Heart Failure Transitions of Care SJMH - Ann Arbor

Transcription

1 Heart Failure Transitions of Care SJMH - Ann Arbor March 4, 2013 Cecelia Montoye, RN, MSN Reducing 30 Day Heart Failure Readmissions: SJMH Ann Arbor See you in 7 Measures Process Measure #4: Identify and address barriers to keeping the follow-up appointments Process Measure #5: Work to ensure patients arrive at appointments within 7 of discharge. 1

2 Challenges Can t always schedule prior to discharge (and then may not have an appointment within 7 ) Office wants the patient to call, not our staff Office wants the patient to call after they get home Patient wants their spouse, son/daughter to call so appt is scheduled to their availability Transportation problems not revealed earlier Denies knowledge of the scheduled appointment Didn t feel well enough to keep appointment Went to a different appointment and doesn t want 2 copays Patient went to ED instead of appointment Strategies Initially hired HF Coordinator so that we have dedicated resource to work with patients will add another post discharge f/u phone call so trying to call before F/U appt to remind and problem solve and also calling after to determine if appt kept Most recently will tailor F/U appt to risk using NEW risk assessment tool 2

3 F/U appt data 76% of readmissions did not have F/U appointment scheduled or if scheduled did not attend Risk Factors in Prediction Rule Provided By Clinician Current or past history of Respiratory failure Injury Heart Failure Sepsis Cognitive Defect (includes delirium) Other Neurological (eg. coma, MS, Parkinson s, seizure disorder) Atrial Fibrillation Cancer Metastatic Cancer Leukemia, Lymphoma Medical vs Surgical Admission Provided Electronically Age Gender BUN WBC Platelet Count Hemoglobin Serum albumin Arterial ph Arterial po 2 Serum troponin Serum lactate Hospitalized at SJMHS within past year Emergent Admission 3

4 PRISM User Input Definitions Current or Past History Present on admission Condition Screen Display (full definition hover) Atrial Fibrillation? Current or history of atrial fibrillation Solid-Tumor Cancer (answer No if metastatic cancer or lymphoma, leukemia also present)? Current or history of solid tumor cancer (does not include lymphoma, leukemia, skin) Metastatic Cancer (regardless whether or not leukemia or lymphoma also present)? Current or history of Metastatic Cancer requiring treatment or management Cognitive Defect? Current or history of Cognitive Defect Other Neurological Conditions? Current or history of Other Neurological Conditions Leukolymphoma? Current or history of Leukolymphoma Respiratory Failure? Respiratory Failure that is present on admission, an active issue requiring attention this hospitalization, or patient on home 02. Heart Failure?*** Heart Failure, current exacerbation of heart failure or on chronic medications (Lasix or Bumex) for heart failure Injury? Injury, present on admission, an active issue requiring attention Sepsis, present on admission, an active issue requiring attention this hospitalization Details, Examples: Atrial fibrillation, atrial flutter head and neck, esophagus, stomach, colon, rectum and anus, liver and intrahepatic bile duct, pancreas, other GI organs, peritoneum, bronchus, lung, bone and connective tissue, melanomas of skin, other non-epithelial skin, breast, uterus, cervix, ovary, other female genital organs, prostate, testis, other male genital organs, bladder, kidney and renal pelvis, other urinary organs, brain and nervous system, thyroid Metastases to bone, brain, lung, malignant ascites, malignant pleural effusion Alzheimer s disease, frontal dementia, vascular dementia, delirium, acute confusional state, dementia, amnestic disorder, mixed paranoid and affective organic-psychotic states, post-traumatic organic psychosis, post-concussion syndrome, dementia with Parkinsonism, Lewy body dementia Parkinson's disease, Multiple sclerosis, Other hereditary and degenerative nervous system conditions, Epilepsy, convulsions, Coma, stupor, and brain damage Hodgkin's disease, Non-Hodgkin's lymphoma, Leukemias, Multiple myeloma ARDS, Acute respiratory distress, Post-traumatic or post-surgical respiratory insufficiency, shock lung, acute respiratory failure, acute and chronic respiratory failure, chronic respiratory failure, respiratory arrest Congestive heart failure, systolic heart failure, acute or chronic, diastolic heart failure, acute pulmonary edema with heart failure, right heart failure secondary to left heart failure Joint disorders and dislocations, trauma-related, Fracture of neck of femur (hip), Spinal cord injury, Skull and face fractures, Fracture of upper limb, Fracture of lower limb, Other fractures, Sprains and strains, Intracranial injury, Crushing injury or internal injury, Open wounds of head, neck, and trunk, Open wounds of extremities, Superficial injury, contusion, Burns, Other injuries and conditions due to external causes.(note: any break/fracture being treated, from any cause) Septicemia, bacteremia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock IHA Follow-up intervention Highly effective for PRISM 2/3 P-Value= % 28.9% P-Value= % 22.3% 18.9% P-Value= % 11.4% 8.3% PRISM 1 PRISM 2 PRISM 3 PRISM 4 N Y N Y N Y N Y 2/18/2013 Patient SJMHS Transitions Seen in 7 Insights? 4% 10.1% PRISM 5 N Y 4

5 Heart Failure Status 30-day Post Discharge 100% 80% 60% 40% 20% 0% PRISM 1 (n=68) PRISM 2 (n=334) PRISM 3 (n=349) PRISM 4 (n=69) PRISM 5 (n=3) Death in Hospital Death, no Readmission Death, w/ Readmission Alive, w/ Readmission Alive, no Readmission Retrospective Data for FY 2012 To be considered: Transition coach Case manager Home Care F/U phone calls Rounding If history of HF and Prism 1,2 or 3 place on PRISM 1 Death in hospital or within 30 19% 16% Placement ICU or IMC Rounding Team and communication CM * PCP or ECF F/U phone Call F/U appt HF Clinic w/n 7 PCP w/n 3 Care bundle Homecare * CM role being redesigned PRISM 2 Death in hospital or within 30 5% 26% IMC CM* PCP or ECf HF Clinic w/n 7 PCP w/n 3 Homecare Transition Coach This is a draft! PRISM 3 16% PRISM 4 or 5 3% IMC IMC or Gen CM* CM* PCP or ECF PCP or ECF HF Clinic w/n 7 PCP w/n 7-10 HF clinic w/n 10 PCP w/n 7 Homecare Transition Coach 5

6 Scheduling appointments. Prior to discharge Heart Failure Clinic appts PCP appts Cardiology patient or Cardiology consult patient Cardiology Rounding Nurse Cardiology Rounding Nurse Heart Hospital non Cardiology patient and non Cardiology consult patient Non Heart Hospital, non Cardiology, non Cardiology consult patients Heart Hospital Clinical Nurse Leader Heart Failure Coordinator Heart Hospital Clinical Nurse Leader Heart Failure Coordinator Next Steps Individualize f/u plans according to risk assessment score Add consistency to care with new HF team to call patients at home twice before and after scheduled appointments 6