Emergency Department/Hospital Inpatient Initiative

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For more information on the Group Health reducing readmissions and innovations like this, please go to www.ghinnovates.org.

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Emergency Department/Hospital Inpatient Initiative

  1. 1. Kate Brostoff, MD, medical director, APPLE (Acute, Post-acute, Pharmacy, Laboratory, Emergency) Patient Resources & Options, Group Health Physicians Brenda Bruns, MD, executive medical director, Health Plan Services, Group Health Physicians Barbara Trehearne, PhD, RN, vice president of Clinical Excellence, Quality, and Nursing Practice, Group Health Barbie Wood, RN, MBA, director, Care Management Services, Group Health Emergency Department and Hospital Inpatient Initiative
  2. 2. <ul><li>OBJECTIVES </li></ul><ul><li>• Improve health care quality for our patients by streamlining care transitions </li></ul><ul><li>• Reduce avoidable costs during care transitions </li></ul><ul><li>• Reduce preventable hospital admissions, readmissions, and ER visits </li></ul>
  3. 3. <ul><li>GOALS </li></ul><ul><li>• Improve the patient experience </li></ul><ul><li>• Ensure the best possible outcomes </li></ul>
  4. 4. PATIENT EXPERIENCE PATIENT EXPERIENCE
  5. 5. STRATEGIES <ul><ul><li>Pre-admission assessment for alternative placement/services </li></ul></ul><ul><ul><li>Personalized transition management for admitted patients </li></ul></ul><ul><ul><li>Coordinated transitions with skilled nursing facilities and home health agencies </li></ul></ul><ul><ul><li>Engaging patients with their end-of-life choices </li></ul></ul>EPRO Transition Mgmt SNF Discharge Palliative Care
  6. 6. PATIENT EXPERIENCE PRE-ADMISSION ASSESSMENT | Emergency Patient Resources and Options (EPRO)
  7. 7. PROVIDING ALTERNATIVES TO ED AND HOSPITAL ADMISSION | 24/7 Telephonic Physician + Care Mgt RN Team <ul><li>Urgent Care access expanded </li></ul><ul><li>Same day or urgent primary care and specialty appointing </li></ul><ul><li>Next morning guaranteed home health RN visit </li></ul><ul><li>Direct Skilled Nursing Facility placement </li></ul><ul><li>Options to avoid “social admits” </li></ul><ul><li>Telemetry Observation in UC or Extended Observation Service care </li></ul><ul><li>24/7 Benefit assessment and explanation </li></ul>EPRO: 2011 Expansion 1/1/2011: Primary Care Pilot using EPRO for all hospitalizations EPRO
  8. 8. PATIENT EXPERIENCE PLACEMENT
  9. 9. PATIENT EXPERIENCE ADMISSION
  10. 10. PATIENT EXPERIENCE THE METHOD | The Four Pillars Teach Medication Self- management Teach a patient about their condition and use of a personal health record Provide knowledge of warning symptoms and how to respond Have a patient set up follow-up care with their doctor
  11. 11. DAILY HUDDLE AND PATIENT IDENTIFICATION <ul><li>Using new standard scripting and processes, staff manage patient care tightly and collaboratively via a daily huddle: </li></ul><ul><ul><li>UPON ADMISSION, sort patients into 4 pathways </li></ul></ul><ul><ul><li>EACH SUBSEQUENT DAY, review patient progress and daily plan, discharge planning, and expected next steps. </li></ul></ul><ul><ul><li>FOCUS ON AVOIDABLE DAYS, review whether admission / day was avoidable, LOS against expected target, and if a re-admit, what they could have improved to avoid the re-admit. </li></ul></ul>
  12. 12. TRANSITION MANAGEMENT | How do we do it? <ul><li>WITHIN THE HOSPITAL </li></ul><ul><ul><li>Huddle </li></ul></ul><ul><ul><li>Transition Coaching (4 pillars) </li></ul></ul><ul><ul><li>48-Hour Post-Discharge Phone Call </li></ul></ul><ul><ul><li>Readmit and Long Length of Stay Reviews </li></ul></ul><ul><ul><li>Avoidable Days / Admissions Capture </li></ul></ul><ul><li>WITHIN THE SNF </li></ul><ul><ul><li>Timely SNF Placement </li></ul></ul><ul><ul><li>SNF MD Rounding within 48 Hours </li></ul></ul><ul><ul><li>ARNP Rounding within 72 Hours </li></ul></ul><ul><ul><li>POLST / DPOA Confirmation or Completion </li></ul></ul>Transition Mgmt SNF Discharge
  13. 13. HOSPITALIST / CARE MANAGEMENT PARTNERSHIP | Collaborative Standard Work <ul><li>Participate in daily huddle </li></ul><ul><li>Transition management dictation </li></ul><ul><li>Palliative care review, discussion, and dictation </li></ul><ul><li>Upon patient admission </li></ul><ul><ul><li>Participate in daily huddle </li></ul></ul><ul><ul><li>Transition coaching using 4 pillars </li></ul></ul><ul><ul><li>Schedule 7-day and 14-day follow-up visits with primary provider </li></ul></ul><ul><ul><li>Readmit and long length of stay reviews </li></ul></ul><ul><ul><li>Avoidable days/admissions capture </li></ul></ul><ul><li>Upon patient discharge </li></ul><ul><ul><li>48-hour post-discharge phone call </li></ul></ul>HOSPITALISTS CARE MANAGERS
  14. 14. HOSPITAL BASED MD TRAINING <ul><li>Communication skills focused on setting Goals for Care, End of Life planning </li></ul><ul><li>Decision support tools for identifying patients in need of those conversations </li></ul><ul><li>Lean principles including Standard Work </li></ul><ul><li>Daily Management system </li></ul>
  15. 15. Would you be surprised if this patient died within the next 2 years? PALLIATIVE CARE SUPPORT Disease Process Functional Status Level of Intervention + = Source: Pyramid tool adapted from Victoria Hospice Palliative Performance Scale; Disease Process Assessment adapted from a variety of hospital-based palliative care service tools. <ul><li>Score = 2 pts </li></ul><ul><ul><li>No intervention </li></ul></ul><ul><li>Score = 3 pts </li></ul><ul><ul><li>Observation </li></ul></ul><ul><li>Score = 4+ pts </li></ul><ul><ul><li>Palliative Care Discussion </li></ul></ul>Palliative Care
  16. 16. PATIENT EXPERIENCE POST-DISCHARGE
  17. 17. CONNECTING BACK WITH OUR MEDICAL HOME <ul><li>Key leadership within our Medical Home and Specialty divisions helped guide how patients would be reconnected back to their primary provider. </li></ul><ul><li>Key Points include: </li></ul><ul><ul><li>All patients called within 7 days following discharge from the hospital by a clinical pharmacist to reconcile medication </li></ul></ul><ul><ul><li>All patients receive 14-day face to face visit with Physician post-discharge </li></ul></ul><ul><ul><li>Initiate palliative care conversations as appropriate/when needed </li></ul></ul><ul><ul><li>Specialists integrate transition management into hospital care of patients (in progress to be completed by end 2009), and incorporate palliative care planning into regular workload ( expected 2010) </li></ul></ul>
  18. 18. <ul><li>Patient </li></ul><ul><li>Satisfaction: </li></ul>SEPT 2010 DEC 2009 91 st percentile 74 th percentile
  19. 19. GOALS AND MEASUREMENT OBJECTIVES • Reduce inpatient costs and readmit rates by providing consistent and reliable post-acute care transitions • Optimize post-acute care processes • Reduce unnecessary Emergency Department (ED) utilization and costs $51 million total savings for 2010 METRICS • Readmit rate • IP admit rates • Hospital length of stay (LOS) • SNF admits/1,000 • SNF LOS • ED visits/1,000
  20. 20. $ 51 m HOSPITAL COST SAVINGS
  21. 21. RESULTS
  22. 22. Medicare patient readmission: NATIONALLY: 19.6 % WASHINGTON: 16.4 % GROUP HEALTH: 15%
  23. 23. <ul><li>Medicare inpatient admits by 6.3% </li></ul><ul><li>Medicare inpatient days by 3.3% </li></ul><ul><li>Non-Medicare inpatient admits by 7% </li></ul><ul><li>Non-Medicare inpatient days by 10% </li></ul><ul><li>SNF Medicare admits </li></ul><ul><li>SNF Medicare inpatient days by 5% </li></ul><ul><li>ER visits by 5% </li></ul>OVERALL IMPROVEMENT

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