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Improving Nursing Home Care by Reducing Avoidable Acute Care Hospitalizations

Objectives. Describe the CMS Nursing Home Special StudyDiscuss the effectiveness of the intervention strategies and tools in reducing avoidable hospitalizations of nursing home residents.. 2. CMS Nursing Home Special Study Project Team . Joseph G. Ouslander, MD

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Improving Nursing Home Care by Reducing Avoidable Acute Care Hospitalizations

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    1. 1 Image of emergency vehicle Mary Perloe, RN, MS, GNP Project Coordinator Georgia Medical Care Foundation Gmcf logo Improving Nursing Home Care by Reducing Avoidable Acute Care Hospitalizations

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    3. CMS Nursing Home Special Study Project Team Joseph G. Ouslander, MD – Clinical Consultant, GMCF, Professor of Medicine and Nursing, Emory University Mary Perloe, APRN-BC, GNP – Project Coordinator, GMCF JoVonn Hughley, MPH – Evaluation Specialist, GMCF Tracy Rutland, MBA, MHA – Quality Improvement & Education Specialist Linda Kluge RD, LD, CPHQ – Nursing Home Project Manager, GMCF Gerri Lamb, PhD, RN – Professor, School of Nursing, Emory University Adam Atherly, PhD – Associate Professor, School of Public Health, Emory University Jeff Hibbert, PhD – Data Analyst/Statistician, GMCF Expert Panel – 10 members National and from Georgia MDs, GNP, PA – all with extensive experience in NH care; two past and one current president of AMDA, and one past president of AGS 3

    4. CMS Special Study Reducing Avoidable Hospitalization of Nursing Home Residents Identify NHs in Georgia with high and low rates of acute hospitalization Compare characteristics of these homes and their residents Structured interviews of NH and hospital staff Expert panel rating of avoidability using a structured implicit review process of 200 hospitalizations Develop potential intervention strategies and tools Pilot test interventions in 2-4 Georgia NHs with high hospitalization rates Disseminate results and intervention strategies 4

    5. 5 Hospitalization rates of nursing home residents in Georgia vary considerably (as expected) Description of table: Hospitalizations per 1000 resident days ALL (N=377), 1.62 (0-4.81) (0.78) Low Decile (N=38) 0.27 (0-0.64) (0.24) Low Group (N=10) 0.74 (0.52-0.89) (0.12) High Decile (N=38) 3.00 (2.54-4.81) (0.50) High Group (N=10) 3.17 (2.81-4.21) (0.40) Hospitalizations per resident ALL (N=377), 0.53 (0-1.50) (0.26) Low Decile (N=38), 0.10 (0-0.24) (0.09) Low Group (N=10), 0.27 (0.19-0.33) (0.05) High Decile (N=38), 0.98 (0.63-1.50) (0.19) High Group (N=10), 1.08 (0.90-1.49) (0.17) Total Hospitalizations ALL (N=377), 104 (0-386) (73) Low Decile (N=38), 14 (0-38) (14) Low Group (N=10), 60 (32-93) (21) High Decile (N=38), 171 (66-386) (74) High Group (N=10), 196 (96-386) (104)

    6. 6 There were no differences in the prevalence of most MDS-derived QIs among the high decile and low decile homes There was no difference in licensed nursing staffing ratios in the 10 high rate and 10 low rate homes involved in the more detailed study Structured interviews of staff in these 20 homes and their affiliated hospitals illustrated many communication problems and substantial mistrust Hospital staff felt that hospitalizations were often avoidable CMS Nursing Home Special Study

    7. 7 Results of Expert Panel Record Reviews (N = 200) Description of table: Was the Hospitalization Avoidable? Medicare A, Definitely/Probably YES, 69% Medicare A, Definitely/Probably NO, 31% Other, Definitely/Probably YES, 65% Other, Definitely/Probably NO, 35% HIGH Hospitalization Rate Homes (N=10), Definitely/Probably YES, 75% HIGH Hospitalization Rate Homes (N=10), Definitely/Probably NO, 25% LOW Hospitalization Rate Homes (N=10), Definitely/Probably YES, 59% LOW Hospitalization Rate Homes (N=10), Definitely/Probably NO,41% Total, Definitely/Probably YES, 68% Total, Definitely/Probably NO, 32%  

    8. 8 Admitting Diagnoses for Hospitalizations Rated as Potentially Avoidable Description of table: Hospital Admitting Diagnosis, Frequency (N = 105) Cardiovascular (mainly congestive heart failure and chest pain) 22 (21%), Respiratory (mainly pneumonia and bronchitis) 21 (20%), Mental Status Change/Neurological 13 (12%), Urinary Tract Infection 11 (11%), Sepsis/Fever 8 (8%), Skin (cellulitis, infected wound or pressure ulcer) 8 (8%), Dehydration and/or metabolic disturbance 7 (7%), Gastrointestinal (bleeding, diarrhea) 7 (7%), Musculoskeletal pain and/or fall 3 (3%), Psychiatric 1 (1%), Other (adverse drug effect, surgical consult) 2 (2%)

    9. 9 Expert Panel Ratings of Factors and Resources Important in Preventing Avoidable Hospitalizations Factors The same benefits could have been achieved at a lower level of care One physician visit could have avoided the transfer Better quality of care would have prevented or decreased severity of acute change Better advance care planning would have prevented the transfer The resident’s overall condition limited his ability to benefit from the transfer Resources Physician/NP present in nursing home at least 3 days per week Nurse practitioner Exam by physician or physician extender within 24 hours Registered nurse providing care Availability of lab tests within 3 hours Intravenous therapy Early identification and reporting of symptoms

    10. 10 Whatever proportion of transfers are avoidable (pick your number – 1/3, 40%, half, 2/3) reducing them will Improve the quality of care Reduce Medicare costs Avoid expenditures that can be re-invested in further improving quality of care Improving Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations

    11. 11 INTERACT Interventions to Reduce Acute Care Transfers logo A Tool Kit to Improve Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations Developed based on the data collected, and Expert Panel ratings of importance and feasibility Care Paths, Communication Tools, Advanced Care Planning Tools

    12. 12 Evidence-based Simple Feasible and efficient to use Acceptable to staff Development of INTERACT Tools

    13. 13 Care Paths Description of table: Target Audience All nursing home licensed nursing staff, administrative nurses, medical director, primary care physicians, nurse practitioners, physician assistants Tools Care Paths for: Acute mental status change Fever Lower Respiratory Symptoms Dehydration UTI CHF Sources Medqic website www.medqic.org Literature citations AMDA Clinical Practice Guidelines

    14. Lower Respiratory Infection Care Path Symptoms of Lower Respiratory Infection Labored breathing /shortness of breath New or worsened cough New or increased sputum production New or increased findings on lung exam (rales, wheezes) Chest pain with inspiration or coughing Take Vital Signs Temperature B / P Pulse Respirations Oxygen saturation For diabetics: Finger stick glucose Vital Sign Criteria Resident unable to eat and drink? Temp >102F (38.9C)? Apical heart rate>100? Respiratory rate >30/min? BP<90 systolic? Oxygen saturation <90%? For diabetics: Finger stick glucose <70 or >400? Yes, Notify MD/NP/PA No, Consider Lab Testing Portable chest X-ray Blood work Complete Blood Count Basic Metabolic Panel Results of chest X-ray show an infiltrate or pneumonia? Critical values in blood count or metabolic panel? Yes, Consider Transfer to Acute Care Facility No, Manage in Facility – Option * Oral, IV or Sub Q Hydration as indicated Oxygen supplementation as indicated Nebulizer treatments as indicated Antibiotic Therapy Oral (7-10 days) Levofloxacin 250-500 mg daily Amoxicillin / Clavulanate 850 mg bid Cefuroxime axetil 500 mg bid IM (2-3 days, then re-evaluate) Ceftriaxone 500-1000 mg IM daily Ceftriaxone 500 mg IM bid *Other options may be appropriate for individual residents. Sources: Loeb M, Carusone SC, Goeree R, et at: Effect of a Clinical Pathway to Reduce Hospitalizations in Nursing Home Residents with Pneumonia - A Randomizes Controlled Trial. JAMA 295: 2503-2510, 2006. Mylotte JM: Pneumonia and Bronchitis from Yoshikawa, Thomas T, Oustander JG: Infection Management for Geriatrics in Long-Term Care Facilities. New York, Informa Healthcare, 2nd Edition, Chapter 14, 223. This material was prepared GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessary reflect CMS policy. Publication No. 8SOW-GA-NHSS-07-01. Interact Interventions to Reduce Acute Care Transfer logo 14

    15. 15 Communication Tools Description of table: Target Audience Certified Nursing Assistants Tools Early Warning Assessment (“STOP AND WATCH”) Early Warning Report Target Audience All nursing home licensed nursing staff Tools SBAR Communication (general) SBAR Communication Templates related to specific conditions Acute mental status change Fever Pneumonia/Lower Respiratory Illness Dehydration UTI CHF Communicating acute changes in status – file cards by the telephone Target Audience Primary care physicians, nurse practitioners, physician assistants Tools SBAR Communication Templates related to specific conditions Communicating acute changes in status – file cards by the telephone Target Audience Emergency room and acute care hospital staff Tools Transfer checklist Target Audience Administrative nurses, medical director Tools Unplanned acute care transfer review

    16. SBAR Communication Tool (Situation, Background, Assessment, Recommendation) Lower Respiratory Infection  Before calling MD/NP/PA: Assess the resident. Check vital signs, and pulse ox and/or finger stick glucose if indicated. Review chart (most recent progress note and nurses notes from previous shift). Have ALL information AVAILABLE when reporting (Resident chart, advance directive status (DNR, Do Not Hospitalize, other care limiting orders) allergies, medication list). SITUATION I am calling about ________________________________________________________ He/she has signs and symptoms of lower respiratory infection, specifically: Labored breathing/shortness of breath New or worsened cough New or increased sputum production Fever New or increased lung sounds BACKGROUND   The resident’s primary diagnoses are _________________________________________ Medication changes in the last week include ___________________________________ The resident [meets/does not meet] the Lower Respiratory Infection Care Path criteria for management of signs and symptoms in the nursing home:   Able to eat and drink [yes/no] Temperature _________________________________________________________ Apical heart rate ______________________________________________________ Respiratory rate _______________________________________________________ BP__________________________________________________________________ Oxygen sat ___________________________________________________________ Gl 16

    17. Interact Interventions to Reduce Acute Care Transfer logo Early Warning Report If you have identified an acute change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Resident Stop and Watch Seems like himself/herself Talking the same Overall function the same Participated in usual activities Ate the same amount Drank the same amount No? Weak Agitated or nervous Tired or drowsy Confused Help with dressing, toileting, transfers Yes? Staff Reported to Date Time Adapted from Boockvar, Kenneth et all, JAGS 48: 1086-1091, 2000. 17

    18. Change in Condition File Cards Immediate Notification Any symptom, sign or apparent discomfort that is: Sudden in onset A marked change (i.e. more severe) in relation to usual symptoms and signs Unrelieved by measures already prescribed Signs & Symptoms A’s Sources: AMDA Clinical Practice Guideline – Acute Changes in Condition in the Long-Term Care Setting 2003. Ouslander, J, Osterweil, D, Morley, J. Medical Care in the Nursing Home. McGraw-Hill, 1996 18

    19. Advance Care Planning Tools Target Audience Residents and families Tools General Education Palliative Care End of Life Decisions: Advance Directives End of Life Decisions: Clinical Issues Conversations Before the Crisis Artificial Nutrition and Hydration at the End of Life Specific Education on Advance Directives Georgia Advance Directive Planning for Important Healthcare Decisions Next Steps Forms Georgia Short Form Durable Power of Attorney for Health Care Georgia Living Will Five Easy Wishes Sources Caring Connections (A program of the National Hospice and Palliative Care Organization (NHPCO); www.nhpco.org) Caring Connections (www.caringconnections.com) Aging with Dignity (www.agingwithdignity.org) NHPCO Aging with Dignity Target Audience All Nursing Home Staff Social Worker (or designated individual who discusses advance directives) Licensed Nurses, Physicians, NPs, and Pas Tools General Education as above for residents and families INTERACT advance care planning communication guide Identifying candidates for palliative care and hospice (Pocket Card) INTERACT advance care planning communication guide Comfort Care Order Set POLST Order Template POLST Paradigm Initiative Sources Caring Connections Literature citations, Birmingham VA BEACON project Literature citations, Birmingham VA BEACON project www.polst.org 19

    20. Advanced Care Planning Communication Guide Part 1 – Tips for Starting and Conduction the Conversation Set the Stage Get the facts-understanding the residents conditions and prognosis. Choose a private environment –neither a hallway nor a curtain provides adequate privacy. Determine an agenda for the meeting and who should be present. Allow adequate time – usually these discussions take 2-30 minutes. Turn beeper/cell phone to vibrate to avoid interruptions and demonstrate full attention. If the resident is involved, sit at eye level with them. Have tissues available. Initiate the Discussion Describe the purpose of the meeting. Identify whether the resident wants or already has a spokesperson and who it is. Ask what the resident/family understands about advance care planning, and the condition and prognosis. Offer to review NHPCO educational materials on advance directives and palliative care. Ask about their goals for care: Most nursing home residents and their families are more concerned about comfort than life prolongation. This opens the door to discuss palliative care and comfort care plans. Attempt to understand underlying rationale for the goals (i.e., “I’ve living long enough, now I’m ready to meet God,” or “I want to keep on living until my granddaughter graduates college next spring.”) this provides insight into specific decisions that are made. Make Key Points About Life-Sustaining Interventions Use simple language. Briefly discuss: Cardiopulmonary arrest and CPR. Artificial Hydration/Nutrition. Palliative care, comfort care orders, and hospice if appropriate. Interact Interventions to Reduce Acute Care Transfer logo 20

    21. CMS Nursing Home Special Study Tools and strategies were pilot tested in in 3 Georgia NHs with relatively high hospitalization rates Substantial time involvement of the GNP project coordinator both on and off-site 3 detailed case studies Use of tools Qualitative feedback on tools Analysis of each unplanned transfer Expert panel re-rating of potential avoidability of hospitalizations Very limited generalizability to the over 15,000 nursing homes nationwide 21

    22. 22 Most of the NH staff indicated they liked the tools and found them helpful Some perceived them as too much added paperwork Others preferred different formats Examples of tool utilization All 3 NHs did not use the Transfer Checklist, despite complaints from the hospitals about lack of information for decision making The Unplanned Transfer Review was a key component of the tool kit Almost 40% of the hospitalizations were rated as potentially avoidable by NH staff in this retrospective review CMS Nursing Home Special Study Reducing Avoidable Hospitalization of Nursing Home Residents

    23. 23 CMS Nursing Home Special Study Reducing Avoidable Hospitalization of Nursing Home Residents Challenges/Barriers to implementation of the tools Culture of using ER for any acute problem Mutiple PCPs Poor survey refocused energy Staff turnover of project leads Filling out transfer checklist and SBAR considered too time consuming SW designee uncomfortable talking about advance care planning Most of SW time spent on dual role as admissions coordinator Cultural issues surrounding advance care planning Lessons Learned See handout

    24. 24 Pre-Post Comparison of Expert Panel Ratings of Potentially Avoidable Hospitalizations in the 3 Pilot Study Homes Description of table: Nursing Home 1 Baseline (N=30) Number of Records Reviewed 10 Number (%) rated as probably or definitely avoidable 6 (60%) During 6-Month Intervention (N=65) Number of Records Reviewed 15 Number (%) rated as probably or definitely avoidable 6 (40%) Nursing Home 2 Baseline (N=30) Number of Records Reviewed 10 Number (%) rated as probably or definitely avoidable 10 (100%) During 6-Month Intervention (N=65) Number of Records Reviewed 25 Number (%) rated as probably or definitely avoidable 13 (52%) Nursing Home 3 Baseline (N=30) Number of Records Reviewed 10 Number (%) rated as probably or definitely avoidable 7 (70%) During 6-Month Intervention (N=65) Number of Records Reviewed 25 Number (%) rated as probably or definitely avoidable 13 (52%) Nursing Home All 3 homes Baseline (N=30) Number of Records Reviewed 30 Number (%) rated as probably or definitely avoidable 23 (77%) During 6-Month Intervention (N=65) Number of Records Reviewed 65 Number (%) rated as probably or definitely avoidable 32 (49%)

    25. 25 Rates of hospitalization of NH residents vary considerably and are related to several characteristics of the NHs and residents A substantial proportion of hospitalizations of NH residents are potentially avoidable Avoidable hospitalizations are costly To reduce avoidable hospitalizations NHs need support for infrastructure and tools that can be used efficiently in every day practice The intervention framework and tools developed and pilot tested in this study are promising, but need to be refined and tested in a larger sample of NHs Individual tools are appropriate for use in the 9th sow CMS Nursing Home Special Study Reducing Avoidable Hospitalization of Nursing Home Residents Conclusions

    26. CMS Nursing Home Special Study Reducing Avoidable Hospitalization of Nursing Home Residents Next Steps Further refinement and evaluation of the INTERACT intervention framework and tool kit through involvement of a larger and more nationally representative sample of NH staff and medical care providers will be helpful maximizing its feasibility, acceptance, and use. The use of components of the INTERACT tool kit for documentation in NH records should be examined, as this strategy may allay some of the concerns expressed about additional paperwork. (In particular, the SBAR Communication tools for nurses, and the “Stop and Watch” tool for CNAs would be amenable to this strategy.) 26

    27. 27 CMS Nursing Home Special Study Reducing Avoidable Hospitalization of Nursing Home Residents Individual Tools can be implemented in NH during the 9th SOW, specifically related to reducing hospitalizations under the Patient Pathways/Care Transitions theme Unplanned Transfer Review to identify areas for improvement by understanding circumstances resulting in a transfer Communication tools (SBAR, STOP and WATCH) to identify and report change in status, all staff reporting the same way Care Paths of common syndromes that often result in acute transfers provide guide to identifying, reporting and decision making Change in Condition File cards offer, quick easy access End of Life tools give staff some communication support

    28. 28 CMS Nursing Home Special Study Reducing Avoidable Hospitalization of Nursing Home Residents Link to Special Study tools: http://qualitynet.org/MedQIC Search INTERACT This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-TRN-08-05

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