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Tobie H. Olsan, PhD, RN* Suzanne Gillespie, MD, RD, CMD* Jurgis Karuza, PhD*

From Isolation to Collaboration: A Rural Nursing Home Initiative to Reduce Residents’ Preventable Hospitalizations. Tobie H. Olsan, PhD, RN* Suzanne Gillespie, MD, RD, CMD* Jurgis Karuza, PhD* Paul R. Katz, MD, CMD ** Cathie Chabrier, MPH, LNHA W James Evinger, MDiv *

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Tobie H. Olsan, PhD, RN* Suzanne Gillespie, MD, RD, CMD* Jurgis Karuza, PhD*

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  1. From Isolation to Collaboration: A Rural Nursing Home Initiative to Reduce Residents’ Preventable Hospitalizations Tobie H. Olsan, PhD, RN* Suzanne Gillespie, MD, RD, CMD* Jurgis Karuza, PhD* Paul R. Katz, MD, CMD** Cathie Chabrier, MPH, LNHAW James Evinger, MDiv* *University of Rochester Medical Center **Baycrest, Toronto, Canada WWayne County Nursing Home and Rehabilitation Center

  2. Speaker Disclosures Dr. Olsan has no relevant financial conflicts to report

  3. Learning Objectives By the end of the session, participants will be able to: • Describe the Greater Rochester Nursing Home Quality Consortium (GRNHQC) collaborative to reduce residents’ preventable hospitalizations • Discuss the three elements of transition of care (TOC) improvement bundle • Assess project milestones and preliminary results • Discuss project success factors

  4. Greater Rochester Nursing Home Quality Consortium • Who We Are • Rural nursing home (NH) quality improvement collaborative • Rural (n=13) and Urban (n=3) NHs • University of Rochester Medical Center Schools of Nursing and Medicine • Finger Lakes Geriatric Education Center • Greater Rochester Quality Council • What We Do • Teach Lean Six Sigma (LSS) QI principles and methods to NH administrators and teams • Provide LSS coaches to teams to implement QI projects • Emphasis on evidence-based improvements and quality and outcome measurement • Share knowledge, expertise, ideas for change, successes • Telepresence videoconference technology

  5. Administrator Perspectives • “We are all alone out here and quality does not happen in isolation.” • ~Joanne Hernick, Administrator • NYS Veterans Home at Batavia • “It is the coming together of all different peoplethat will change the way we think and care for residents.” • ~Mark Wheeler, Deputy Director • Livingston Co. NH & Rehab. Ctr.

  6. QI Projects • Clinical Quality • Falls • Pressure Ulcers • Resident Aggressive Behaviors • Restorative Nursing Care • Organizational Effectiveness • Medication Administration • Admission Bed Hold Process • Reducing Hospitalizations • Utilization of Incontinent Products • Supply Expenses and On-Time Delivery • Staff Health and Well-Being • Workplace Injuries

  7. Improving Transitional Care: A National Priority • High volume • 29% of NH residents are discharged to hospitals annually (Kasper, 2005) • 25% of Medicare beneficiaries discharged from hospitals to NH are rehospitalized in 30-days (Mor, 2010) • High Cost • $4.34 billion Medicare expense for 30-day readmissions (Mor, 2010) • Transitions put residents at risk for harm • Adverse drug events (Boockvar, 2004) • Gaps in communication (Terrell, 2005) • Resident and family dissatisfaction and distress (Levine, 1998)

  8. GRNHQC Phase 2 • AMDA Foundation/QI Pfizer Award 2011-2012 • Six GRNHQC homes formed our first inter-facility QI team • Problem: 30-day resident rehospitalization rate of 28% resident compared to overall NYS average of 25.3% (Mor et al, 2010) • Goal: Reduce 30-day readmissions to 10%-12% by December 2012

  9. Project Timeline

  10. Methods: Planning and Organization • Project Team • Team Leader, Cathie Chabrier, MPH, LNHA, Wayne County Nursing and Rehabilitation Center • Members, NH leaders, hospital staff, and faculty • Master Black Belt, LSS Coach • Research Subcommittee • Identify best practices and quality measures • Major transitional care models reviewed • INTERACT II, Project RED, STARR, BOOST, Coleman’s Care Transitions, Naylor’s Transitions of Care

  11. Methods: Planning and Organization • Data Subcommittee • Data sharing agreement • Data team • Senior programmer, senior analysts, statistician • Created three project databases • Facility (web based) • Referral Hospitals (web based) • Resident • Merge NH’s LeadingAge New York’s Equip for Quality MDS 3.0 data with each NH’s Admission/Discharge/Transfer data

  12. Process Analysis and Improvement • Root Cause Analysis • Phase 1: Communication, Coordination, Safety Gaps • Phase 2: Elder Entrée to the NH, End-of-Life Care, Family Involvement issues • Transition of Care (TOC) Bundle Elements • Medication reconciliation • Communication, coordination, monitoring resident care • Transfer of resident information from NH to hospital

  13. Primary Sources for TOC Bundle Development • AMDA Clinical Practice Guidelines: Transitions of Care in the LTC Continuum http://www.amda.com/tools/guidelines.cfm • Interact II tools http://interact2.net/ • Gillespie (2008) Improving NH to ED Transfer

  14. Standardized Tools • Medication Reconciliation • Work group developed based on AMDA Transitions of Care Practice Guideline and NTOCC Essential Elements • Communication, Coordination, Monitoring • Work group adopted Interact II tools • Care Plans • Early Warning Tools • Change of Condition Guidelines • SBAR for Communication • Transfer Checklist/Envelope • NH to ED Resident Transfer Form • Work group adapted from Gillespie (2008)

  15. Framework for EvaluationPre (2011) – Post (2012) TOC Bundle Structure Process Outcomes • Nursing Home: • Characteristics • Longevity • Medical Staff • Organization • Nursing Staffing • Unit Services • Reimbursement Rates • Resident: • Demographics • Diagnosis • Health Status • Insurance • Care Processes: • Medication Reconciliation • Care Planning • Monitoring • Communication • Team • ED • Culture: • Hierarchical • Group • Rational • Developmental • Quality Measures/ Outcomes: • Readmission Rate • LOS NH and Hospital • Team determination if transfer was preventable

  16. Preliminary Results • Participating Nursing Home Profiles (n=6) • Organization • Setting: 5 Rural,1 Urban • Governance: Public, Non-Profit, Proprietary • Hospital Affiliated: 2 • NH Residents • Long-term and rehabilitation: 126 – 475 beds • Case Mix: 0.80-1.32 • Staffing • Medical Director: Full-Time: 3; Part-Time: 3 • Community Physicians: 5 • Nurse Practitioner: 0 – 2

  17. 2011 Resident Profile (Baseline) (n=1 Nursing Home, Rural, Public) • Baseline: January 1, 2011 • Residents: 186 • Female: 67% • Average Age: 82 years • Rehabilitation Care: 7% • Average Resident LOS: • 19 days rehab • 2 years long-term • Medicaid: 64% • Medicare: 5%

  18. 2011 Resident Profile (n=1 Nursing Home, Rural, Public) • Primary NH Diagnosis (ICD-9) • Circulatory: Stroke, heart failure, MI • Mental: Dementia • Neurological: Multiple Sclerosis. Parkinson’s disease • Injury: Fractures • Health Status • Mean ADL: 8.36 • Falls: 23.0% • Antidepressant medications: 57.9% • Risk for pressure ulcers: 80%

  19. 2011 Admits/Readmits(n=1 Nursing Home, Rural, Public) Admissions: 465 Readmission Rate: 30% 1.59 readmissions/ 1,000 resident days Pattern: Highest readmission activity early winter and fall (January, September to December)

  20. Early Post-Intervention Process Evaluation(n=1 Nursing Home, Rural, Public) • January – February 2012 (7 weeks) • Process Audits • Medication Reconciliation • 70% of admissions • Discrepancies involved Insulin, Lovenox, Antibiotics, Prednisone, Proventil, Simvastatin • Communication, coordination, monitoring tools • Stop and Watch: 11% (1/9) • Care Plans: 89% (8/9) • Change of Condition Cards: 78% (7/9) • SBAR: 89% (8/9) • NH – ED transfer form, checklist, envelope: 100% (10/10)

  21. Early Post-Intervention Outcomes(n=1 Nursing Home, Rural, Public) • Readmissions: • 50% occurred on Thursday • 50% based on medical evaluations conducted over the phone • 90% due to worsening condition despite intervention

  22. Future Analyses • Residents’ transitional care trajectories The completed data set will include two years (2011-2012) of trajectories for ~2500 rural residents transitioning between hospitals, NHs, community

  23. Project Success Factors • Established collaborative, with information and videoconferencing infrastructure • Team members’ strong base of QI knowledge and LSS coaching • High regional interest in transitional care and readiness to collaborate with NHs • Leadership commitment • Human dimensions • Rapport, Trust • “Can Do” spirit • Meliora – Ever Better

  24. Contact Information • Tobie Olsan, GRNHQC Project Director • Tobie_Olsan@urmc.rochester.edu • (585) 275-5828 • Cathie Chabrier, Readmission Project Director • cchabrier@co.wayne.ny.us • (315) 946-5673 • Greater Rochester Nursing Home Quality Consortium Website • http://research.son.rochester.edu/grnhqc/ • Click on Readmission Project – For bundle tools and audit forms • See the November/December 2011 Gate Review Newsletter for description of tools

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