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Kathy Clodfelter, MSN, MBA, RN, NE-BC
Shelly Evans, B.S.
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BACKGROUND Our Story Begins With SWIONE
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2014 SWIONE Presentation by Memorial Hospital and Health Care Center Nurse Practitioner Roles in Community Health
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It’s all about relationships….
Partnership with 6-area Skilled Nursing Facilities (SNF) and their staff Relationship building with patients, families, and significant others Relationship building with SNF Medical Directors
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Trends MHHCC experienced
Earlier intervention of chronic illness issues Staff education opportunities Interaction with family members increased trust and confidence in level of care Rapport and support from Medical Directors
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Why and How We Got to Where We are Today
Shelly Evans
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Healthcare Reform / Accountable Care Organizations (ACO’s)
High post-acute spend and readmission rates Lack of continuity of care High emergency department utilization Patient transition issues – no coordination Patient / family dissatisfaction High cost of care
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Next Generation ACO – 2016 Assumed risk for readmission rates, Medicare spend for our ACO population Strategic Initiatives to improve patient care while lowering readmissions and Medicare costs NP model created to drive desired outcomes – Triple Aim Improving patient care & quality Improving patient & family experience Reducing LOS, readmission rates & Medicare spend Deliver the right care at the right time at the right place
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Challenges / Gaps Documentation
Patient orders (therapy, diet, medications) Dialysis treatments Transitions in care Patient resources Quality data reporting Emergency Department Palliative care – early interventions Technology / EMR SNF staff coordination / education Medication gaps Transportation issues Discharge summaries Therapy department coordination Acute – Post Acute care coordination
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Skilled Nursing Facility (SNF) Networks
POST ACUTE NP PROGRAM Skilled Nursing Facility (SNF) Networks Partner Facilities (Embedded NP model) 11 SNF’s / 5 Nurse Practitioners Developed parameters for SNF selection (Star rating, quality metrics, rates) Call center – enhanced NH triage service (clinical protocols) Development of facility fees – subsidize NP costs NP’s bill for patient visits Collaborating physician / Medical Director Preferred Provider facilities (3-day SNF waivers) 24 SNF’s / local & regional facilities 3 day SNF waiver benefit – ACO patients Deaconess, Memorial Hospital, Good Sam, GGH, Ferrell, Methodist CMS requirements – overall star rating of >3
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Post Acute NP program Program Enhancement NP Nursing home visits
Admission, acute, discharge, regulatory visits NP Services agreement – admitting physicians Quality Metrics – track 22 metrics monthly Monthly meetings – SNF administrator, admissions, social work, therapy department, discharge planners Discuss all readmissions and why they occurred NP education for SNF staff Infection prevention, wound care, what to look for SNF discharge planning coordination– transition to home Enhanced communication and hand off processes streamlined
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All Facilities Combined
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Skilled Nursing: Embedded NP Initiative Measuring Success
____________________________________________________ Baseline Data FY15 vs FY18 (All Deaconess Patients) 30-day Readmission rates: 26.9% to 11.0% Average Length of stay (short term, rehab to home patients): 36 days to days Provider Visits within 2-business days of SNF admission: 12% to 91.8%
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All Facilities Combined
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All Facilities Combined
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SNF Partner
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Current Initiatives Progress
SNF Waiver programs Anthem / Humana Floor to SNF, ED Intercept 3-day SNF waiver program 465 waivers / 1163 IP days saved Utilization Management Meds to Beds Program ↓LOS 5+ days – SNF therapy department collaboration ↓RA rates ↑patient care & satisfaction Post Acute Services In – Network Utilization Improved handoff processes COPD / CHF Education – SNF’s Risk Stratification Tool, D/C summaries, Deaconess Care Link Acute readmission teams Case management collaboration
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Future State - Initiatives
NP program expansion 9 NP’s, 20 SNF’s NP on-call Telehealth Solutions Waivers Post Discharge waiver Anthem / Humana waiver program expansion Advanced Directives Project 24 hour RN triage (call center) Post acute case manager model Community organization collaboration Readmission projects Acute nurse managers SNF Education program
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Contact Information Kathy Clodfelter, MSN, MBA, RN, NEM-C DVNA, Case Management, Post Acute Services Shelly Evans, B.S., Post Acute Services
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