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Project Presentation
- 1. Avoiding 30-day Readmissionsof Acute MI Patients Utilizing Cardiac Rehabilitation DNP Project Presentation Pat Forsberg, DNPc, MBA, RN, NE-BC November 17, 2014
- 2. Setting • 600 BedAcademic Medical Center at Parnassus • Ranked among the nation’s top 10 hospitals for the past 10 years by U.S. News & World Report • Tertiary/Quaternary referral center hospital • TJC certified • Stroke center • VAD destination therapy • Over 2092 physicians • Over 90 clinics with more than 75 adult specialties
- 3. Readmission Rates –Based on CMS 2014 Measures Updates and Specification Report* FY 2012 FY 2013 FY 2014 AMI Index 58 52 62 Readmits 5 7 9 Rate 8.6% 13.5% 14.5% CHF Index 98 133 144 Readmits 20 23 29 Rate 20.4% 17.3% 20.1% COPD Index 73 55 46 Readmits 11 6 8 Rate 15.1% 10.9% 17.4% PN Index 129 96 99 Readmits 22 14 15 Rate 17.1% 14.6% 15.2% * Medicare FFS patients only
- 4. Medicare FFS ReadmissionsCY 2013 – Discharged to
- 5. Medicare FFS ReadmissionsCY 2013 – Days to readmission
- 6. Current Engagement • MCparticipating in CMS demonstration program Delivery System Reform Incentive Payment, (DSRIP) • Designed to improve care and lower costs by transitioning hospital funding to a model where payment is contingent on achieving health care outcome goals • 4 categories of participation • 1 – Infrastructure Development • 2 – Innovation & Redesign • 3 – Population Focused Improvement • 4 – Urgent Improvement in Quality & Safety
- 7. Current Practices • ActiveTransitions in Care team sponsored by DSRIP project to reduce 30-day hospital readmissions • Early improvements seen in CHF patients with the use of in hospital CHF nurses on sight providing in patient education, support, and follow up phone calls to CHF patients • Implemented formal discharge phone call program • Evolved from decentralized unit based call program to centralized call back program utilizing Cipher, an automated call back system
- 8. Cipher Cardiology PostDischarge Call Breakdown 4/14-7/14 Issue Breakdown Issue Rates Reach Rates Home Discharges 479 patients discharged to home 386 patients reached (81%) 140 (36%) patients required callback 237 issues captured (auto + live calls) 156 Clinical Issues 66% 81 Satisfaction Issues 34% 246 (64%) of patients were found to have no issues with auto calls 93 patients not reached (19%)
- 9. Breakdown of ClinicalIssues Symptoms (49) 31% Prescriptions (20) 13%Medications (22) 14% Medication Class (11) 7% Other D/C Instructions (3) 2% Care Coordination (14) 9% Wound/ Incision (1) 1% Action Taken (36) 23%
- 10. Our Patient IssuesCompared to the Evidence • Follow up to occur within 7 days of discharge • Medication Reconciliation must occur in a timely manner • Recognition of Signs and Symptom management Evidence • Patients could not get follow up appointments within 14 days of discharge • 34% of patients called back had questions or concerns about their medications • 31% of patients had questions around symptom management The MC
- 11. Initial Direction ofthe Project – Optimizing patient discharge and post discharge follow-up to reduce hospital readmissions • Improve access to outpatient care in the cardiology clinic • Location at new Mission Bay ambulatory clinic • Space not an issue, but unable to increase access to clinic appointments due to: - Providers with competing priorities - Unable to obtain any additional staff positions, NPs
- 12. What About CardiacRehabilitation? • Currently have an active pulmonary rehab program at the Mt Zion campus • Funded by donation with strong medical director • Cardiac Rehabilitation program was dissolved in 2000 when the MC and Stanford de-merged • Cost savings effort as recommended by The Hunter Consulting Group • What would it take to re-establish the program at the MC? • Patients could be seen for intake soon after discharge • Medication reconciliation and symptom management
- 13. Evidence to Supportthe Concept
- 14. Can Participation ina Cardiac Rehabilitation Program Decrease AMI Readmissions? Case Control study of 147 post CABG patients in Sweden (Perk et al. 1990) • 49 enrolled in cardiac rehab post surgery • 14% were readmitted at one time in the study year • Those that were readmitted had lower LOS • 98 did not participate in cardiac rehab • 32% were readmitted at least one time in the study year • When readmitted had a higher LOS than treatment group RCT of 308 post AMI patients in Australia (Meshgin 2008) • 110 enrolled in cardiac rehab • 7% readmission rate • 198 did not participate in cardiac rehab • 38% readmission rate
- 15. What would ittake to convince hospital leadership? Capital Request 12 Channel Telemetry with Central Station $80,000 10 Treadmills @ 3,000 $30,000 1 Recumbant Exercise Bicycle $1,800 4 Airdyne Exercise Bicycles @ 900 $3,600 1 Eliptical $2,500 Emergency Code Cart with Defibrillator $10,000 Subtotal: $127,900 Sales Tax & Shipping @ 13.5% $17,267 Other costs - $145,167 Total Capital Request: $145,167
- 16. Volume Discharges by Diagnosis FY13FY14 AMI 84 69 CABG 61 69 Other Heart Surgery 83 99 Valve Surgery 125 85 Cardiac Transplant 12 22 Stents 118 124 HF/Shock 204 219 Advanced Heart Failure 150 256 Total 837 943
- 17. Operating Budget Projection 189Patients 20% of eligible patients Medicare Revenue $59,492 Volume: UOS 55% of patients x 36 sessions 3,744 Rate: $15.89 Commercial Revenue $274,880 Volume: UOS 45% of patients x 36 sessions 3,060 Rate: $89.83 Gross Patient Revenue $334,372 Deductions Net Patient Revenue $334,372 Other Operating Revenue $0 Total Operating Revenue $334,372 Salaries $187,200 FTEs - RN 1.5 Rate: $60.00 FTEs - Exercise Tech 1.0 Rate: $39.50 Benefits 30.00% $56,160 Contract Labor - RD 1 hour/week $2,500 Professional Fees - MD Director $12,500 Contract Labor Expenses $15,000 Total Labor Expenses $258,360 Depreciation --->> Enter Useful life 10 Half Year $7,258 Interest $0 Bad Debt $0 Other Expenses $2,500 Service Contract $0 Rent $0 Supplies $1,500 Marketing $1,000 Total Expenses $268,118 Excess Revenue over Expenses $66,254
- 18. Evaluation • Unable toimplement program within timeframe • Plan is to submit proposal for FY16 implementation – start date July 1, 2015 Weeks Initiation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Assessment & Recommendations Create proposal* Finalize budget projections Submit proposal to Administration Administrative approval obtained* Planning Review state requirements Order Equipment Modify existing space Equipment procurement Hire , orient, and train staff Develop work flows and order sets# Execution Project tem kickoff meeting Work observation (Gemba) Practice "Day in the Life" Implement small test(s) of change Meaure short term results ReEvaluate as necessary Control Project status meetings Monitor outcome reporting Adjust or redirect as necessary Closeout Report out on process/outcomes* Plan on sustaining improvement Assumptions include: Week 8 starting July 1, 2015 * Milestones # Deliverables
- 19. Survey Tool forLocal Hospital Based Cardiac Rehab Programs
- 20. Results Diagnoses Served Facility AACVPR Certified Phases Offered AMIAngina Cardiac Surgery Heart Failure Earliest Enrollment for AMI post Discharge Hours of Operation Comments and Best Practices CPMC X I, II X X X 9-10 days M-F 8-4:30p Discharge order set includes CR referral automatically Seton X I, II, III X X X X 2-3 weeks MWF 7-5p TTh 7-11a Also offer Healthy Heart Program to public St. Marys I, II, III X X X 4 weeks MWF 7-4:30p TTh 7-11a Some Phase III participants have been participating for over 10 years. Oldest patient is 98. UC Davis X II, III X X X X 2 weeks M-F 7-4:30p Offer CR for privately insured diabetic patients for risk reduction
- 21. Some Local BestPractices • CPMC • Referral to Cardiac Rehab is part of the discharge order set • Seton • Offers Healthy Heart Program to the public • St. Mary’s • Some Phase III patients have been participating for over 10 years. Eldest patient is 98. • UC Davis • Offers Cardiac Rehab for privately insured Diabetic patients for risk reduction
- 22. Intervention – EducationalPower Point
- 23. Essentials of EducationalPower Point • Common reasons for readmission • No timely follow up, medications, and symptoms • Highlighted the ACC/IHI H2H program • Post DC visit within 7days, “mind your meds”, and “signs and symptoms” • Listed barriers to reducing readmissions • Hospital environment not conducive to learning • Stated the positive impact of CR • Reviewed the evidence supporting CR • Shared best practices • CR in DC order set, increase Phase I visits to patients
- 24. Evaluation Facility Contact Was Info Helpful What wasnew or surprising? Will you add any of this content to your practice? Other Comments CPMC Yes, Definitely Barriers Identified – patients should not wait greater than 7 days for post DC visits Better surveillance of post DC follow up via EHR Was invited to attend their Cardiology meeting on ACC Seton Yes, well done Not really Inertia of the cardiologists due to multiple priorities at the facility. Excited to hear about the possibility of CR at the MC. St. Mary’s Yes, very Surprised to hear that it was taking over 14 days for PCP appointment. Need to consider seeing patients early in CR based on evidence presented. UC Davis Yes No We will be implementing Phase I in the near future in our program to try to capture more patients Patients who make to it rehab may be higher functioning and might have fewer medication issues and can better advocate for themselves if new symptoms arise.
- 25. Lessons Learned • CardiacRehab can be revenue producing • Revenue is also enhanced by decreasing readmissions and the associated fines to the facility • Also enhanced by lower incidence of lack of payment to the facility for patients readmitted within 30 days • Start on a smaller scale • Could a smaller project – Cardiology service line CNL implementation decreased the readmission rate of AMI patients? • Great deal of camaraderie and support among the participating CR programs surveyed
- 26. Summary • Strong evidenceto support implementation of CR program at the MC • Poor recall of discharge instructions after discharge including medications and symptom management • Decreased LOS not associated with higher readmissions • 2 RCT demonstrated lower readmission rates in subjects that participated in CR programs • Findings from survey will be incorporated into MC proposal • Including order for CR in discharge order set in HER • Consider other populations – Diabetes risk reduction
- 27. Summary - continued •Medical staff leadership very optimistic about the proposal • Planning to present proposal utilizing Aristotle’s Modes of Persuasion • Ethos – credibility of the speaker – evidenced based • Pathos – emotional influence – right thing to do for the patient population • Logos – sound and logical – positive ROI • Dr. Dean Ornish interested in partnering with the MC to establish his CMS reimbursable Intensive Cardiac Rehabilitation Program at the MC
- 28. Thank you….time forquestions “Nothing worthwhile is ever easy” Anne V. Turton, RN Thank you Frosty…