual mental state 50% contact information 45 residents’ transitions audited 17 (38%) nothing- no information 16 (36%) used an old form 12 (27%) new form 100% code status 100% reason sent; often with extra detail 100% usual mental state 50% contact information
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Pilot Challenges Change Xeroxing Option to use something else… Revisions Hospitalists call…. Acute Quality Measures (Smoking, Vaccination, Wound status) Streamline data included Process Re-engage staff Units pre-customize data Re-assessment Challenges Change Xeroxing Option to use something else… Revisions Hospitalists call…. Acute Quality Measures (Smoking, Vaccination, Wound status) Streamline data included Process Re-engage staff Units pre-customize data Re-assessment
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Reflections The improvement is not just the form….it is the process Most valuable aspect of this QI initiative Introduction of joint accountability for transitions Establishing a feedback mechanism The improvement is not just the form….it is the process Most valuable aspect of this QI initiative Introduction of joint accountability for transitions Establishing a feedback mechanism
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Next Steps Reassess after revisions Implement at other local facilities Regional standard Define the role of verbal communication Improvements in Ed to NH transitions Reassess after revisions Implement at other local facilities Regional standard Define the role of verbal communication Improvements in Ed to NH transitions
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