8/14/2016. Inpatient Strategies to Drive Hospital Systems Towards the Triple Aim Goals in Diabetes Care. Objectives. Disclosure to Participants

Transcription

1 Inpatient Strategies to Drive Hospital Systems Towards the Triple Aim Goals in Diabetes Care Joyce Najarian MSN, RN, CDE Program Manager, Inpatient Diabetes Department of Medicine Lehigh Valley Health Network Allentown, PA Objectives 1. Describe how some evolving health care initiatives are positive drivers of changes, especially for persons with diabetes (PWD). 2. Identify quality improvement interventions CDEs can initiate to improve diabetes care in their hospital and community. 3. Describe how one facility grew its hospital CDE team, a non-billable service, and saw a positive ROI. Disclosure to Participants Notice of Requirements For Successful Completion Please refer to learning goals and objectives Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours Conflict of Interest (COI) and Financial Relationship Disclosures: Presenter: Joyce Najarian, MSN, RN, CDE Eli Lilly, Merck, Sanofi- Aventis(Ownership Interest). Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration. 5 Campuses 1 Children s Hospital 160 Physician Practices 17 Community Clinics 14 Health Centers 11 ExpressCARE Locations 81 Testing and Imaging Locations 14,361 Employees 1,496 Physicians 642 Advanced Practice Clinicians 3,140 Registered Nurses 57,801 Admissions 208,882 ED visits 1,236 Acute Care Beds 1

2 The Triple Aim Understanding the New Faces of Health Care 1. Triple Aim 2. Pay for Performance Initiatives 3. Accountable Care Organizations 4. Population Health Management What is the Triple Aim? BETTER CARE: The Patient Experience. BETTER HEALTH: Population Health. Optimize performance, safety, and care for the people in the community. BETTER COST: Per capita cost. Value based care. Profitable growth. Donald Berwick, MD IHI (Institute for Healthcare Improvement) Understanding the New Faces of Health Care 1. Triple Aim 2. Pay for Performance Initiatives 3. Accountable Care Organizations 4. Population Health Management Understanding the New Faces of Health Care 1. Triple Aim 2. Pay for Performance Initiatives 3. Accountable Care Organizations 4. Population Health Management 2

3 Pay for Performance Initiatives Improve the quality of care by aligning treatment with the most current scientific guidelines. Our past involvement included incentives to: Reduce hyper, hypo, and severe hypo- glycemic rates. Assess continuum of care by reviewing A1C. Show evidence of diabetes education performed. Refer newly diagnosed for outpatient education. How the MSSP Works COST MEASURES: Historical costs/trends for Medicare Part A & B are determined to develop a baseline Your ACO must reduce the costs by a set amount Shared savings can be up to 50% based on performance Understanding the New Faces of Health Care 1. Triple Aim 2. Pay for Performance Initiatives 3. Accountable Care Organizations 4. Population Health Management How the MSSP Works QUALITY MEASURES: Quality standards must be met Three years of monitoring Year 1 = reporting; Year 2 and 3 Performance /Reporting depending on measurement For further information, visit: CMS (Dec 2015) Medicare Shared Savings Program Shared Savings and Losses and Assignment Methodology Specifications Version 4. What is an Accountable Care Organization? A legal, recognized health care entity for contracting with payers. Brings physicians, hospitals & other providers together to better coordinate care for patients. Creates incentives for providers to work together to treat an individual patient across care settings. What is and ACO and shared savings? The Advisory Board. ACO Accountability Improving the care experience for individuals through better coordination of care and patient engagement. Improving health of populations. Reducing the rate of increase in health care spending. Safeguarding beneficiary data. Improving quality. 3

4 Understanding the New Faces of Health Care 1. Triple Aim 2. Pay for Performance Initiatives 3. Accountable Care Organizations 4. Population Health Management New Faces in Health Care A win win for persons with diabetes All with similar focuses: Better Health Better Care Lower Cost Population Health Management Focuses on proactive support for a defined & prepared patient population. Provision of support between clinical visits. Enhance decision support for more comprehensive care with visits. Registries to measure quality, compliance, and safety. Current State of Diabetes in U.S. Burden of Diabetes By 2050, 1 in 3 adults will have diabetes. Every 6 seconds someone with diabetes dies! Costs rose 41% from (total $245 billion) 43% of the total were related to inpatient care. $1 in $3 Medicare dollars is spent on diabetes care. $1 in $5 health care dollars is spend caring for diabetes. diabetes.html (accessed ) Population Health Strategies to Lower Cost Identify relevant patients and stratify them according to clinical risk. Coordinate care across continuum. GAPS IN CARE Engage patients to improve outcomes. 4

5 Diabetes Subjects at Goal Nathan D. Wong, et al. Diabetes Care 2016; 39: BP at target (<130/80 mmhg) LDL-C at target (<2.6 mmol/l [100 mg/dl]) HbA 1c at target (<53.0 mmol/mol [7%]) None (BP, LDL-C, HbA 1c) at target Any one (BP, LDL- C, HbA 1c) at target Any two (BP, LDL- C, HbA 1c) at target All three (BP, LDL- C, HbA 1c) at target ARIC Study MESA JHS All 3 Studies Pooled 431 (52.2%) 376 (50.8%) 37 (8.2%) 844 (41.8%) 157 (19.0%) 353 (47.7%) 137 (30.2%) 647 (32.1%) 266 (32.2%) 378 (50.1%) 201 (44.4%) 845 (41.9%) 228 (27.6%) 104 (14.1%) 176 (38.9%) 508 (25.2%) 374 (45.3%) 267 (36.1%) 189 (41.7%) 830 (41.1%) 189 (22.9%) 267 (36.1%) 78 (17.2%) 534 (26.5%) 34 (4.1%) 102 (13.8%) 10 (2.2%) 146 (7.2%) Hospital RN CDEs Education Monitoring Glycemics Medication Input Care coordination EBP: Policies/Order Sets Quality & safety across continuum Good resource describing role of inpatient diabetes educators: AADE Position Statement, Inpatient Glycemic Control (2009). Diabetes Educator, 35(Suppl 3) DSME Utilization 6.8% of individuals with newly diagnosed T2DM with private health insurance receive DSME within 12 months of Dx. 4% of Medicare participants received DSME &/or MNT. Duncan et al. Diab. Educ. 2009, 35: Li et al. MMWR. 2014; 63: Better Health Strategies Improving/standardizing education for PWD and care providers, based on EBP Monitoring high risk individuals Focus on employee health Develop community partnerships Supportive services Other Gaps in Care Real time Reports Professionals knowledge Bias in health care and community 5

6 A1C Reports Benefit: Stratify by risk (high or too low) Monitor compliance obtaining Population Management: Diabetes Red / Green Report BP < 140/90 Eye Exam Foot Exam IVD: On antiplatelet For Example, on left can see DM admissions A1C data: 16% (42/257) have A1C > 8.5%. 9.7% (25/257) have A1C < % (5/257) do not have A1C < 90 days or 98.1% have current A1C today! Attn to Neuropathy A1C > 9 A1C < 8 LDL < 100 Tracking Persons with IV insulin Population Management: Diabetes Pre-Visit Planning and Huddle Report Other uses of this tool: Screening GFR for persons on Sulfonylureas, Metformin, etc. Weekly POC reports Goal = 80% in range Better Care Goals Improving/standardizing care and education for persons with diabetes Needle lengths, lancing devices Coordination of educational resources Diabetes Teachback Patient Engagement Tools Outpatient f/u: Bridge Clinic, Referrals for DSME Community Care Teams/PCP/ Home Care 6

7 Better Care: Diabetes Teachback What, Why, and How Low BG: what it is, how to recognize, how to treat & prevent Medications: name, how they work, when to take, ways to remember to take Home BG monitoring/target Blood Sugars Insulin info (as applicable): benefits, action, when to take, sites/rotation of sites, drawing & injection technique, storage and disposal of syringes Day 1, 2, 3 questions Built as order set in EMR Q & A built into EMR for RN reference Laminated references on unit Better Care INPATIENT ACUTE CARE LVH -17th LVH -CC Transitional Care Management Specialty Care - Neighbors LVH -M LVHN Care Continuum FACILITIES SNF ALF LTC Community Agencies Examples of Patient Engagement Tools (videos, ipad, my LVHN, etc.) Better Care: Community Care Teams Facilitate coordination of social, behavioral and educational needs for high risk patients. Members of team supporting provider practices include: RN care managers Social workers Behavioral health Clinical pharmacists IT support Electronic Referral: Initiated by CDE, routed to PCP Also Bridge Clinic Endo CRNPs follow new to insulin post d/c Better Care: Professional Education Learning needs assessments Real time chart reviews Glycemic control Medication lists Glycemic recommendations (worksheets or EMR notes) Patient Safety Reporting & trending 7

8 Professional Educational Resources & Support Web site, E-learning modules, on-line videos On-boarding education CNE, CME, Grand Rounds, team meetings Flyers & Newsletters Book or Journal Clubs Annual Education Days Pocket guides, worksheets Organized for use by Ambulatory & Inpatient Professionals Develop EBM Policies & Guidelines CSII (Insulin Pump) Therapy Care Diabetes Teaching CPG (adult, peds, pregnancy) Glucose Monitoring Hyperglycemia Management Hypoglycemia Management IV Insulin Protocols Hyperkalemia Management EBM Order Sets in Epic Insulin Dosing Tools Insulin Action Profiles Script Writing Tips Comparative references to actions of: Oral Meds GLP1 injectables Cost information DKA/HHS (ED & Admission) IV Insulin (non-dka/hhs) Insulin Pump Self-Regulated by Patient Insulin SQ Orders for Glucose Control BG Monitoring/Hypoglycemia Management Post hypoglycemia POC monitoring Hyperkalemia 8

9 SQ Insulin Order Sets: Only way allowed to order SQ insulin! Basal insulin plus Rapid acting Insulin based for: CHO consumed (1 unit per x grams CHO) Insulin correction scales based on ISF (Insulin Sensitivity Factor) POC BG testing Hypo CPG protocol & prn meds Notifications: NPO or PO status change BG < 70, 2 or more BG > 180, BG > 400. Option rapid acting mix plus ISF Patient Centered Care & Collaborative Rounding Residents Multi-disciplinary Phone/face to face with providers or staff Glycemic suggestions in chart Unit safety huddles (BG s < 70, IV insulin, etc.) Facilitate Better Care Outside the Inpatient Walls Example of Glycemic Review Notes: Example: Safe care practices with pumps in radiology Patient Centered Care & Collaborative Rounding Glucoses in range? If no, why not? Timing, dose, or nutrition issues; condition change; patient or nurse compliance, etc.? Medication adjustments, if applicable Discharge plan re: diabetes A1C result/validity; Adjust PTA meds? Insurance preferences for discharge formularies Education needs and follow-up care Continued Example: 9

10 Better Care - QI Monitoring: Deciding what and how? Key Considerations: How are we doing? Can we do it better, more timely? Ensure metrics known when get started. Provide timely & ongoing feedback. Celebrate successes! CDEs can Facilitate Better Transitions for Better Care ED, peri-op & anesthesia, ICU, floor & PCP staff Hospital to home discharge instructions, scripts Hospital to rehab or SNFs Street Medicine/shelters F/u care (PCP/CCT; Clinic; DSME; school nurses? QI Monitoring Examples Hypo, severe hypo, hyper rates Compliance with : Hypoglycemia protocols IV insulin titration Timing of POC BG values related to meals Timing of correctional insulin related to POC BG Timing of CHO dosing related to meals Obtaining A1C Documentation of care, education, etc. Proving Your Worth Reduce hypo/hyper days = shorter LOS Shorter LOS = Reduced Cost/Case Reduce Readmissions Improved overall care Improved patient, RN, provider satisfaction Better Care: Supporting Transitions Transitions = most dangerous times ED or OR to unit ICU to floors Discharge from Hospital various settings Home Rehab Long term care Shelters Financial Analysis Not Well vs. Well Controlled Year 4 Year 3 Not Well Controlled = 1 BG < 70 and/or 2 or more BG s > 180 FY 14 7/13-3/14 N Days Avg. LOS Total Cost Avg. Cost per Case Not Well 4,245 29, ,000,050 38, Well 2,230 8, ,669,123 19, FY 13* 7/12-3/13 N Days Avg. LOS Total Cost Avg. Cost per Case Not Well 1,644 18, ,831,836 31, Well 5,327 23, ,762,597 12,

11 Growth of Education Visits & Glycemic Evals and Inpatient CDE Team FTE 1676 FY 11 - FY 14 P4P initiative FY 07 FY 08 FY 09 FY 10 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 - FTE July - Mar Ed Visits Linear (Ed Visits) Glycemic Evals Linear (Glycemic Evals) FY 16 Annualized: 6106 & *? LVHN Hyperglycemia Rates per 1000 Patient Days P 4 P Hyper Rates (Days one or more BG > 180 mg/dl) P 4 P FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 Muhl Hyper Rate CC Hyper Rate Key Points Hospital CDEs with the support of other allied health professionals, can work together to: Enhance the quality and safety of diabetes care Improve care outcomes Increase revenues with appropriate payment for care provided and resources expended Proactive implementation of programs to improve diabetes control improves both patient outcome and hospital bottom lines LVHN Hypoglycemia Rates per 1000 patient days (Days with one or more BG < 70 mg/dl) FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 P 4 P Muhl Hypo Rate CC Hypo Rate Finally, how to grow team? Find strong administrator support Develop proposal which includes rationale, data, and benefits to new model. List current staff & propose ratio 11

12 New Era Competencies for CDE s to Focus on: Engage patients: robust care management Form effective teams for seamless patient centered care Coordinate and standardize care across settings Build in quality, reduce waste good stewardship Create and sustain community partnerships Develop IT tools, use data to drive change Focus on health of population, not just disease Joyce Najarian, RN, MSN, CDE Program Manager: Inpatient Diabetes, Dept. of Medicine joyce.najarian@lvhn.org phone (office/voice mail) A Passion for Better Diabetes Care 12