OUR STORY

1. OUR STORY STAAR STATE ACTION ON AVOIDABLE REHOSPITALIZATIONS Cherelyn Roberts, RN, BSN

2. Holyoke, Massachusetts Income is 61% below the state average Cardiovascular disease is 278% above the state average Poorest municipality in Massachusetts 30% of community are tobacco users Alcohol and Drug related illnesses are 246% above the state average 5th highest rates of suicide 2nd highest rate of teen births 48.5% of population is Latino, primarily Puerto Rican 36% prefer a language other than English

3. Our Hospital • Holyoke Medical Center is the largest provider of inpatient and outpatient healthcare services to the poorest community in Massachusetts • 80% of adult patients admitted to the hospital from the community are cared for by a Hospitalist • 189 Beds consisting of a MedSurg Unit including Orthopedics , ICU , Telemetry , Birthing, and a Psychiatric Unit • Our average readmission rate was 14.8% for all causes all payors

4. STAAR PROGRAM • HMC began working on the STAAR Program actively in August of 2011. • The STAAR Program perfectly aligned with other work being done such as Patient Centered Medical Home and Care Transitions • Four Key Changes were addressed: 1.Perform and Enhanced Assessment of Post Hospital Needs 2. Provide Effective Teaching and Facilitate Enhanced Learning 3. Ensure Post Hospital Care Follow up 4.Provide Real Time Handover Communications

5. Our Partners

6. Holyoke Health Center.

7. http://www.rebhc.org/ Soldiers Home In Holyoke HOLYOKE HEALTH CARE CENTER (M) 282 Cabot Street

8. PCP/Medical Home Providers • WMPA ( Western Mass Physician Associates) • Holyoke Health Center • Valley Medical PCP Offices ,Amherst

9. Current Members • 7 Different Home Health Agencies • 14 Facilities consisting of Acute Hospitals , Skilled Nursing Facilities and Acute Rehabs • Several PCP Offices and Health Clinics • 2 Patient/Family Members • Other stakeholders such as Pharmacists, RT, IT as needed per project

10. Understanding the Continuum of Care Primary Care Acute Care Hospital LTAC – Long Term Acute Care Hospital IRF – Inpatient Rehabilitation Facility SNF/sub-acute/Skilled Nursing Facility / Nursing Home LTC – Long Term Care ALF – Assisted Living Facility VNA – Home Health Care / Visiting Nurse Hospice Care – End of life care in various settings 10

11. The Eyes of the Patient • The PFAC members keep us tuned in to how the patient is feeling • We had predicted that waiting for paperwork to be completed was the delay in getting a patient out the door but quickly learned through them that it was something totally different!

12. OUR TEAM

13. Rules of Engagement • Throw out your old attitudes about work • Don’t think of reasons Why it Won’t Work, Think of Ways to Make the New Ideas Work • Don’t Make excuses, and Don’t Accept Excuses. Don’t say, “ We can’t” • Don’t wait for perfection; 50% ,is fine for starters • Correct Problems Immediately • Wisdom Arises from Difficulties • Ask “Why” at least 5 times until you find the root cause. • Better the “Wisdom” of Ten people then the “Knowledge” of One. • Improvements are Unlimited. Don’t Substitute Money for Brains. • Improvement is Made at the Workplace NOT from the Office.

14. OUR AIM STATEMENT: HMC will decrease the monthly readmission rate by 20% from 14.8% and maintain that rate by Dec 2013 by improving the handoff of critical information to the next provider

15. May 2010 thru Oct 2013 CHF program CTEP COPD

16. Holyoke Medical Center

17. Accomplishments • Heart Failure and COPD Redesigned Educational Tools shared across the Continuum • Teach Back taught and used across the Continuum • Heart Failure Protocol established in One SNF with Resource RN and spreading to other SNFs • Identification for High Risk For Readmit • Warm Handoffs • Care Transitions Education Project • Pharmacy Education at the Bedside of HF patients • PCMH work • Appts prior to discharge • Follow up calls • Priority to HF patients for Home Health Visits

18. How we established our CCT • Networking • Visiting Facilities • Offering to introduce the STAAR program at the Health Clinic, PCP, offices, VNAs and SNFs • Asked for frontline staff to join us as they have the most access to our patients and they were the ones that would keep this going and know what needed to be done

19. Sharing of Information • Relationships were formed • Resource RN visited the facility • Respect for each other’s environment was established • Realization that we cared for the same patients but with different goals • How could we, while working together, help the patient succeed?

20. We started with a Site Visit • HGA, a long term care facility that also provides short term rehab and adult day care for our patients agreed to trial a Resource Nurse • Hospital RN spent the day at the Nursing Home after the facility had sent 2 RNs and 2 nurse aides to shadow here on the cardiac unit

21. Barriers Identified • Poor Health Literacy • Time and Access to front line staff • Inconsistent communication between hospital providers (MDs, RNs) and PCPs • Limited electronic registers and tools for communication and tracking patients

22. CHF TOOLS FOR SNF

23. SNF TOOL FOR CHF PATIENT 2GM NA DIET 2GM SODIUM DIET 2GM SODIUMDIET Intake/output Daily weight Same way/same time HF ZONE Check every shift Green-yell-red Notify MD if Yellow zone per protocol

24. Enhanced Educational Tools

25. ZONE EDUCATION

26. CCT MEETINGS ALL members meet monthly now at different sites! • We discuss case reviews, each organization presents a readmit and the group brainstorms on: • “What went wrong?” “what went well?” • “Was the readmission avoidable?” • What are we doing to prevent readmits?

27. Recent Evidence of Success of CCT • Holyoke VNA Project : “Heart Failure Boot Camp” 5 day program • Mary’s Meadow Warm handoff progress • Home Health Transition Coach Tracer • Care Transitions Education Project • Forum held with Hospitalists and Community Physicians (next one being planned)

28. Care Transitions Education Project Complement and Leverage Existing Care Transitions Efforts 28 28

29. Care Transitions Education Project Grantee MA Senior Care Foundation Timeline Sept 1, 2011 – Aug 31, 2014 Budget $450,000 Partners 32 organizations Project Co-Investors • Partners Investing in Nursing’s Future -- Collaborative of Robert Wood Johnson Foundation & Northwest Health Foundation • Massachusetts Senior Care Foundation • Irene E. & George A. Davis Foundation • Home Care Alliance of MA • Regional Employment Board of Hampden Co. • Healthcare Workforce Partnership of Western MA • United Way of Pioneer Valley • Commonwealth Corporation 29

30. Care Transitions Education Project Nurses are in unique position at every step of the patient’s journey 30

31. Equipping nurses to lead effective patient-centered care transitions 31

32. Care Transitions Education Project Year 1 9/11-9/12 Year 2-3 9/12-12/13 Year 3 1/14 - 8/14 Project Objectives • Increase competency to lead and improve care transitions • Increase mutual respect across care settings • Improve coordination and collaboration • Demonstrate nurse-led quality improvement 32

33. What Causes Adverse Events During Care Transitions? Care Transitions Education Project • We fail to communicate critical information about a person’s care, safety, medications, advance directives, in-home support services and social situation • We fail to identify issues such as health literacy, cultural barriers and educational issues 33

34. The Opportunity:Why This Why Now? Care Transitions Education Project “Improving care transitions can save lives and reduce adverse events and disability due to gaps or omissions in care.” Massachusetts Strategic Plan for Care Transitions 34

35. Cross Continuum Team Branches COPD team PulmonaryRehab Team Partnering with RT and Pharmacy Teach back sessions Heart failure program Community partners Chronic Disease Patient Education Tools Resource Nurse Care Transitons Project Tobacco education committee PCMH

36. Our Relationships Allow Us to Reach across the Barriers and open up the lines of communication to provide more “patient centered care” that is improving the lives of our patients especially those with chronic illness

37. CCT in the Community • Assisted a Public Housing Corporation with smoking cessation support and education sessions in Senior Housing Communities • Other members of our CCT did the same in their community • Public Housing was going smoke free and asked us to help • Great opportunity to reach out to our elders in the community and establish realtionships

38. STAAR “Bursts” • We feel the STAAR program has laid the groundwork and ground rules for this Transition Program to take place. • Everything we have been working on is going to become “real” as the frontline nurses make it happen! • We are excited to be Pioneers in providing “Patient Centered Care”

39. Solutions to Organizing a CCT • Start at the top • Approach the Organization you want to partner with and explain the importance of transition work and what it will mean for the patient and their organization. • Always bring it back to the patient. We all want what is best for the patient • Offer to share your knowledge, expertise , time and materials • Develop tests to trial together • LISTEN to each other

40. Future Plans • Sustain • Spread THANK YOU!

41. Questions?