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CMS National Conference on Care Transitions

CMS National Conference on Care Transitions. December 3, 2010. READINESS TO INTERACT Inter ventions to Reduce A cute C are T ransfers. Dianne M. Richmond, RN, MSN, APN Theme Lead for Care Transitions and Patient Safety Alabama Quality Assurance Foundation. CMS Special study.

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CMS National Conference on Care Transitions

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  1. CMS National Conference on Care Transitions December 3, 2010

  2. READINESS TO INTERACTInterventionsto Reduce AcuteCareTransfers Dianne M. Richmond, RN, MSN, APN Theme Lead for Care Transitions and Patient Safety Alabama Quality Assurance Foundation

  3. CMS Special study 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 Linda Kluge, RD, LD,CPHQ – Nursing Home Project Manager 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, with extensive experience in nursing home care; 2 past and 1 current president of AMADA, and 1 past president of AGS

  4. Commonwealth Fund • Principal Investigator: Dr. Joseph G Ouslander • Co-Principal Investigator: Dr. Gerri Lamb Independence Foundation and Wesley Woods Chair Associate Professor of Nursing Emory University • Collaborators: Laurie Herndon, MSN, GNP-BC Senior Project Coordinator Alice Bonner, PhD, RN Co-Investigator Massachusetts Department of Public Health Multidisciplinary teams from MA, NY, and FL

  5. Acute Care Transfers (ACT) • Commonly occur • Disruptive • Potential for complications • Delirium, incontinence, Foley catheter use, pressure ulcers, polypharmacy, injury • Costly

  6. Expert Panel Medical Record Review • 68% of 200 admissions classified as potentially avoidable • Top 10 Admitting Diagnoses were ranked • Opportunity to improve care and reduce costs

  7. Goals of the INTERACT Toolkit • Aid in the early identification of a resident change of status • Guide staff through a comprehensive resident assessment when a change has been identified • Improve documentation around resident change in condition • Enhance communication with other health care providers about a resident change of status Ouslander, J. G

  8. INTERACT Toolkit • Communication Tools • Clinical Care Paths • Advance Care Planning Tools • Quality Review Tools

  9. Communication Tools Early Warning Tool Used by Non-licensed staffs • Spend lots of time with staff • Develop trust of resident • Viewed as confidant • Pick up on changes in resident conditions

  10. Communication Tools When to report changes in resident condition • Immediate Notification • Non-immediate • Routine

  11. SBAR COMMUNICATION TOOL • Organizes reportable information to ensure pertinent and relevant information transfers to the next provider of care • Increases likelihood of best level of care selection

  12. Six Care Paths Clinical Care Paths • Acute change in mental status • Fever • Dehydration • Urinary Tract Infection • Pneumonia/Lower Respiratory Infection • Congestive Heart Failure

  13. Advance Care Planning Tools • Identifying Residents to Consider for Palliative Care and Hospice • Advance Care Planning Communication Guide • Comfort Care Order Set • Educational Information for Families • Reprints

  14. Quality Improvement Review Tool Data Collected • Background Information • Demographics, payor, status • Transfer Information • Date time, nurse, authorizing MD, symptoms • What happened before the transfer? • Changes in status, actions taken, factors affecting ACT • Was ACT Avoidable • Opportunities and Action Plan

  15. Readmission Trend for Memory Lane Nursing Home Started out just over 30% Increased to 40% and started declining Followed by a sharp increase

  16. Investigation of ACT Patterns Using the data from Quality Improvement Review • Day of week • Time of day and shift • Staffing Patterns • Providers • Use of available resources • Transfer facilities

  17. Investigation of ACT Patterns Precipitating Condition Communication Issues Access Issues Ethical Issues Outcomes of the Transfer

  18. Bibliography Buchanan, J. L.; et. al; (2006) Nursing home capabilities and decisions to hospitalize: A survey of medical directors and directors of nursing. JAGS 54: 458-465 http://www.amda.com/tools/guidelines.cfm www.medqic.org https://www.qualitynet.org/dcs/ContentServer?c=MQWeblinks&pagename=Medqic%2FMQWeblinks%2FWeblinkTemplate&cid=1228755816398 http://www.cfmc.org/caretransitions/ http://www.gmcf.org/transitions/resources.shtml http://interact.geriu.org/ http://www.commonwealthfund.org/Content/Innovations/Tools/2010/INTERACT-II.aspx

  19. For more information, contact: drichmond@alqio.sdps.org 205 970 1600 ext 3249

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