Ensuring Patient Safety at Home

1. Ensuring Patient Safety at Home Mary Ann Christopher, MSN, RN, FAAN President & Chief Executive Officer Visiting Nurse Service of New York 5th Annual Lorraine Tregde Patient Safety Leadership Conference June 14, 2012

2. VNSNY: Who We Are The Visiting Nurse Service of New York • Founded in 1893 by Lillian D. Wald, VNSNY is the largest non-profit community-based health care agency in the U.S. • Serves all five boroughs of NYC, plus Westchester, Nassau, and Suffolk Counties • Plans a statewide expansion • Provides a range of services to an average daily census of 31,000 patients, from newborns to seniors • 16,000 employees – most are field staff providing direct care • Serve a socio-economically diverse population (36% speak a foreign language) 2

3. Presentation Framework • Industry perspective • Magnitude of Problem • Patient Anecdotal • Interventional strategies with qualitative and quantitative outcomes

4. Safety Issues at Home • Falls Prevention • Non-Healing Wounds • Depression • Transitions of Patients Across the Continuum • Adverse events related to medication administration • Patient Preference

5. Falls Prevention • 1 in 3 adults over 65 will suffer a serious fall this year • 70% of these falls occur at home • 1 in 2 adults 85 and older fall • Falls are the leading cause of fatal and non-fatal injury in older adults • Every 17 seconds, an elderly person is taken to the ER because of a fall • High likelihood of a fall within 48 hrs of changes or additions to medications

6. Risk Factors for Falls MultipleMedications Medical and Falls History Balance & Mobilityfootwear & devices FALLS Muscle Weakness EnvironmentSafety Vision

7. Strong Foundations: Background • “Strong Foundations” is a multidisciplinary initiative aimed at patients at high-risk for falls. Falls interventions combine skilled nursing care and physical therapy in a 4-part course of treatment • Data will be obtained from patient self-report and VNSNY administrative and clinical systems on: • Incidence of falls and hospitalizations • Quality of Life • Satisfaction with Care • Ambulation • Sustainability of exercise plan

8. Strong Foundations: Risk Assessment Tool • Nurse and a physical therapist assess the following 8 factors for falls, as consistent with the American Geriatrics Society guidelines on falls prevention: • The RN assesses the first 5 factors on the patient’s first visit using OASIS measures • For the remaining measures, the physical therapist performs a number of standardized, quantitative assessments:

9. Non-Healing Wounds • Affect over 1 million people, exceeding $11 billion in all settings • Wound infection rates increased 27% from 2000 – 2005 • 30% of patients have wounds and 42% have multiple wounds • Unacknowledged impact of patient preference on quality outcomes

10. Non-Healing Wounds (cont.) • Communication reminders to clinicians improve patient safety • Management guidelines include WOCN (Wound Ostomy Continence Nurse) Consultation • New Jersey Hospital Association: • Cross continuum collaborative involving 150 organizations • Use of Braden Scale and implementation of 3 preventive measures: • Manage moisture • Optimize nutrition and hydration • Minimize pressure • Outcomes: 70% reduction in decubitus ulcers

11. Depression • Affects more than 6.5 million (or 18%) of the 35 million Americans aged 65 years or older • major depression is twice as common in elderly patients receiving home care than in those receiving primary care • chronic illness is the most common factor associated with depression (prevalence of depression can rise from 10% to 30%) • Even if diagnosed, roughly 18% of the elderly are on the wrong meds or have an ineffective dose; thus receiving inadequate therapy • If untreated, depression can lead to: • poorer outcomes for hip fractures, heart attacks & cancer • decline of cognitive abilities • avoidable hospitalizations • increased risk of suicide • Of those elderly who attempt suicide, 80 percent are reported to have major depression

12. VNSNY Behavioral Health Program • Employs psychiatric nurses, psychiatric nurse practitioners and in-home visiting psychiatrists and receives referrals from community primary care physicians, hospitals and family members • In 2011, 1100 patients were admitted to the VNSNY Behavioral Health Program with the following 5 top diagnoses: • depression • anxiety • dementia (early onset) • bipolar disorders • schizophrenia • VNSNY Behavioral health specialists employ: • PHQ-9 assessment tool • Evidence-based practice treatments, using anti-depressive medication and Cognitive Behavioral Therapy (CBT)

13. Transitions of Patients Across the Continuum • Rehospitalizations are costly and avoidable • 1 in 5 Medicare patients are rehospitalized in 30 days • 34% are rehospitalized within 90 days • Half never see an outpatient doctor within 30 days after discharge • Costs $17.4B* *Coleman, Williams, et al. NE Journal of Medicine

14. Drivers of Hospitalization Risk Higher hospitalization risk is associated with: Previous Hospitalization Unhealed Pressure & Stasis Ulcers Diagnosis Type Medication Use Illness & Symptom Severity Urinary Incontinence & Catheters Respiratory Symptoms ITAC 2012

15. Transitional Care Model • Predictive Algorithm with alerts to clinicians • Short and long-term transitions of care program • Adapted Brenner Model • Continuity of Care Challenges

16. Transitional Care ProgramResults: 30 Day Readmission Rates

17. Opportunities for Improved Outcomes ER Visit Continuity of Care Hospital Readmission - - + ADL Functioning

18. Medication Management Patients who did not take medications as prescribed cost the health care system $290B in available medical spending 2009 (New England Health Care Institute) In a study of patients, 1/5 had adverse events due to inadequate medical care after returning home, with Rx drugs accounting for most injuries after discharge Some medications get discontinued inadvertently(mostly statins and anticoagulants) with a resultant adverse impact on patient safety and hospital recidivism Non-geriatric friendly medications can result in unnecessary falls and motor vehicle accidents

19. Components of an Effective Medication Program • Care Coordination • Utilization Management • A well thought out formulary structure • E-prescribing • Basing pharmacists and nurses at neighborhood and senior centers • Automatic medication dispensers • Involvement of PharmD in interprofessional team

20. VNSNY CHOICE Model has Produced Measurable Outcomes Hospital Admissions: Utilization data for a cohort of 573 members enrolled in our care coordination program for 24 months showed significant reductions: • 54% decrease in hospital admissions • 24% decrease in readmits within 30 days to 16% • 27% decrease in ER visits

21. Vulnerable Patient Study • Background: • VNAA, in collaboration with the VNSNY Center for Home Care Policy & Research, initiated a patient study in 2010 to collect data on a range of patients and their associated costs • Initiated by 9 VNAs across the country • Now being replicated nationally with 50 home care organizations • Adequacy of Risk Adjustment: • Identified variables: health literacy, stasis or pressure ulcers, presence of caregiver, access to primary care, clinically complex conditions, functional disability with poor rehabilitation potential