1. Collaborating with Community Nursing Homes to Improve Transitions and Care Patrick Schultz, MS, RN, ACNS-BC Director of Quality and Patient Safety Sanford Medical Center Fargo, ND

2. Roadmap Who We Are What Drove Us What We Did Where We’re At Where We’re Going

3. Who We Are

4.  Serving 2.3 million people  27,000 employees including 1,400 physicians  43 hospitals  45 long-term care facilities  243 clinic sites  92,000 health plan members in four states  $3.2 billion in annual net operating revenue Sanford Health

6. Barney

7. What Drove Us

8. Drivers Readmission Reduction Program – Began October 1, 2012 Professional Practice Review (Peer) Medicare Spending per Beneficiary Sepsis Measure

9. Readmission Reduction Program FFY 2017 Readmission Reduction Program DiagnosesDischarge DatesPayment Impact AMI HF PN COPD THA/TKA Isolated CABG July 1, 2012 through June 30, 2015 3%

11. Professional Practice Review Caregivers of HF Patients Can Have Unrealistic Hopes for Prognosis – Steve Stiles, September 28, 2015 More often than not, family members caring for loved ones with advanced heart failure don't understand how serious the disease is, have unrealistic expectations about the patient's chances for survival, and even may be looking forward to recovery, suggests a study based on interviews of 80 such caregivers. http://www.medscape.com/viewarticle/851630

12. Medicare Spending per Beneficiary Value Based Purchasing – Began October 2012 – An MSPB Episode includes all claims between 3 days prior to index admission to 30 days after the hospital discharge

13. Sepsis Sepsis as an Inpatient Quality Reporting measure – 10/01/15 – 06/30/16 Discharges

14. Focus

15. What We Did

16. One Care for Seniors Started 09/2011 Purposes – Improve transitions from hospital to nursing homes – Reduce readmissions from nursing homes to hospital

17. Call for Partners Bethany—288 Skilled Nursing beds Eventide—260 Skilled Nursing beds Elim—136 Skilled Nursing beds

18. One Care for Seniors New leadership 1/2013 Expanded work – Advance Care Planning – Heart Failure, Sepsis, Renal Failure

19. Challenges How to measure readmission? How to measure advance care plan use? How to know transitions went well?

20. Overcoming Challenges How to measure readmission? – First try: Hired PhD part time to collect data – Next: Epic report with discharge destination triggers when a patient returns to Sanford within 30 days (dependent on proper entry)

21. Overcoming Challenges How to measure advance care plan use? – Epic report includes presence or absence of Advance Care Directive

22. Overcoming Challenges How to know transitions went well? – Monthly meetings 0700 – HF mismatches – ACPs not entered – NP issues – Xrays done in the nursing homes – Connection with Director of Quality

23. Overcoming Challenges Added a Partner—QIO – CMS Data Reports

24. Home

25. Interventions One call back phone number for questions EpicCare Link Interventions to Reduce Acute Care Transfers (INTERACT) tools https://interact2.net/index.aspx https://interact2.net/index.aspx Increased Nursing Home capabilities

26. EpicCare Link: Access to EMR EpicCare Link is Epic’s web-based application for connecting organizations to their community affiliates.

27. INTERACT: Care Paths

29. INTERACT: QI Tool

30. INTERACT: Advance Care Planning

31. INTERACT: Communication

32. INTERACT: NH Capabilities

33. Traveling Dentist

34. Heart Failure Actions Education – CNS and NP sessions for partners – Expanded to 5 teleconference sites which reached 87 rural nursing home workers – Weigh daily (dehydration a problem also) – IV diuretics and IV fluids

35. Risk?

36. Sepsis Actions Education – CNS presentation to combined group – UTI antibiotic stewardship program (symptomatic with UC+) – Emphasis on INTERACT Care Paths – Discussion with providers regarding trusting Xray

37. Advance Care Planning Actions ACP education for all Nursing Homes Increased number of facilitators Created HF referral for ACP for all NYHF Class III & IV Added NYHF Class to order sets

38. Where We’re At

40. Heart Failure Data Private data

41. Sepsis Data Private data

42. Acute Renal Failure Data Private data

43. Advance Care Planning Data Private data

44. Mellow

46. Where We’re Going

47. SIM-ND

48. Training for Nurses and Unlicensed Personnel Geriatric MI in LTC “There is an elephant on my chest” - Geriatric CVA in LTC “What about the droop”? Geriatric DVT/PE in LTC “My leg hurts” Geriatric GI Bleed “It won’t stop” Geriatric HF in LTC “Why are my ankles so fat?” Geriatric Progressive from Admit to Fall in LTC “I need the bathroom” Geriatric UTI in LTC “What day is it again?”

49. Telemedicine Partners have all put telemedicine into their budgets Challenge: CMS payment only for a rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract

50. Next Steps ACP for COPD State of ND following WI and MN lead HF education and expectations to RN Health Coaches and Provider Panel Specialists in our clinics Palliative care clinic (may change name)

51. No Readmission/ACP in place!