Care Transitions from the
Skilled Nursing Facility
Perspective:
What Hospitals Need to Know
Lessons Learned from working in a
Skilled Nursing Facility
Presented by:
Pat Sutton, LSCW, ACM
Goals and Objectives
• To identify the challenges Skilled Nursing Facilities have had in
adapting hospital expectations of practice into the skilled setting
• To understand the differences in Medicare PPS reimbursement
between hospitals and SNFs and how payment methodology impacts the focus of care provided in the two settings
• To demonstrate the importance of hospital and SNF
developing collaborative programs of mutual respect in order to enhance quality of care for patients
• To suggest strategies for improving the care transition process
Start of my journey in working with SNFs to
reduce hospital readmissions began in 2010
Co-‐‑chaired a SNF task force with Manager of Cardiac Services
• Invited Administrators and Directors of Nursing to a>end
• Initial focus was on Congestive Heart Failure
-‐‑ Provided an educational program on HF & how heart failure is managed in the hospital with implication that it should be managed in the same way in the SNF-‐‑
daily weights; identifying changes in condition, such as edema, SOB, etc.
• Emphasized importance of continuing education of patients regarding medication management, using Stoplight form for monitoring their daily status, etc.
Lesson Learned
What works in the acute care se>ing cannot be
cut and pasted into the skilled se>ing.
WHY?
•
The SNF is not an acute care environment.
Hence different methods for conducting the
business of patient care;
•
Different focus in patient care;
•
Different Reimbursement and Regulatory
Requirements from Medicare/Medicaid
In terms of daily patient care,
hospital and SNF are not different
Daily care in each se-ing is pre-y much the same
• Special Treatments: wound vacs/wound care, TPN, Tracheostomy, PEG
tube or J-‐‑tube, dialysis, oxygen, Nebulizer Treatments, Bi-‐‑Pap • Medications, including IVs
• Continual Monitoring for changes in condition
• Personal care/Assistance based on level of ADLs they can manage
• Rehabilitation therapy: PT, OT, and/or Speech
• Clinical testing: As ordered by MD, lab work, x-‐‑rays, etc.
• Communication: with MD/PA/APN regarding test results; adjusting
orders, and rounding with other team members to collaborate on status, treatment plans/goals, and discharge plans
What is different: Hospital focus on testing to identify diagnosis,
initiating treatment to stabilize, & education to prevent re-‐‑occurrence
Skilled Nursing Facility focuses on rehabilitation while maintaining stability
Different focus on care based on se\ing
Shifting from finding cure to maintaining stability
• Patients are medically stable but need more care than can be managed in their home, i.e. more physical rehab, complex skilled care, lack of a caregiver, etc.
• “Diagnosis” equates to “history of”
• For short term stay patients, Focus is on rehab, maintaining stable condition, meeting daily ADL needs
• Up to 100 days of covered skilled care if patient continues to progress-‐‑ no rush to move patients out quickly based on LOS • History of Li-le to No focus in SNF on patient education related to
diagnosis or how to manage chronic medical conditions prior to discharge
What factors into Payment for Care?
SNF RUGS-‐‑IV MDS Payment
• CMS implemented the RUG-‐‑IV classification system that incorporates the Minimum Data Set (MDS) 3.0 initiated in October, 2010
• RUG-‐‑IV groups form a hierarchy from the greatest to the least resources used
• MDS contains extensive information on the resident’s nursing & therapy needs, & ADL impairments
• Based on a case mix payment system, payment to the SNF determined by the resource intensity of resident’s care needs as measured by items on MDS
• As of 10/1/2012, there are 66 categories that combine the nursing and therapy needs with an ADL scores to determine where the patient falls on the reimbursement hierarchy
SNF Per Diem Payment Factors
Some residents require total assistance with their activities of daily living (ADLs) and have complex nursing care needs.
Other residents may require less assistance with ADLs but may require rehabilitation or restorative nursing services.
• Recognition of these differences is the premise of SNF case mix system • Reimbursement levels differ based on the resource needs of residents • 66 Categories of payment are divided into, from highest to lowest:
Rehabilitation plus extensive services Rehabilitation
Extensive Services: Trach &/or vent; isolation for infectious disease
Special Care High: IVs; fever w/pneumonia; septicemia Special Care Low: dialysis; pressure ulcers stage II or more Clinically Complex: surg wounds w/txmt; oxygen; chemo Behavioral Symptoms and Cognitive Performance Reduced Physical Function
Pu\ing it all together
from the SNF Perspective
• With the focus in the SNF on therapy and patient daily care needs, concept of thinking in terms of medical diagnoses that drive specific interventions has required a shift in clinical focus for SNF staff
• Example: Patient treated in hospital for diagnosis of “Pneumonia” and is discharged to SNF because too weak to return home alone, and caregiver not able to provide physical assistance
Patient arrives at SNF with diagnosis of “Status Post Pneumonia,” so focus of care in the SNF is on:
rehab therapy for strengthening to be able to return home; assisting with ADLs as needed;
and on “Pneumonia Prevention” to prevent relapse or aspiration
Pu\ing it all together
from the SNF Perspective
Reflecting back on that initial talk with the SNF task force and the
puzzled look we received, it is now apparent that in the SNF world,
patients are not typically admi\ed for “Heart Failure”.
Patients with history of Heart Failure go to SNFs for:
• rehab therapy to get strong enough to return home, • or may be end stage HF & SNF will be a final destination
• or Heart Failure is a secondary diagnosis that is managed through physician orders related to medication, diet, etc.
Hospital Management of Disease Specific Protocols
full of barriers in the SNF Se\ing
Diet and Compliance with Diet
•
Most post-‐‑acute facilities serve a low sodium diet, but
not necessarily 2Gm sodium
•
Patient rights allow for salt shakers on the table, to have
family bring in food for patient, etc.
Medications
•
Recognizing medications based on diagnosis and then
asking hospitals why patient is on not on it at time of
handoff from hospital to SNF not the historical norm
•
Implications of asking about a potential omission
correlates to questioning the care the patient received
at the hospital, which historically has been viewed as
“the authority”
Hospital Management of Disease Specific Protocols
full of barriers in the SNF Se\ing
Education-‐‑
• Sharing during admission report done at time of transition regarding what has been taught to pt. &/or caregiver not standard protocol for the acute or the SNF side
• Continuing the education in the skilled facility as part of daily clinical care and discharge planning that includes patient education
-‐‑ Not widely implemented at Post-‐‑Acute level;
-‐‑ Lack of training on the appropriate educational tools to use for diagnosis specific teaching;
-‐‑ Using the same tools across the continuum of care for reinforcement -‐‑ Historically SNF staff managed the care so no need to educate patient or family on living with chronic disease
Discharge Planning-‐‑
• se\ing up MD appointments, referrals back to hospital HF clinics, follow-‐‑up phone calls, referring to providers that close the loop back to the hospital; • assuring access to medications post discharge;
are NOT part of a typical post-‐‑acute SNF discharge plan
Why Collaboration is Important
• A change in se\ing can cause a great deal of anxiety for both patients and families, esp. when there has been a significant change in health and/or function, & li\le time to process the implications of the new changes
• Inadequate sharing of information adds to stress & undermines confidence that the new staff will be able to provide the necessary care
• Quality & timeliness of the information provided by the hospital makes all the difference in quality outcomes of care in the SNF
• Patients admi\ed to the SNF from hospital are most vulnerable to medical errors in the first few days of transfer
Why Collaboration is Important
Keep in mind that returns to the hospital for Emergency Department visits, Inpatient Admissions, Observation stays for SNF patients are:
• Expensive;
• Disruptive and disorienting to the patient, particularly those with underlying dementia;
• May result in complications
• May result in unnecessary tests and duplication of services if information is not shared
• May result in medication errors or omissions
All Levels of Care are part of the team!
Collaboration is the key!
Transparency across the continuum is essential!
Post acute providers want to help hospitals reduce readmissions.
There is no understanding of what is broken without effective dialogue on both sides.
Neither side must begin from a silo perspective that leads to blaming the other for missed opportunities-‐‑
No one se>ing is the Authority! We can learn from one another
Skilled Nursing Facilities are not cookie
cu\er in the way in which they operate
They may all be paid in the same way, but focus and operations vary• The patients they accept to the facility vary
• The percentage of short term rehab versus long term care varies
• The services offered vary (Vent, Dialysis, Tracheostomy, etc.)
• Ability to absorb high cost medications or prolonged TPN varies on the size of the company-‐‑ stand alone facilities do not have the pockets of facilities that are part of a national chain
So ask each of your SNFs the following:
1. What is your readmission rate?
2. Is there an APN on staff? If yes, how many days per week?
3. Who does your patient education, and what educational materials do you provide patient and family related to their diagnosis?
5. What does your discharge planning process for patients going home include? 6. Do you screen patients for palliative care? If yes, at what point in the stay? 7. What tools are you using from Project Interact?
Other Questions to ask the
SNF Administrator or DON
Advance Practice Nurse
• Is the APN a physician extender who rounds for one or a group of your staff physicians?
• Does the APN see all patients at the facility or just those in the physician group?
• How often does the APN round? Is this a full-‐‑time position in the building?
Patient Education
• What materials from your hospital is the facility using for further education prior to patient discharge from SNF?
• How has hospital collaborated with the facility regarding these educational materials? What if there are changes to what the hospital uses?
• Knowing that patients whose discharge plan is SNF retain li\le information from teaching started at the hospital, does hospital adjust education shared if patient goes to SNF vs. home?
• What is the handoff from hospital to facility re: what education was provided and to who, patient and/or family?
Heart Failure Guidelines
EVERYDAY
• Weigh yourself in the morning before breakfast and write it down • Take your medicine as ordered by your doctor • Check for swelling in the feet, ankles, legs and stomach • Eat low salt foods
• Balance activity and rest periods
• Which Heart Failure Zone are you today: green, yellow or red?
GREEN – ALL CLEAR – this zone is your goal
• No worsening shortness of breath • No weight gain of more than 2 pounds from
baseline (it may change 1 or 2 pounds some days)
• No worsening swelling of your feet, ankles, legs or stomach
• No chest pain
Your symptoms are under control
• Continue taking your medications as ordered
• Continue daily weights • Follow low salt diet • Keep all doctor appointments
YELLOW – CAUTION – this is a warning zone. Contact your doctor today
• You have weight gain of 3 or more pounds • Increased shortness of breath with activity • Increased number of pillows needed to sleep
at night
• Increased swelling of your feet, ankles, legs or stomach
• Feeling more tired, no energy • Dry hacking cough
• Dizziness or lightheadedness after standing up
• Feeling uneasy; you know something isn’t right
Your symptoms may mean that you need an adjustment in your medications
Call your Home Health Nurse or Physician Name: _______________________ Number: _____________________
RED – EMERGENCY – Go to the Emergency Room or call 911 if you have any of the following:
• Struggling to breathe, unrelieved shortness of breath while sitting still • Chest pain/tightness • Confusion or cannot think clearly • You have a weight gain of 5 pounds or more • A fall related to dizziness/lightheadedness
You may need to be evaluated by a physician right away
Call your home Health Nurse right away Name: _______________________ Number: _____________________
Encourage local SNF facilities to use the same education materials the hospital is providing to patients
A trip to the ED does not mean
the SNF expects the patient to be admi>ed
Many reasons Skilled Nursing Facilities send patients to ED:
•
CTs or MRIs that cannot be done in the skilled se\ing
•
Confirmation of a suspected diagnosis
•
Family insists despite efforts of the SNF staff
•
Hospitals need to work with each facility to determine what
types of treatments can be managed at the sending facility
•
Once diagnosed in ED, if plan is to admit to a medical unit,
contact the SNF to discuss sending patient back to the Facility
for antibiotics or other treatment if the treatment is on the
facility’s list of options
(Especially important if IP admission will be a 30 day
readmission!)
Project Interact is the SNF equivalent of
Hospital Readmission Reduction Programs such as
Project Red, BOOST, etc.
INTERACT is an acronym for"ʺInterventions to Reduce Acute Care Transfers"ʺ.
The interventions is a quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status.
INTERACT was first designed in a project supported by the Centers for Medicare and Medicaid Services (CMS).
The current quality improvement project is supported by a grant from the Commonwealth Fund, and initially involved a total of 30 nursing homes in the states of Florida, New York and Massachuse\s.
Many nursing homes across the country are now using INTERACT
Tools Available to SNFs
through Project Interact
Universal SNF to Acute Hospital Transfer form• Contains all pertinent information hospitals need for review in the Ed and also upon admission
Quality Improvement Tool For Review of Acute Care Transfers
• Standardized form that facility staff should complete for every acute care transfer
• Purpose is to identify areas for internal process improvement in caring for patients who have a change in condition
Care Paths for Use in the Facility
• Mental Status Change • Fever
• Symptoms of Lower Respiratory Infection • Symptoms of Congestive Heart Failure • Symptoms of UTI
• Dehydration
The Dialogue at Time of Transition
Medical Record Information
Sending the basics of H & P, consults, therapy notes, is no longer sufficient. Send additional info based on individual diagnosis
SNFs need to know more specifics related to diagnosis and care: • A1C for diabetics, EF for Heart Failure
• Therapy goals and results of Short Blessed, Allen Cognitive Tests • Most recent Swallow study results and date done
• Last 2 days of progress notes to provide context for what was being addressed
• Pertinent Radiology or procedure reports • Wound care notes
• PHQ-‐‑9 or other depression screening results if done during hospital stay
Advance care planning now a CMS Requirement for
Skilled Nursing Facilities
Effective November 30, 2012
• SNFs must have an identified process for advance care planning that is incorporated into the patient’s comprehensive health care plan in order to assure:
-‐‑ reevaluation of the patient’s desires on a routine basis -‐‑ reevaluation when there is a significant change in condition
-‐‑ Goal: to help the patient, family, and care team prepare for the time when a patient becomes unable to make decisions or is actively dying
The Dialogue at Time of Transition
The Dialogue at Time of Transition
QUESTION
regarding Advance Care Planning on the Acute side?
If discussing advance care planning is addressed during the
admission to a skilled nursing facility, and when there is a significant change in condition, should the discussion not begin in the acute care se>ing as part of the discharge planning process for patients going to these facilities?
• The discussion could be as simple as asking the patient if she/he has an advance directive.
• If yes, based on all the patient has recently experienced relating to their chronic illness, does it still reflect the patient’s wishes? • Reminding patient that advance directives are not wri\en in stone,
and can be modified, rescinded, or updated by adding a POLST form to a Power of A\orney for Health Care.
The Dialogue at Time of Transition
When the hospital staff do have the discussion regarding
advance care planning with patient and family,
share the results with the SNF staff
• What was discussed (Palliative, DNR, Hospice, POLST) • What was initiated
• Who at hospital had the discussion (MD, discharge planner, palliative care nurse or MD, etc.)
• Barriers to having the discussion or during discussion
• Outcome of discussion should be communicated with SNF staff as part of the referral process
Regarding tube feedings, SNFs must now:
• Fully inform the patient of his or her total health status /prognosis
• Provide the patient with wri-en information about use of a feeding tube (including risks, benefits, and alternatives) so that an informed decision can be made
• Inform the patient of the right to make an advance directive and to decline life sustaining treatments including artificial hydration and nutrition
• Periodically reassess for the continued necessity of the feeding tube, and
revise the care plan, as necessary, with input from the patient or legal representative
Given the above, if not already protocol in the hospital se>ing, an Ethics consult for a hospitalized acute care patient
would be appropriate before proceeding with insertion of feeding tube
Improving Care Transitions
from Hospital to SNF
Questions?
References
• IHI (STAAR Initiative) h\p://www.ihi.org/IHI/Programs/StrategicInitiatives/
STateActiononAvoidableRehospitalizationsSTAAR.htm
• IHI Transforming Care at the Bedside (TCAB) h\p://www.ihi.org/IHI/
Programs/StrategicInitiatives/TransformingCareAtTheBedside.htm
• CMS
Affordable Care Act: Readmission payment reform h\p://www.govtrack.us/congress/bill.xpd?bill=h111-‐‑3590
• Community Care Transitions Program (CCTP)
h\p://www.cfmc.org/caretransitions/files/rem_ja10-‐‑care_transitions.pdf
• INTERACTh\p://interact2.net/docs/INTERACTDec%2029%20Revised.pdf
References
• Care Transitions Project
Information and tools, including the Med Discrepancy Tool h\p://www.caretransitions.org/documents/checklist.pdf
• Project Boost
Robust info site with tools, etc. on care transitions
h\p://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/ CT_Home.cfm • Project RED h\p://www.bu.edu/fammed/projectred/
• National Priorities Partnership
7 key targets, including “Continuity of Care” h\p://www.nationalprioritiespartnership.org/ Patient Disease/Self-‐‑Management
h\p://patienteducation.stanford.edu
