Maximizing HHQI Resources to Reduce Readmissions: Part 1

1. Maximizing HHQI Resources to Reduce Readmissions: Part 1 Presented by: E. Eve Esslinger, Lead HHQI Project Coordinator Cindy Sun, HHQI RN Project Coordinator

2. Home Health Quality Improvement

3. History 101 Phase 1: 2007-2008 Phase 2: 2010-2011

4. Phase 3: Sept. 2012 – July 2014

6. www.homehealthquality.org

7. www.homehealthquality.org

11. Best Practice Intervention Packages (BPIPs) • Phase 1 BPIPs (12) • Monthly • Phase 2 BPIPs (6) • Quarterly • Phase 3 BPIPs (8) • 6 Focused • 2 Primary

12. Focused BPIPs

13. Primary BPIPs

17. Fundamentals of Improving ACH • Introduction BPIP • January 2010

18. BPIP Contents • Introduction • Leadership • Tools • Checklists • Organizational Culture • Ideas for working with other providers • Timeline • Discipline Checklists

19. Timeline and Checklist • Page 14 (Timeline) • Pages 20-23

20. Home Health Compare • How often patients had to be admitted to the hospital (End Result Outcome Measure) • Tennessee: 29% National 27%

21. Absolutes • Hospitalization Risk Assessment • Emergency Care Planning • Front loading based on risk assessment • Easy access to a nurse (24/7 call, office nurse) • Phone monitoring and/or telehealth • Patient education centers on patient participation

22. Hospital Risk Assessment • What it isn’t— • M1032 • A stand-alone document • What it is— • Individualized • Helps guide care plan

24. Discipline Tracks

25. To Do List • To do by week 1: • Download the BPIP • Break it apart (e.g., circulate discipline tracks) • Check compliance with ACH risk assessment, emergency care plan (or initiate implementation ASAP)

26. Continue… • To do by week 2: • Ask staff to tell you what they think about reducing ACH • RULES: No whining; No throwing up hands like it is a lost cause • Use staff meetings, post-it boards, etc • Adopt a turn-key tool and circulate it • Start concurrent evaluation on every single hospitalization

28. Call First

29. Improving Management of Oral Medication April 2010 • Medication adherence can often be a problem among older adults and requires additional resources and strategies on the part of health care providers (MacLaughlin et al., 2005). • Multiple factors impact adherence.

31. OASIS-C • A complete drug regimen review for any potential clinically significant medication issues (M2000) • Documentation of follow-up with the physician regarding clinically significant medication issues, including medication reconciliation (M2002 and M2004) • High-risk drug education to the patient/caregiver (M2010) • Drug Education to the patient/caregiver (M2015) • Assessment of management of oral medications (M2020) • Assessment of management of injectable medications (M2030) • Prior medication management (M2040)

32. Home Health Compare • How often patients got better at taking their drugs correctly by mouth (End Result Outcome Measure) • Tennessee: 49% National 48% • How often the home health team taught patients (or their family caregivers) about their drugs (Process Measure) • Tennessee: 89% and National 90%

33. Potentially Avoidable Events • Emergent care for improper medication administration, medication side-effects • Emergent care for hypo/hyperglycemia • Substantial decline in management of oral medications

34. Medications and Hospitalizations • Adverse drug events cause over 700,000 emergency department visits each year. Nearly 120,000 patients each year need to be hospitalized for further treatment after emergency visits for adverse drug events. (CDC) • Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for ADEs in older adults (Budnitz et al., 2011)

35. Medications Causing Hospitalizations Budnitz et al., 2011.

36. Discipline Tracks

37. Oral Medications: The Essentials

38. Using the Evidence • Reminders, feedback, and decision-support systems lead to quality care by alerting clinicians to problems • Fewer medications reduce the likelihood of medication problems • Packaging, memory and organizing aids such as pillboxes or blister packs help adherence http://champ-program.org/page/68/evidence-briefs

39. Using the Evidence, cont. • Medication “reconciliation” and reviews conducted by doctors, nurses or pharmacists reduce discrepancies and errors and help find potential drug related problems • Multifaceted programs that include ways to simplify medications, increase convenience, and provide counseling help with medication adherence CHAMP Evidence Briefs: http://champ-program.org/page/68/evidence-briefs

40. Implications for Home Care • Compile and communicate accurate, complete, and current medication information. • Assure that older people and everyone involved in their care understand the purpose of their medications and signs of potential problems. • Simplify medications whenever possible given medical needs. • Identify and address barriers to medication adherence. http://champ-program.org/page/68/evidence-briefs

41. Medication Management Tools

42. To Do List • To do by week 1: • Download the BPIP • Break it apart (e.g., circulate discipline tracks) • Check compliance through record reviews and staff discussion with: • Medication Reconciliation • Medication Adherence • Medication Management • Medication Simplification

43. Continue… • To do by week 2: • Ask staff to tell you what they think about improving management of oral medications • RULES: No whining; No throwing up hands like it is a lost cause • Use staff meetings, post-it boards, etc • Adopt a turn-key tool and implement with small group of nurses

44. Continue… • Appoint medication nurse leaders • Staff need to understand which meds cause more ADEs and Show –don’t tell: • Tell me how you take your medicines • How do you schedule your meal and medication times? • Do you use a pill box or organizer to help you take your medicines? • How do you manage to pay for your medicines? • If possible, would you like me to simplify your medication regimen? • If possible, would you like to explore some options for reducing your out-of-pocket medication expenses? • Show me how you use your inhaler. (MacLaughlin et al., 2005)

45. Medication Management: A Community Project • Who is on the ‘team’? • Nurse? • Physician? • Therapist? • Pharmacist? • Patient? • Caregiver/family? • Social worker? • Show Me and Teach Back

46. Patient Medication Management

47. Resource links • Speak up: • http://www.jointcommission.org/speakup.aspx • AHRQ guides: • http://www.effectivehealthcare.ahrq.gov/index.cfm/research-summaries-for-consumers-clinicians-and-policymakers/

48. Fall Prevention • July 2010 • Falling is NOT an inevitable result of aging. Through evidence-based interventions, practical lifestyle adjustments, and community partnerships we can substantially reduce the number of falls (Bonita) Lynn Beattie, PT, MPT, MHA Vice President, Injury Prevention Falls FreeTM Initiative Center for Healthy Aging National Council on Aging

50. OASIS-C • M1910: Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, generally mobility/transferring impairment, and environmental hazards)? • M2250 Plan of Care Synopsis: Does the physician-ordered plan of care include fall prevention interventions? (Note: Fall prevention interventions is only 1 of 7 selected interventions for this measure.) • M2400 Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Note: Fall Prevention interventions is only 1 of 6 selected interventions.)