1. Optimizing Transitions of Care: Redesigning Nursing Roles to Improve Quality and Reduce Cost Suneela Nayak, MS, RN, Clinical Quality Improvement Specialist, Center for Quality and Safety David Bachman, MD Senior Medical Director, Clinical Integration

2. Learning Points Preventable Readmissions in the context of Transitions of Care Why now? Where to Start? MaineHealth Transitions of Care Program Leading with Innovation: Redesigning Roles, Competencies

3. Case Study : Mr. S 76 year old male, living independently, limited social supports Past Medical History –Congestive heart failure –6 routine medications including Coumadin Admitted for evaluation of syncopal episode

4. Mr. S: Hospital Course Cardiac monitoring and diagnostic testing Developed urinary retention –Urology consultation –Urologic procedure performed Discharged on Coumadin, new antibiotic, with urinary catheter

5. Mr. S: One week later Developed hematuria, urinary retention ED Visit –Dramatic hematuria with catheter obstruction –INR 9.6 (ideal range 2 –3) –More urological intervention Readmitted –Reversal of anticoagulation Transfused 6 units of blood

6. Questions to Consider Was this readmission predictable? Was this readmission preventable? What went wrong with the transitions of care? How can we do better?

7. Why now ?

8. 2007 MedPac Report Medicare Payment Advisory Committee Readmissions –“sometimes indicators of poor care or missed opportunities to better coordinate care” –17.6% of Medicare patients readmitted within 30 days –$15 billion in annual spending –76% of readmissions potentially avoidable Recommended public reporting, payment reform

13. Jencks S et al. N Engl J Med 2009;360:1418-1428 Rates of Rehospitalization within 30 Days after Hospital Discharge

14. Health Care Reform: Hospitals Reduce reimbursement for hospitals with high risk-adjusted rates of readmission by 1% a year beginning in 2012 (up to 5% total) –2012 : CHF, pneumonia, AMI –2013: Add COPD, CABG, PTCA, Other vascular procedures, potentially global readmission rate Reduce reimbursement to SNF, Home Health when patient under their care readmitted

15. Health Care Reform: Physicians Create new payment code for patient visit within one week of discharge Apply payment reductions for physicians who treat a patient during an admission that results in a readmission

16. Payment Reform: MaineCare Reimburse for only one hospitalization when MaineCare patient readmitted to same hospital within 72 hours for the same diagnosis.

17. Why Now? Frequent & costly Issue of quality of care and patient safety Source of patient & provider dissatisfaction Waste increasingly scarce clinical resources such as nursing care Integral to movement towards Accountable Care Organizations

18. Where to start? Lots of Data and Tools at your fingertips

23. MaineHealth: Efforts to Date Transitions of Care Pilots Supported by funding from the Cardinal Health Foundation Three pilot sites selected from MaineHealth hospitals

24. Transitions of Care Pilots Key Outcomes  MaineHealth Transition of CareBundle  Implications for Role Redesign

25. MaineHealth Transitions of Care Bundle 1. Risk stratification for readmission 2. Transition Checklist 3. Medication reconciliation 4. Patient/family health education 5. Timely communication among hospital and post-hospital providers 6.Timely follow-up of patients

26. Leading with Innovation: What are implications for Redesigning Nursing Roles and Competencies?

27. National Summit of Advancing Health Through Nursing.. Key Messages from Institute of Medicine and the Robert Wood Johnson Foundation Nurses should practice to the full extent of their education and training. Nurses should be full partners with physicians and other professionals in redesigning health care Washington DC, October 2010

28. Focus on Reduced Readmissions Findings from MaineHealth Pilots: 1. Advocacy for patient’s agenda for care 2. Focus on safety, improved outcomes 3. Fully engage clinical skills, scope of practice 4. Develop ability to network across continuum …Offers Abundant Opportunities for Clinicians, Educators, & Leaders to Redesign Roles and Competencies

29. Roles and Competencies Key RolesCliniciansEducatorsLeaders 1. Advocacy for patient’s agenda for care 2. Focus on safety, improved outcomes  Skilled Patient Centered Care Practices  Skilled Hand-Off Communication all levels of care Instill:  Patient/ Family as central members of the care team  Comfort with transparent Communication  Innovate for improved outcomes and reduced costs  Sustain an environment of knowledge sharing (translate knowledge from individual to system)

30. Roles and Competencies Key RolesCliniciansEducatorsLeaders 3. Fully engage clinical skills, scope of practice  Assessment skills & related actions  Develop comfort with “Teach back”  Knowledge access : -continuum networks -electronic media  Quality through measured outcomes  Assessment & related actions  Focus on what is learned; skilled use of “teach back”  Refine networking skills  Operationalize roles to optimize practice and scope  Sustain the gain through visible and engaged continuum leadership.  Facilitate knowledge exchange across continuum Facilitate knowledge exchange between providers (Teach back) Sustain the gain through visible engaged leadership.

31. Roles and Competencies Key RolesCliniciansEducatorsLeaders 4. Develop ability to network across continuum  Establish networks with -continuum -payers -patient groups  Develop transition plans that ensure right care, at the right level.  “Admit to home” Instill  Continuum Navigation skills  Optimal use of EMR to enhance hand-offs  Shape pressing agenda of reimbursement reform - Lead early ACO work -Build and sustain networks to reduce downstream spending

32. Mr. S, revisited Admitted for syncopal episode Hospital Course: - Cardiac evaluation - urologic procedure - Discharged on Coumadin, new antibiotic, with catheter One week later: - ED Visit - Dramatic hematuria, obstruction - INR = 9.6 - Readmitted - Reversal of anticoagulation - 6 units of blood transfused

33. Mr S: Risk for Readmission (8P‘s) Prior hospitalization: in last 6 months Problem medications: anticoagulants Polypharmacy: > 5 routine medications Principal diagnosis: heart failure Psychological: PHQ2 screen Poor health literacy: unable to Teach Back Patient support: lives alone Palliative care : advanced illness

34. Case Study: The New Post Hospital Scenario Home support services –Monitoring of anticoagulant status Follow-up phone call Office visit within 5 to 7 days *No ED visit *No readmission *Decreased morbidity *Decreased cost *Increased patient satisfaction

35. Summary Focus on Reduced Readmissions offers Abundant Opportunities for Nurse Educators, Clinicians and Leaders Innovative redesign of roles, competencies to -Improve clinical outcomes, quality, satisfaction -reduce cost

36. Questions?

37. Thank-you!