An Organizationa l Strategy to Prevent Hospitalizations

1. An Organizational Strategy to Prevent Hospitalizations Mary J. Dyck, PhD, RN, LNHA MyoungJin Kim, PhD Susan Hovey, MSN, RN Readmission 2014

2. Purpose • Determine if there is a significant difference in readmission rates from SNFs to hospitals with the implementation of a day long skills lab training program for SNF nurses   Readmission 2014

3. Review of Literature • The Affordable Care Act established a Hospital Readmission Reduction Program • Center for Medicare and Medicaid Services (CMS) must reduce payments to hospitals with excess readmissions • Started 10/1/2012 • (CMS, n.d.) Readmission 2014

4. Review of Literature • Included readmissions for AMI, HF, and pneumonia. • Penalties to hospitals with excess readmissions for patients discharged with these three diagnoses include • a 1% reduction of total Medicare billings in 2013, • 2% reduction of total Medicare billings in 2014, • 3% reduction of total Medicare billings in 2015 • (Zigmond, 2012) Readmission 2014

5. Review of Literature • all-cause readmission • within 30 days of discharge • the patient does not have to be readmitted for the same condition or related conditions to be included. • This policy has driven hospitals to find ways to decrease their readmission rates. Readmission 2014

6. Review of Literature • In 2006, one-fourth of Medicare beneficiaries discharged from a hospital to SNF were readmitted within thirty days costing Medicare 4.34 billion dollars • (Berkowitz et al., 2011; Boxer et al., 2012; Mor, Intrator, Feng, & Grabowski, 2010) • In Illinois, readmissions from SNF in 2006 were 24 – 26.9% • (CMS, n.d.) Readmission 2014

7. Review of Literature • Currently, the only penalty to SNF with an excess of readmissions is a loss in revenue due to a decrease in referrals • SNF providers are sure that a similar penalty structure is inevitable in the future • (Zigmond, 2012) Readmission 2014

8. Review of Literature • The American Health Care Association (AHCA) Quality Initiative is to reduce the number of hospital readmissions within 30 days from SNF by 15% by March 2015 • (American Health Care Association [AHCA] website, n.d.) Readmission 2014

9. Review of Literature Strategies to Reduce Readmissions Rates from SNF to Hospitals Follow-up phone calls within 48 hours of discharge (Jacobs, 2011) Partnerships between acute and post-acute providers (Aston, 2011). • Standardizing physician admission procedures • (Berkowitz et al., 2011) • Heart failure staff education programs for SNF nurses • (Boxer et al., 2012) Readmission 2014

10. Research Questions • Is there a difference in readmission rates after a one day skills lab implementation for nurses employed in SNF 3 months, 6 months, and 9 months after training Readmission 2014

11. Sample • Used secondary data collected and de-identified by a senior care corporation in Illinois • Staff from each facility collected data on hospital readmissions and it was aggregated by the senior care corporation • 32 SNF owned and operated by the senior care corporation. Readmission 2014

12. Sample • Data included • By facility by month • Admissions (New admissions to the facility and admissions to the hospital by current residents) • all cause readmissions within 30 days • Number of nurses employed and the number of nurses that completed skills lab training • Approved by the Illinois State University Institutional Review Board before data was analyzed and a Data Use agreement was signed by the senior care corporation Readmission 2014

13. Procedure *February 2013 50% of nurses from 12 of 32 facilities Training consisted Hour lecture CHF Hour lecture COPD 45 minutes of practice on breath sounds with simulation manikin 3 hours discussion and practice on acute changes in patient condition 1.5 hour scenarios with SBAR and calling physician • The senior care corporation implemented a full day skills lab in September 2011 • Revised January 2012 • 2012 all training was done at the simulation lab at Illinois State University • A nurse with a Master’s of Science degree in Nursing (MSN) conducted the training Readmission 2014

14. Methodologies • Data were analyzed using Statistical Package for the Social Sciences (SPSS) 20 • Data were assessed for outliers • Assumptions were checked prior to data analysis. • Mann-Whitney test • All statistical significance were reportedat p ≤ .0167 using Bonferroni's adjustment for Type I error due to multiple tests Readmission 2014

15. Results No significant difference found Readmission 2014

16. Discussion • Hospital readmission rates did not change significantly for SNF who had 50% or more of their nurses complete the skills lab training 3 months, 6 months, and 9 months after training Readmission 2014

17. Discussion • When you look at the descriptive statistics, SNF with 50% or more of their nurses completing training had a slightly higher median of readmissions for each month in comparison to the total and SNF with less than 50% • Why? Readmission 2014

18. Discussion • Improved assessment skills • Increased awareness on identifying changes in condition • Skilled at using the SBAR and notifying physicians • Evolving skills lab Readmission 2014

19. Limitations Nurse staffing is constantly changing so data may have not accurately captured nurses actually trained Cannot capture training of nurses outside of the simulation lab The sample size was small • Only one senior care corporation may not be representative of SNF in general. • The senior care corporation collected the data so the study is relying on the accuracy of their data collection techniques. Readmission 2014

20. Future Research • Currently, research in this area is limited so the need is great • How many days following discharge residents are generally readmitted • The reasons that residents from SNF are readmitted following discharge from the hospital Readmission 2014

21. Future Research • Readmission rates for residents recently admitted to SNF vs. residents who were hospitalized from the SNF to the hospital Readmission 2014

22. Conclusion • This is a hot topic • Interest from federal and state government • Interest from healthcare corporations • Studies can ultimately impact • Patient outcomes • Reduce costs of healthcare • Improve reimbursement • Relevant to today’s healthcare Readmission 2014

23. References • American Health Care Association website (n.d.). Retrieved from http://www.ahcancal.org/quality_improvement/qualityinitiative/Pages/TheGoals.aspx#1 • Aston, G. (2011). Long-term care: Your new priority. H&HN: Hospitals & Health Networks, 85(4), 30-32. • Berkowitz, R., E., Jones, R., N., Rieder, R., Bryan, M., Schreiber, R., Verney, S., &Paasche-Orlow, M. (2011).Improving disposition outcomes for patients in a geriatric skilled nursing facility. Journal of the American Geriatrics Society, 59(6), 1130-1136. doi: http://dx.doi.org/10.1111/j.1532-5415.2011.03417.x • Boxer, R., S., Dolansky, M., A., Frantz, M., A., Prosser, R., Hitch, J., A., & Piña, I., L. (2012).The bridge project: Improving heart failure care in skilled nursing facilities.Journal of the American Medical Directors Association, 13(1), 83.e1-7.doi: http://dx.doi.org/10.1016/j.jamda.2011.01.005 • Centers for Medicare and Medicaid Services [CMS] (n.d.).Readmissions reduction program. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html • Jacobs, B. (2011). Reducing heart failure hospital readmissions from skilled nursing facilities. Professional Case Management, 16(1), 18-26. doi: http://dx.doi.org/10.1097/NCM.0b013e3181f3f684 • Medicare Hospital Quality Chartbook, (2012).Performance report on outcome measures. Retrieved from http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HospitalQualityInits/Downloads/MedicareHospitalQualityChartbook2012.pdf • Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010).The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. doi: http://dx.doi.org/10.1377/hlthaff.2009.0629 • Zigmond, J. (2012). Avoiding the penalty box. Modern Healthcare, 42(5), 38-39. Readmission 2014