Safe Transitions Workgroup

Transcription

1 Community Cross Continuum Collaborative Safe Transitions Workgroup Final Summary Heart Failure Screening Initiative July 25, 2017 Background A subcommittee of the Community Cross Continuum Collaborative (4C) was formed in the Spring of 2015, to focus on improving transitions of care and reducing unnecessary readmissions. The group convened and developed a shared vision: To research and implement new standards to improve quality of life and health outcomes for all patients, to improve transitions of care through increased understanding, coordination, cooperation, and communication, and to educate and empower patients and care team members. Medicare FFS data reports were made available from the QIN QIO. o The population of patients in the Southeast Massachusetts region (see appendix A for zip codes), are noted to have a higher rate of all cause readmissions as compared to the State rate and New England Region (6 states of New England). See Figure 1. o The 30 day readmission rate for Heart Failure also is higher for this population as compared to the State and New England rates. See Figure 2. Figure 1: Southeast Massachusetts Transitions Coalition

2 Figure 2: 30 Day Congestive Heart Failure Readmissions per 1,000 Medicare FFS Beneficiaries The group reviewed results of a Heart Failure Study, Mini-Cog Performance Novel Marker of Post Discharge Risk among Patients Hospitalized for Heart Failure. The study found that nearly one quarter of inpatients hospitalized for heart failure performed poorly on the Mini-Cog, suggesting high prevalence of cognitive impairment in this population. Poor performance on the Mini-Cog was related to poor post hospitalization outcomes, most commonly hospital readmission.1 Christine Sullivan, the Tufts Project Coordinator for Coastline, presented facts and figures on the impact of food insecurity: o Low food security predicts malnutrition- nationally, 16% of seniors are food insecure and 50% are malnourished. o Food insecurity may increase the odds of CHF by 60%. o Poor nutrition is associated with reduced cognitive function, and vice versa (complex association- likely related to specific nutrient deficiencies). o Poor nutrition is associated with increased risk of CHF. A decision was made by the group to implement a protocol for screening heart failure patients: o Screening includes the Mini-Cog tool and 2 questions to screen for food insecurity. o Patients with either primary or secondary diagnosis of heart failure. o A score of 0-2 is considered a failure on the Mini-Cog but patients who score 0-3 are to receive at least one intervention in the protocol. 1 Mini-Cog Performance Novel Marker of Post Discharge Risk Among Patients Hospitalized for Heart Failure, Apurva Patel, MD; Roosha Parikh, MD; Erik H. Howell, MD; Eilwwn Hsich, MD; Steven H. Landers, MD, MPH; Eiran Z Gorodeski, MD, MPH. December Available at

3 o Patients who score positive for food insecurity are to receive at least 1 referral for food resources (lists provided.). Development of Tools/Implementation A form was created for bedside data collection by the staff performing the mini-cog and food insecurity screening. See Appendix B, 4C Safe Transitions Initiative: Heart Failure Protocol Minicog and Food Insecurity Screening. Training was offered by Coastline Elderly Services, (Aging Service Access Point, New Bedford) in February of Participants had hands on practice with the screening tool, including role playing. Data Collection and Measurement Initially, 8 community providers agreed to participate, including 3 nursing homes, 4 home health agencies, and 1 assisted living facility. Process measures identified: o Number of HF patients who receive cognitive screening. o Number screened for food insecurity. Proximal outcome measures: o Heart Failure patients with cognitive issues identified via screening, receive interventions. o Heart Failure patients with food insecurity identified via screening, receive interventions. An excel workbook was distributed to each participating organization and data was sent in monthly to the QIN QIO Program Administrator, without PHI. All data was aggregated to measure outcomes. Outcome At the June 2017 workgroup meeting the results were reviewed from 16 months of data collection, March 2016 June See Figure 3 for participating Organizations as of June Highlights: o 137 patients with Heart Failure as primary or secondary dx have been identified since March 2016, and 124 were screened with the protocol tool (94%) o 35% of patients also had BH diagnosis Figure 3: Participating Organizations Caregiver Homes Our Lady s Haven Southcoast VNA o 69 patients (60%) scored 0-3 on Mini-cog, and 33 (27%) failed with a score of 0-2 Bayada Community Nurses

4 Percent who recieved intervention o 93 patients were screened for food insecurity and 10 were identified with low food security Success measured by: o 94% of patients who scored 0-3 on Mini-cog received an intervention. This rate was sustained at 100% from Sept through June See Figure 4. o The most common interventions included notifying the PCP and caregiver teaching. Other interventions included in the protocol were assess for clinical change, refer to Aging Service Access Point (ASAP), or physical/occupational therapy referral. o Food screening was intended to be conducted with each HF screening but results of this were low in the first 4 months. Food insecurity was not identified until questions were modified in September Once participating organizations re-educated their staff, food screening increased to 100% and was sustained through June See Figure 5. Figure 4: Intervention Rate among Heart Failure Patients 100% 80% 60% 40% 20% 0% Intervention rate among heart failure patients with low mini-cog scores (0-3), N=69 Q (n=15) Q (n=9) Q (n=18) Q (n=14) Q (n=8) Quarter

5 Number of Referrals/Interventions Figure 5: Food Insecurity Positive Screening Referrals Food Insecurity Positive Screening and Referrals Baseline: March-August 2016 September-November 2016 December February 2017 Conclusion A second Train-the-Trainer session was hosted by Coastline in March 2017, to spread the initiative to other organizations. See Figure 6. The original participants agreed to continue to use the protocol as results have been positive. Data collection ended June 22, 2017 as outcome measures demonstrated sustainability. Figure 6: New Participants Alden Court Royal Fairhaven Steward Home Care Home Instead Royal Cape Cod Although data was not collected to measure the impact on readmissions, it is expected that, by identifying heart failure patients with cognitive impairment and/or food insecurity, setting up interventions to address these issues will have a positive effect on patients ability to remain safe in their environment, without unnecessary readmissions due to failed discharge plans.

6 Appendix A: Appendix B: Community Zip Codes include: 02072, 02301, 02302, 02303, 02304, 02305, 02322, 02324, 02325, 02333, 02334, 02337, 02338, 02341, 02343, 02344, 02346, 02347, 02348, 02349, 02350, 02351,02356, 02357, 02368, 02375, 02379, 02382, 02401, 02538, 02543, 02558, 02571, 02576, 02702, 02713, 02714, 02715, 02717, 02718, 02719, 02720, 02721, 02722, 02723, 02724, 02725, 02726, 02738, 02739, 02740, 02741, 02742, 02743, 02744, 02745, 02746, 02747, 02748, 02764, 02767, 02768, 02770, 02777, 02779, 02780, 02790, See next page This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, 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. CMSMA_C3-1_072617_1098

7 4C Safe Transitions Initiative: Heart Failure Protocol - Mini-cog and Food Insecurity Screening Patient Name: Date: Organization: BACKGROUND INFORMATION COMPLETE IN FULL AT TIME OF SCREENING Diagnosis Heart Failure Primary Secondary BH diagnosis Yes No Unknown Dual Eligible (Medicare and Medicaid) Yes No Unknown Has there been a recent change in baseline cognition? Yes No Unknown Dementia Dx: Yes No Unknown If Yes, is there a capable, qualified caregiver available? Yes No Unknown UNABLE TO COMPLETE SCREENS Patient unable and no caregiver OR Refused A. PATIENT SCREEN USING MINI-COG TOOL SCORE: Mini-Cog Failing score is 0-2. Total scores of 0-3 indicate the need for the following intervention(s): Note: Also Score 0 if screening not completed, and consider interventions. Scores Intervention Yes/No 0-2 Notify PCP 0-2 Assess for change in clinical status (decompensating HF) 0-3 Refer to Coastline (or communicate if known patient) 0-2 Teach caregiver 0-3 Refer for PT, OT, and/or ST assessment 0-2 and transferring to another setting B. PATIENT SCREEN FOR FOOD INSECURITY Refer to 4C Safe Transitions Workgroup HF Project Use Contact List (Complete Section D below) 1. In the past 12 months, have you had to skip any of the following because there was a shortage of money? 2. How confident do you feel that you can eat heart-healthy food at home? Yes No Utilities (heat, electric, phone, etc.) Rent or mortgage Prescription drugs Grocery shopping or meals Very A Little Not Sure Not Very Not At All C. FOR WARM HANDOFF ONLY (Send this form with transfer documents) Your Name/Phone # Warm Handoff to (name) Case ID # COMMENTS: Community Cross Continuum Collaborative, Safe Transitions Subcommittee (Form updated ) This material was prepared by Healthcentric Advisors, the Medicare Quality Improvement Organization for New England, 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. CMSMA_C3-1_092016_0756