The Role of the Medical Director in Care Transitions and Quality Assurance and Process Improvement

1. The Role of the Medical Director in Care Transitions and Quality Assurance and Process Improvement Karyn P. Leible, MD, CMD President AMDA-Dedicated to Long Term Care Medicine October, 2011

2. Speaker Disclosures Dr. Leible has disclosed that she has no relevant financial relationship(s).

3. Learning Objectives: By the end of the presentation, participants will be able to: List areas for the medical director review and involvement in a facility Quality Assurance and Assessment Process. Discuss how the medical director can assist a facility to employ principles of root cause analysis to address a potential issue of quality List key issues in individual transfers between sites of care Discuss interventions and tools being developed to address key issues Discuss the processes of care specific to the skilled facility interface in transitions of care

4. Role of the Medical Director F Tag 501 Coordination of medical care Implementation of Resident Care Policies

5. What is �Transitions of Care� The movement of patients from one health care practitioner or setting to another as their condition and care needs change

6. What is �Transitions of Care� Occurs at multiple levels Within settings Primary care specialty care ICU Ward Between settings Hospital skilled nursing facilities Ambulatory clinic senior care center Hospital home Across health states Curative Care Palliative care/hospice Personal residence Assisted living Transition cross multiple levelsTransition cross multiple levels

7. 7 Nursing HomesNursing Home Patient Flow After an admission to a nursing home, many things can happen. It depends on the initial reason for admission. More recently there has been the first admission from the acute setting into a facility for �rehab� and the goal to return to home. A small percentage will stay in the nursing home setting after a rehab stay. Others will return to home or to the community at a higher level of care such as ALF. During the rehab stay readmission to acute care can be as high as 25%. A subgroup of these will require repeated hospitalizations to remain stable. After an admission to a nursing home, many things can happen. It depends on the initial reason for admission. More recently there has been the first admission from the acute setting into a facility for �rehab� and the goal to return to home. A small percentage will stay in the nursing home setting after a rehab stay. Others will return to home or to the community at a higher level of care such as ALF. During the rehab stay readmission to acute care can be as high as 25%. A subgroup of these will require repeated hospitalizations to remain stable.

8. What is �Transitions of Care� A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location Based on a comprehensive care plan and availability of well trained practitioners that have current information about patient�s goals, preferences, and clinical status. Includes: Logistical arrangements Education of the family and patient Coordination among the health professionals involved in the transition

9. Introduction Little written on effective care transitions from nursing facilities AMDA Public Policy Committee organized a subcommittee to develop a white paper to address transitions to the community 2009 AMDA Clinical Practice Guideline on care transitions includes the white paper 2009 AMDA Public Policy Committee developed a white paper on transitions to and from facility and acute care 2010

10. Need for Better Care Transitions Key elements identified Patient-centered care Communication Safety

11. Need for Better Care Transitions Patient-centered care Transfers occur with the patient and/or family�s input and understanding to the extent possible Transfers are consistent with goals of care and advanced directives Transfers include appropriate patient and caregiver education

12. Need for Better Care Transitions Communication Information about the patient should be collected through the stay and be available in advance of any transfer When possible communications about transfers should be from professional to professional The sending and receiving professionals should have reliable contact information (phone, pager, fax) Professionals working with the snf/acute care interface should work together to develop standards for accurate and timely communications

13. Need for Better Care Transitions Safety Safe transfers of the resident to the acute setting requires accurate assessments and communications. Tools such as SBAR from the Interact II group, AMDA�s Acute Change in Condition in the Long Term Care Setting CPG help with the assessment and communication.

14. Need for Better Care Transitions Safety Safety requires accurate and timely transfer of key information Patient�s functional and cognitive status Goals of care and advanced directives Current problem list Current treatment regimen, including all necessary equipment Allergies Meal consistencies and preferences Recent labs consultations and diagnostic test results or those that are pending

15. Need for Better Care Transitions Promoting better care transitions in and out of nursing facilities promotes continuity of care throughout the healthcare continuum improve the quality of care, by reducing rehospitalization reducing adverse outcomes from medication errors. May improve a facility�s satisfaction and performance ratings and the public�s perception of facilities. A problematic transition to the community may discourage individuals from choosing to return to that facility for subsequent care.

16. Barriers to Effective Care Transitions Identifying and communicating with the patient�s primary care physician Working with patients who do not have a primary care physician Inadequate reimbursement to support adequate care transitions

17. Barriers to Effective Care Transitions The lack of accurate, pertinent, and timely information about the patient sent to the receiving facility, provider, or community-based care setting; Inadequate instructions for follow-up care, including monitoring the patient and identifying and managing risk factors An absence of appropriate measures to determine good care The patient and family understanding of condition, prognosis, and treatment.

18. Patient Follow-up After a Transition Essential information includes Whether the discharged patient can afford discharge medications, and whether the patient has a means (e.g., transportation, delivery, family) to obtain medications; Whether there are caregivers to appropriately support the patient after discharge; Whether the patient has responsibilities to care for someone else upon returning home; and Other significant risks for discharge issues, such as non-English-speaking, low-income, social isolation, multiple chronic conditions, and cognitive impairment.,

19. Identifying and Communication with Primary Care Physician PCP often left out of the transition process Do not know of the acute stay or the NF stay Various providers at the different care sites Consultants may change depending on the site of care Loss of continuity of health related information History, medications

20. Identifying and Communication with Primary Care Physician Who is the patient to follow up with at discharge? Patients and or families are to be given a choice of provider in the SNF Frequently unknown to the patient Problems can occur with medication renewals, DME, Home health, medication monitoring Discharge into the community Health Care Reform physician who certifies services to see elder

21. Patient Follow-up After a Transition Little standardization of approaches to care transitions Discharge planning should begin at admission. Essential information needed at admission includes but is not limited to: Whether there is a primary care physician, medical home, or clinic that will assume care; The identity of the receiving entity, and the contact person to receive information; The best way to communicate information to the receiving facility; The identity of family or other individuals acting on the patient�s behalf.

22. Patient Follow-up After a Transition  Responsibility for care does not end when the elder is discharged. Attempts need to be made to contact PCP Notify of impending discharge Assist with locating a PCP in the area Names of available practitioners and an appointment made Be available to answer questions after discharge 24 to 48 hours call to answer potential questions Reinforce need to contact community PCP

23. Recommendations: Identifying Responsibility Facility identifies someone to coordinate: Identify and/or confirm the resident�s community-based as well as facility-based (if different) PCP upon resident�s admission. Ensure that contact information for both the nursing facility attending physician and the community-based PCP is available in the facility�s record and for the patient. Ensure the patient/family understands the next step in follow up care. Ensure that the facility�s discharge information regarding medications is correct and complete. This information should be based in part on the patient�s current medication regimen, and should reconcile that regimen with the one prior to the current episode of illness.

24. Recommendations: Information Transfer Establish how to update PCP during resident stay Discharge information should be a �story� of the residents stay Episodes of delirium Falls Specific information for follow up i.e. treatment of anemia Medications started and rationale

25. Medication Management Medication reconciliation required at all transitions Discuss with PCP or elders pharmacy Formulary changes Initiation of medications for prophylaxis Continued indefinitely

26. Recommendations: Medication Reconciliation Communication with elders PCP Current medications Past medications Plans for follow monitoring Review of elders meds with elder and or family prior to discharge Avoid restarting previous meds on discharge

27. Recommendations: Resident Centered Approach Nursing facilities should give patients and PCPs key information such as the following: A reconciled medication list; Discharge instructions from the facility; Specific next steps in care (e.g., which provider to see next, why, and when); Specific follow-up tests to be performed, why and when; Who at the facility (or a specific provider) to call if questions arise, and how to reach them; Pertinent laboratory and x-ray test results; Pertinent consultations, emergency room and other encounters for continuing care; and Advance directives.

28. Recommendations: Resident Centered Approach Make a post-discharge call to the patient and/or family 1 to 2 days after discharge, this call might include the following: Inquiries about whether a home health visit is scheduled, or was made as scheduled; Reinforcement of medication adherence until the community-based PCP can be seen; Reinforcement of the need to follow up on physician visits and diagnostic tests; Review of whether supplemental resources have started (e.g., Meals on Wheels); and Checking whether the patient understands the next steps in care.

29. Medical Director Approach to Address Transitions Assisting staff to recognize that transitions from one level of care to another are a stressful time for many of our residents. It is a time when vital information maybe lost or forgotten

30. Approaches to Address Transitions Transitions into the facility: Prior to arrival to the facility: If able learn from the resident what simple pleasures he/she would enjoy while in the home and provide if able Have available specific DME, equipment, consider advanced scripts for medications (narcotics)

31. Approaches to Address Transitions Arrival Provide transportation when needed Assure all paper work/equipment comes with resident Discharge summary if available Provide sending facility with contact information for facility attending

32. Approaches to Address Transitions While at facility: Make contact with resident�s primary care provider. (Usually hospital physician is not the PCP) Alert that the resident is in the facility Ask about the best way to communicate progress to the PCP while resident is at facility Weekly fax, phone call or just at time of discharge

33. Approaches to Address Transitions Place name of PCP on face sheet and communicate with facility attending contact information for community PCP requires change on face sheet Advanced directives need to be clearly addressed at time of admission by social services or attending physician. Admission may ask about the presence and any preferences if known but discussions about advanced directives should be addressed by the attending or social services.

34. Approaches to Address Transitions Medication Reconciliation at time of admission Discharge planning begins at time of admission when appropriate Availability of caregivers Appropriate follow up Home health services PCP visits Outstanding diagnostic tests, labs

35. Approaches to Address Transitions Home assessment Discharge Planning Medication reconciliation Discharge booklet Adapted from NTOCC and Eric Coleman, MD Telephone follow up 24 to 48 hours Is there food Is the elder able to access help if needed

36. Approaches to Address Transitions Return to acute care Use of Interact II tools SBAR Physician/NP/PA communication and Progress note Resident Transfer form

37. Monitoring of Transitions Role for Quality Assurance and Process Improvement

38. Role of the Medical Director F Tag 501 Coordination of medical care Implementation of Resident Care Policies

39. Quality Assessment and Assurance F Tag 520 (1) A facility must maintain a quality assessment and assurance committee consisting of � (i) director of nursing services (ii) a physician designated by the facility; and (iii) at least 3 other members of the facility�s staff

40. QAA F Tag 520 (2) The quality assessment and assurance committee- (i) meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary and (ii) develops and implements appropriate plans of action to correct identified quality deficiencies.

41. QAA F Tag 520 (3) A state or secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. (4) Good faith attempts by the committee to identify and correct deficiencies will not be used as a basis for sanctions.

42. QAA Definitions Quality Assessment- is an evaluation of a process to determine if a defined standard of quality is being achieved. Quality Assurance- is the organizational structure, processes, and procedures designed to ensure that care practices are consistently applied and the facility meets or exceeds an expected standard of quality. Quality assurance includes the implementation of principles of continuous quality improvement.

43. QAA Quality Improvement- (Process Improvement) is an ongoing interdisciplinary process that is designed to improve the delivery of services and resident outcomes.

44. Quality Assurance and Process Improvement The Patient Protection and Affordable Care Act (ACA) Many provisions for which CMS is responsible for implementing Survey and Certification Group Section 6102 Establishment of standards relating to quality assurance and process improvement Purpose of program is to strengthen current requirements and promote accountability for resident care and safety by nursing facilities

45. Quality Assurance and Process Improvement CMS will establish a prototype QAPI program Independent contractor Pilot testing summer of 2011 Provision for stakeholder feedback Goal Establish on line resource library Upgrade current QAPI programs Best practices approach establish a QAPI online resource library and tools geared towards helping facilities to upgrade their current QAPI programs using a best practices approachestablish a QAPI online resource library and tools geared towards helping facilities to upgrade their current QAPI programs using a best practices approach

46. AMDA Policy March 2011 Role and Responsibilities of the Medical Director in the Nursing Home states that the medical directors should assist in developing formal patient care policies on quality of care that: Help the facility establish systems and methods for reviewing the quality and appropriateness of clinical care and other health-related services and provide appropriate feedback; Participate in the facility�s quality improvement process; and Help the facility provide a safe and caring environment.

47. AMDA Policy March 2011 AMDA policy on Performance Review supports performance review conducted under the auspices of the Quality Assessment & Assurance process for all attending physicians caring for residents in long-term care facilities, including performance review of the medical director when the medical director is also serving as attending physician.

48. AMDA Policy March 2011 AMDA policy on Performance Review states that medical directors should provide guidance in the development and implementation of policies on oversight and review of attending physician services, including those situations when the medical director is the attending physician.

49. AMDA Policy March 2011 AMDA recommends that the medical director should be a part of the Quality Assurance, Infection Control, and Pharmacy Committees. AMDA recommends that medical directors be familiar with the facility process of gathering MDS (minimum data set) data and reviewing the quality indicators/quality measures at least quarterly as a part of ongoing quality assurance activities.

50. QAA Tools My InnerView Proprietary Dashboard ABAQIS Proprietary QIS survey Point Right Proprietary MDS based Corporate systems and benchmarks

51. QAA Tools Facility reports Pressure ulcers Falls Accidents Infection Control QI/QM data (not available) Availability uncertain at least one year (spring 2012) MDS derived Graphs available for the QI/QM MDS 3.0 data

52. 52 THIS SLIDE SHOWS AN EXAMPLE OF THE QUALITY MEASURE/INDICATOR MONTHLY TREND REPORT AVAILABLE THROUGH THE MDS SYSTEM THE X AXIS SHOWS THE MONTH. THE Y AXIS SHOWS THE OBSERVED % OF NEW FRACTURES THE RED LINE IS THE FACILITY DATA THE GREEN LINE IS THE NATIONAL AVERAGE THE BLUE LINE IS THE STATE AVERAGE This slide shows an example of the capability of getting MDS QM data plotted longitudinallyTHIS SLIDE SHOWS AN EXAMPLE OF THE QUALITY MEASURE/INDICATOR MONTHLY TREND REPORT AVAILABLE THROUGH THE MDS SYSTEM THE X AXIS SHOWS THE MONTH. THE Y AXIS SHOWS THE OBSERVED % OF NEW FRACTURES THE RED LINE IS THE FACILITY DATA THE GREEN LINE IS THE NATIONAL AVERAGE THE BLUE LINE IS THE STATE AVERAGE This slide shows an example of the capability of getting MDS QM data plotted longitudinally

53. ABAQIS

54. ABAQIS

55. Dashboard: My InnerVeiw

56. Point Right

57. Point Right Can look at MDS items such as fall depressionCan look at MDS items such as fall depression

58. MDS 3.0 Opportunities to assess quality through the facility own data collection opportunities with 3.0 Assessments are done for OBRA Day 14 then quarterly Annual review Discharge Assessments are done for PPS Days 5, 14, 30, 60, 90

59. MDS 3.0 Potential areas for quality monitoring BIMS scores PHQ-9 scores Pain management Late loss ADL (toileting, eating, transfers, bed mobility) Urinary incontinence/ infections Weight loss Prognosis (less than 6 months) Pressure ulcers

60. CMS 672

61. CMS 672

62. Quality Assurance and Assessment Facility Reports Pressure ulcers Infection control UTI with and without catheters Falls Warfarin use INR > 3.5 Resident and family complaints Hospital transfers

63. Run Charts Example of a run chart looking at incident of falls per 1000 resident daysExample of a run chart looking at incident of falls per 1000 resident days

64. Control Chart View a process over time Give a visual description of what the process has done and is doing If the process is in control, (random normal variation or random walk), you can predict how the process will perform over time 64 USE OF A CONTROL CHART ALLOWS YOU TO VIEW A PROCESS OVER TIME. LIKE THE PREVIOUS GRAPH IT SHOWS YOU A PLOT OF DATA POINTS OVER TIME. IT PROVIDES A VISUAL DESCRIPTION OF WHAT THE PROCESS HAS DONE AND IS DOING. IF THE PROCESS HAS ONLY RANDOM NORMAL VARIATION (ALSO KNOW AS RANDOM WALK), THEN THE PROCESS IS SAID TO BE IN CONTROL. IN THIS CASE IF WE PLOTTED OUT A FREQUENCY HISTOGRAM OF THE DATA POINTS IN THE TIME SERIES, WE WOULD GET SOMETHING THAT LOOKS LIKE A BELL-SHAPED CURVE, AND WE CAN MARK LIMITS BEYOND WHICH THE PROCESS IS UNLIKELY TO GO SIMPLY DUE TO RANDOM VARIATION. THESE ARE KNOWN AS THE CONTROL LIMITS AND ARE MARKED ONTO THE CONTROL CHART GRAPH AS WE WILL SEE IN THE NEXT SLIDE. This slide introduces the Control Chart.USE OF A CONTROL CHART ALLOWS YOU TO VIEW A PROCESS OVER TIME. LIKE THE PREVIOUS GRAPH IT SHOWS YOU A PLOT OF DATA POINTS OVER TIME. IT PROVIDES A VISUAL DESCRIPTION OF WHAT THE PROCESS HAS DONE AND IS DOING. IF THE PROCESS HAS ONLY RANDOM NORMAL VARIATION (ALSO KNOW AS RANDOM WALK), THEN THE PROCESS IS SAID TO BE IN CONTROL. IN THIS CASE IF WE PLOTTED OUT A FREQUENCY HISTOGRAM OF THE DATA POINTS IN THE TIME SERIES, WE WOULD GET SOMETHING THAT LOOKS LIKE A BELL-SHAPED CURVE, AND WE CAN MARK LIMITS BEYOND WHICH THE PROCESS IS UNLIKELY TO GO SIMPLY DUE TO RANDOM VARIATION. THESE ARE KNOWN AS THE CONTROL LIMITS AND ARE MARKED ONTO THE CONTROL CHART GRAPH AS WE WILL SEE IN THE NEXT SLIDE. This slide introduces the Control Chart.

65. 65 THROUGH THE USE OF FORMULAS OR EXCEL SPREAD SHEETS THAT ARE INCLUDED IN YOUR RESOURCE GUIDE, YOU CAN CALCULATE WHAT ARE KNOWN AS THE UPPER(UCL) AND LOWER (LCL) CONTROL LIMITS OF YOUR PROCESS. THE EXCEL FILES ONLY REQUIRE YOU TO ENTER THE DATA POINTS, AND THE PROGRAM WILL PRINT OUT THE GRAPH WITH THE CONTROL LIMITS ON IT. NOTE THAT THIS DOESN�T TELL US THAT OUR PROCESS IS GOOD (OR BAD), BUT ONLY THAT WHAT WE ARE DOING IS FAIRLY CONSTANT. THAT IS, OUR PROCESS IS STABLE. This slide depicts the upper and lower control limits drawn on a Control Chart, and further explains the meaning of a Control Chart when the points are all between the control limits.THROUGH THE USE OF FORMULAS OR EXCEL SPREAD SHEETS THAT ARE INCLUDED IN YOUR RESOURCE GUIDE, YOU CAN CALCULATE WHAT ARE KNOWN AS THE UPPER(UCL) AND LOWER (LCL) CONTROL LIMITS OF YOUR PROCESS. THE EXCEL FILES ONLY REQUIRE YOU TO ENTER THE DATA POINTS, AND THE PROGRAM WILL PRINT OUT THE GRAPH WITH THE CONTROL LIMITS ON IT. NOTE THAT THIS DOESN�T TELL US THAT OUR PROCESS IS GOOD (OR BAD), BUT ONLY THAT WHAT WE ARE DOING IS FAIRLY CONSTANT. THAT IS, OUR PROCESS IS STABLE. This slide depicts the upper and lower control limits drawn on a Control Chart, and further explains the meaning of a Control Chart when the points are all between the control limits.

66. Meetings Agenda Reports prepared in advance Consider sub committees to address a question Involve staff working closest to the residents whenever possible Sub committee meets identifies potential root case Develops action plan/intervention Monitors and reports back to QAA Manage the time of the meeting

67. Quality Improvement Process Three fundamental questions What are we trying to accomplish? How will we know that change is an improvement? What changes can we make that will result in improvement?

68. Quality Improvement Process Three fundamental questions What are we trying to accomplish? How will we know that change is an improvement? What changes can we make that will result in improvement?

69. The Model for Continuous Improvement - PDCA THE BASIC PROCESS IMPROVEMENT CYCLE CONSISTS OF 4 MAIN COMPONENTS: PLAN DO CHECK ACT This slide introduces the 4 major elements of the Continuous Improvement Model THE BASIC PROCESS IMPROVEMENT CYCLE CONSISTS OF 4 MAIN COMPONENTS: PLAN DO CHECK ACT This slide introduces the 4 major elements of the Continuous Improvement Model

70. Identify Root Causes Fishbone Flow charting 6 Whys

71. Root Cause Analysis Identification of process issue Fishbone Brainstorming

72. Fishbone resident

73. Flowcharting Why use it? To allow a team to identify the flow or sequence of events in a process; helps picture the process. 73 FLOWCHARTING IS USED TO ALLOW A TEAM TO IDENTIFY THE FLOW OR SEQUENCE OF EVENTS IN A PROCESS. IT HELPS TO VISUALIZE THE PROCESS. This slide and the next slide explain the utility of Flowcharting.FLOWCHARTING IS USED TO ALLOW A TEAM TO IDENTIFY THE FLOW OR SEQUENCE OF EVENTS IN A PROCESS. IT HELPS TO VISUALIZE THE PROCESS. This slide and the next slide explain the utility of Flowcharting.

74. 74 THESE NEXT 2 SLIDES PROVIDE AN EXAMPLE OF FLOWCHARTING This slide introduces and example of a flowchartTHESE NEXT 2 SLIDES PROVIDE AN EXAMPLE OF FLOWCHARTING This slide introduces and example of a flowchart

75. Flowcharting Sticky notes

76. 6 Whys A resident fell in the night? Why She was getting up to get to the rest room Why She did not have an opportunity to use the restroom before laying down Why The CNA did not know the resident well and did not know to take her Why

77. 6 Whys The CNA had not previously worked on the neighborhood and was filling in for another but did not know the routines of this neighborhood Why There had not been an opportunity to orient the CNA to the neighborhood at the start of the shift Why The LPN was busy with a resident who was being sent to the hospital

78. Action Plan

79. The Model for Continuous Improvement - PDCA THE BASIC PROCESS IMPROVEMENT CYCLE CONSISTS OF 4 MAIN COMPONENTS: PLAN DO CHECK ACT This slide introduces the 4 major elements of the Continuous Improvement Model THE BASIC PROCESS IMPROVEMENT CYCLE CONSISTS OF 4 MAIN COMPONENTS: PLAN DO CHECK ACT This slide introduces the 4 major elements of the Continuous Improvement Model