Best of New Jersey: Readmission Reduction Successes INTERACT Quality Improvement Program Version 3.0

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Loretta Kaes, BSN, RN-B-C, C-AL, LNHA, CALA

Director, Quality Improvement & Clinical Services Health Care Association of New Jersey

Janet Knoth, BS, RN, CHPN

Quality Improvement Specialist Healthcare Quality Strategies, Inc.

Best of New Jersey: Readmission Reduction Successes

INTERACT Quality Improvement Program Version 3.0

This material was prepared by Healthcare Quality Strategies, Inc., (HQSI), the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NJ-C.8-13-21 7/2013

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INTERACT Webinar Series

Overview and Communication Tools March 14, 2013 Advance Care Planning Tools April 11, 2013 Quality Improvement Tools June 26, 2013 Best of New Jersey: Readmission Reduction Successes August 21, 2013 2

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Housekeeping

 _{Materials at qualitynet.webex.com}  _{Submit chat questions to}

“All Participants”

 Phone lines have been muted

 _{Evaluation poll at the end of}

the presentation

 _{Webinar will be recorded}

and available on HQSI.org

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Today’s Presenters

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INTERACT Quality Improvement

Program: A Hospital Perspective

Teresa De Peralta, MSN, ANP-BC

Transitional Care Coordinator

Robert Wood Johnson University Hospital- New Brunswick

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Identifying Partners

 When RWJUH started its program how did you identify/

select/invite facilities to participate?

 RWJ TCP started enrolling Jan 2012

 May 2012 – invited area SARs to dinner meeting to

 Outline TCP program

 Set expectations of SARs

 Communicate what help RWJ can give to SARs

 Care One East Brunswick – charter partner with Care Navigator

Model

 Other preferred partners

 Bridgeway Care Center  Aristacare

 Genesis

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Engagement

 How did you engage nursing facilities with

INTERACT Quality Improvement Program?

 Reviewed SAR QI programs to recommend  Recommended Care One and Bridgeway for

INTERACT National study

 National INTERACT training

 Offered to help SARs with INTERACT implementation  Follow up meetings in facilities or TCP meetings

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Community Collaboration

Current active INTERACT Partners

 Care One E. Brunswick  Bridgeway Care Center  Merwick Care Center  Genesis Care Center

Strategies 8  New implementation – Bridgeway  Re- start/re-energize / re-focus – “ Is it truly implemented?”

 Provide model for

evaluation

 Statistics

 Root cause analysis  Workflow modification

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Lessons Learned – Barriers

 RWJ management

 Legal and risk management requirements

 RWJ Foundation – need to stay prominent for future funding

 RWJ VNA

 Staff education focus on problem of readmission

 Nursing facilities

 Champions & early adapters

 Identify facility-specific project owner  Effective and efficient implementation

 Other nursing facilities

 Lack of corporate QI strategy

 Need for education re: readmission problem

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Lessons Learned – Benefits

 What have been your lessons learned in

collaborating with facilities?

 There will always be “champions” and forward thinkers  A new program is best partnered with early adaptors

 What benefits does RWJUH receive?

 Reduction in readmission for targeted diagnoses  Increased collaboration with area NH and PACs

 What benefits does RWJUH provide the nursing

facilities?

 Subsidized care navigator model through RWJVNA  NJ Health Connect

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The Program

 What aspects of the INTERACT Quality

Improvement Program are the most valuable to your hospital?

 Capabilities checklist  Triage caremaps

 Do you find that your providers are utilizing

interact2.net?

 Both Interact 2 and Interact 3

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Measurements

 Sample preferred partner data: 2013 Re-hospitalization

Rates: GOAL: 3% decline per quarter ending at 20.4%

0 5 10 15 20 25 30 35 12 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

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Analysis of 2012 and Plan for 2013

 Partner 1 overall re-hospitalization rate was comparable to NJ

averages, however our re-hospitalization rate for “penalty diagnoses” was significantly higher.

 In addition to following patients on our Transitional Care

Program, the Care Navigator also evolved into a program

development advisor . This resulted in programs such as the Walgreens Program, and a new process for Discharge

Medication Reconciliation for Transitional Care Patients. This became a facility-wide model in 2013.

 The Care Navigator is also involved in roll-out of INTERACT 3,

CHF, COPD and Palliative Care Programs, partnerships with Cardiology Groups, Staff in-services and Case Studies, NJ Relay, and EMR.

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Measurements

 Sample Preferred Partner 2 data:

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Measurements

 Sample preferred partner data:

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Measurements

 Sample Preferred Partner 2 data:

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Measurements

 Qualitative

 Increased communication and learning from regular

TCP meeting attendance

 Improved data presentation and communication  Case studies

 Root cause analysis skills honed  Better follow up and feedback

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RWJ Readmission Data - CMS

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Metrics Jan 09 – Dec 11 (36 mos)

Jan – Dec12

(12 mos) % Reduction Medicare readmission

rates for AMI 23.55% 22.3% 5.3%

Medicare readmission

rates for CHF 27.59% 24% 12.7%

Medicare readmission

rates for PNA 23.74% 19.5% 17.9%

Combined (AMI, CHF,

PNA) 25.5% 22.49% 11.8%

Improvement applied over prior 30 months = 107 less AMI, PNA, HF readmissions

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RWJ Readmission Date - CMS

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Metrics Jan 09 - Dec ₁₁ Jan – Dec 12 % Reduction All Cause Readmission to

RWJ 17.3% 16.5% 4.6%

All Cause Readmission to

Any Hospital 22.87% 21.7% 5.1%

Improvement applied over prior 30 months = 280 less readmissions

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Contact Information

Teresa De Peralta, MSN, NP-C

Transitional Care Coordinator

Robert Wood Johnson University Hospital Phone Numbers:

Office: 732 253 3482 Cell: 732 484 0741

teresa.deperalta@rwjuh.edu

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The Journey of Victoria Manor

in Reducing Readmissions

Donna Mayer, RN, BSN

Director of Nursing Victoria Manor

Denise Raymond, CDP, LPN, CSW, NJCALA

Senior Admissions and Marketing Director Genesis HealthCare

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Decision Makers

 _{Genesis HealthCare presented a global}

implementation of INTERACT Quality Improvement Program to its facilities

 _{Goal: Reduce readmissions to acute care facilities}

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Championing Quality Improvement

 _{Directors of Nursing}  _{Root cause analysis}

 _{Evaluate where change}

needs to take place

 _{Identify the best tools} possible

(www.interact2.net)  Fill your gaps with

viable tools

 _{Do not duplicate existing forms}

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Discovering the INTERACT Quality

Improvement Program

 _{INTERACT Care Paths have been a part of clinical}

education

 _{Root cause analysis identified reasons for transfer}  _Goals:

 _{Catch patient changes in} condition sooner

 Manage patients at facility  If transfer needed, send the

best report possible

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INTERACT Tools and Staff Education

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Care Paths

• Clinical staff

Stop and Watch

• Support staff

SBAR

• Clinical staff

Nursing Capabilities list

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INTERACT Tools and Goals

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Care Paths

• Consistent clinical protocol

Stop and Watch

• Engage additional staff members

SBAR

• Consistent reporting

• Track patient condition changes

Nursing Home Capabilities List

• Provide to the hospital ED and primary care physicians • Every transfer is not an admission

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Barriers and Successes

Barriers

• Corporate initiatives are sometimes challenged • Culture-change

• Time consuming (initial concern of nurses)

Successes

• New unit managers quickly adapted to new system • Improved communication increased ED awareness of

Nursing Facilities Capabilities list

• SBAR improved staff confidence when giving report

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Embedding INTERACT at Victoria Manor

Stop and

Watch

• Used by therapy and aides

• Left on medication cart; decreases interruption during medication pass • Passed on to unit manager; actively

trends patient

SBAR

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• Left in MARS for consistent review and update

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Embedding INTERACT at Victoria

Manor…continued

Nursing

Capabilities

List

• Face-to-face meeting with two hospital ED liaisons

• Include Nursing Capabilities Flyer in transfer envelope

INTERACT

Transfer

Envelope

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• EMT staff expectation of envelope value during transfer

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Continuous Quality Improvement

Quality

Improvement Review

• Ongoing clinical review of all hospital

readmissions

• Using root cause analysis

• Including staff involved with transfer

Quality

Assurance Meetings

• Quarterly readmission report

• Ongoing staff input

about implementation process of INTERACT Quality Improvement Tools

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Contact Information

32 Donna Mayer, RN Director of Nursing Victoria Manor (609) 898-0677 Donna.mayer@genesishcc.com

Denise Raymond, CDP, LPN, CSW, NJCALA

Senior Admissions and Marketing Director Genesis Healthcare

(609) 602-7193

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Polling Question #1

 _{What barriers do you need to remove?}

 _{Leadership/staff buy-in}

 Lack of physician collaboration and cooperation

 Families want residents hospitalized

 _{Your facility already has similar forms and processes}

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Let’s Discuss the INTERACT

Quality Improvement Program

in Assisted Living Communities

Interviewer:

Loretta Kaes BSN, RN-B-C, C-AL, LNHA, CALA

Interviewee:

Elaine Jeffers RN, LNC, CCM, CDP, C-AL Regional Director of Health Services

Chairperson of NJ Assisted Living Nurses Association

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Discovering INTERACT

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The assisted living INTERACT Quality Improvement Program is still in the pilot stage.

 _{How did you find out about the}

INTERACT Quality Improvement Program?

 _{Who would make the decision to}

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Implementation

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 _{Do you think champions/}

co-champions would be effective in your setting?

 _{How would you implement}

INTERACT? Would it be by area or system wide?

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The Tools

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 _{Which INTERACT tools would you use and why?}

 _{Stop and Watch}  SBAR

 Capabilities List  Other

Have you found interact2.net useful, such as resident education handouts and/or guidance for having

end-of-life conversations?

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Advance Care Planning

38  _{Will you consider using the}

INTERACT Quality

Improvement Program tools to increase awareness of advance care planning?

 _{Has your facility incorporated}

the POLST form in patient education?

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Barriers and Successes

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Often assisted living communities follow the mantra, “When in doubt send them out.”

 _{What challenges do you anticipate in changing the}

culture in order to improve transfers and reduce readmissions?

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Measurement

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 _{Are you measuring resident}

transfers and readmissions?

 _{Have root cause analyses of}

readmissions been effective for identifying areas that may need reassessment?

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Assisted Living Capabilities

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Considering that the goal is to keep residents out of the hospital and improve communication between healthcare providers:

 _{What services would}

you include on the assisted living

capabilities list?

(i.e., stat blood work, Doppler studies,

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INTERACT Quality Improvement Program

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 _{How do you anticipate that using the INTERACT}

Quality Program will increase resident satisfaction and quality of life?

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Contact Information

Loretta Kaes BSN, RN-B-C, C-AL, LNHA, CALA

Director of Quality Improvement & Clinical Services Health Care Association of New Jersey

(609) 890-8700

Loretta@hcanj.org

Elaine Jeffers RN, LNC, CCM, CDP, C-AL

Regional Director of Health Services

Chairperson of NJ Assisted Living Nurses Association Chelsea Senior Living

(908) 872-5911

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Polling Question #2

 _{What do you see as the biggest value in the INTERACT}

Quality Improvement Program?

 _{Developing a shared vision within your facility}  _{Focusing on continuous quality improvement}

 Streamlining work processes and avoiding redundancies

 Developing cross-continuum partnerships

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Implementing the INTERACT

Quality Improvement Program

Karen Gentile, RN

Director of Nursing/Assistant Administrator Inglemoor Rehabilitation and Care Center

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The Decision Makers

Nursing administration was

supported by management

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Looking to be the leader in reducing

readmissions from our long-term

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Champions

1 nurse and 1 CNA from each of the 4 units (we had to work with staff on changing the culture)

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Discovering INTERACT

 _{INTERACT was the buzzword for everyone in the}

long-term care/sub-acute industry

 _{Researched online}

(www.interact2.net) and the information was easy to use

 _{Training session}

at Health Care Association of New Jersey (HCANJ)

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Implementation

 _{Implemented with the nurses on all 4 units to}

emphasize:

 _{Early identification through frequent assessments/} reassessments using the INTERACT Care Paths

 Evaluating, documenting, and communicating changes (with SBAR) in patients’ assessment

 _{Rolled out the “Stop and Watch” with aides,}

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The Tools

Stop and Watch

• Struggled a little because the CNAs were not completing the form, although they were communicating the information SBAR • Utilizing the SBAR for over 8 months. It has increased communication and nurses’ credibility • Use of SBAR allows nurses to capture and communicate critical information Nursing Home Capabilities List • Share capability list with hospitals to update them on services offered Interact2.net • A wealth of information and resources to help “roll out” the program

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Advance Care Planning

 _{POLST education for patients}

is the focus for our social

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Barriers and Successes

Barriers

 Biggest barrier is CHANGE; staff education is ongoing

 _{Nurses had to realize that}

they were capable of caring for more acute patient

conditions

 Mindset had to be changed: “sending a patient out to the emergency room is better”

Successes

 Staff is better trained to

handle more acute patients

 _{Patient changes assessed}

more consistently

 _{Increased communication}

across the board

 Decreased readmissions

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Measurements

 _{Tracking transfers (planned/unplanned) and acute care} readmissions

 _{Continuing to see a decrease in readmissions, as well} as improving patient outcomes

 _{Conducting root cause analysis helps nurses to see a} transfer through fresh eyes, such as:

 _{Assessment was not as complete as it could have been}  _{Information could have been better communicated}

 Covering physician was not fully informed and chose to inappropriately send a patient to the emergency room

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Success/Patient Story

 _{Prior to INTERACT implementation, cardiac patients} (with diagnosis of CHF, COPD) would bounce back and forth between the hospital and our facility

 _{Empowered staff (with physician support) to better} assess and recognize changes

 _{INTERACT Care Paths and Acute Change in Condition} File Cards have significantly reduced the number of patients readmitted to the hospital

 _{Symptom management has improved our patients’} satisfaction

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