IMPLEMENTING A HOSPITALIZATION MONITORING SYSTEM IN MULTIPLE NURSING FACILITIES: A Two-Year qi project ACROSS A CCRC cor

1. IMPLEMENTING A HOSPITALIZATION MONITORING SYSTEM IN MULTIPLE NURSING FACILITIES: A Two-Year qi project ACROSS A CCRC corporation Peter Jaggard MD CMD Mary Ann Anichini, GNP-BC et. al. Presbyterian Homes Evanston, Illinois

2. Speaker Disclosures: Dr. Jaggard is an employee of Presbyterian Homes. He has no other relevant financial disclosures.

3. Learning Objectives: By the end of the session, participants will be able to: • Objective 1: Describe reasons why hospitalization, rehospitalization, and preventable hospitalization rates are important for nursing facilities to track • Objective 2: Describe tools and interventions which may be helpful in understanding and reducing unnecessary hospitalizations from NFs • Objective 3: Discuss possible factors affecting a facility’s rate of hospitalization and re-hospitalization

4. Background: Why Hospitalizations and Rehospitalizations from Nursing Facilities Matter • Reveals some aspects of Quality of Care at NF • Refocuses Nursing Education onto “Change of Condition” • Resident Satisfaction • Regulatory: OIG Work Plan for 2011 - 2012 • Readmission Penalties for Hospitals began October 2012 • Recognizing and realigning with partners for collaboration between acute and subacute care (e.g., Lehigh Valley Health Network - JAMDA 13(2012) 811-816, Prioritizing Partners Across the Continuum) • Reducing Costs: $12-44 billion/year spent on preventable hospitalizations?

5. Presbyterian Homes (IL): Overview • Multi-campus CCRC corporation in suburban Chicagoland, with NFs at its 3 major campuses approximately 13 – 17 – 20 miles apart. • Facility A: Located on “Flagship” campus. NF ADC 174. Four core physicians care for >80% of patients; three are on-site multiple days per week. Full-time APN. 5 Star Facility. • Facility B: 25-30 years old. NF ADC 92. Acquired approximately 15 years ago. Employed medical director devotes half-time at CCRC campuses A and B. No APN. 5 Star Facility. • Facility C: Built 14 years ago. NF ADC 58. Maturing CCRC. Part-time APN. 2 local MDs provide weekly rounding for subacute care; medical director on-site one day a week. APN 3 days per week. 4 Star Facility.

6. Presbyterian Homes CQI Project: Getting Started Pilot Project (CQI Cycle 1) • Conceived in response to OIG focus on hospitalizations. • Opportunity for comparative QI across campuses. • Literature search revealed work of INTERACT research and INTERACT Tools (Ouslander, Lamb et.al. http://interact2.net) • 3-Month Pilot project at Facility A: Results Hospitalization Rate 1.47/1000 pt-days (Sept-Nov 2010). 36% rated as preventable, using INTERACT QI Tool. Preventables were disproportionately patients with an outside physician; communication with outside MDs found to be a factor in preventable hospitalizations.

7. CQI Cycle 2 Methods and Interventions:Creating and Sustaining Momentum • Hospitalization data collected at all NFs, Oct ’10– Sep ’12 KEYS TO KEEPING FOCUS ON ISSUE • Monthly reporting of data at each facility QI (train staff how to collect and report data; expect data reporting) • Quarterly reporting of data at corporate QI and/or compliance meetings (share successes and challenges) • Development of corporate clinical dashboard for data (develop a consistent standard for reporting data) STAFF EDUCATION ACROSS THE CAMPUSES • INTERACT Webinar training all 3 NFs, April-Aug. 2011

8. CQI Cycle 2 Facility-A Specific Interventions Facility A • Improved communication with outside physicians – APN task • INTERACT Transfer Log • INTERACT QI Tool by nurse clinician to assess avoidable hosps. • Developed log for tabulating QI Tool findings • Identified pneumonia as the most frequent diagnosis in preventable hospitalizations in Year 1 • Targeted pneumonia as a topic for staff education to recognize onset of early symptoms • Used AMDA reference cards (Early Management of Clinical Conditions) to increase nursing assessment skills • Touch screen of Vision EMR found to be more useful than INTERACT “Stop and Watch” tool for CNAs

9. Facility A Results

10. Facility A Results Hospitalization Rate – Year 1: 2.07 Year 2: 2.35 30-day Rehosp Rate – Year 1: 9.9% Year 2: 13.4% Preventable Hosp. Rates: Sept-Nov 2010 36% (8/22) May-August 2011 12.8% (5/39) Oct-Dec 2012 2.1% (1/48)

11. Facility B- Specific Interventions Facility B • Began a weekly hospitalization IDT review meeting in May 2011, after first 7 months of data revealed high rates of hospitalization and readmission. • Meetings include administrator, DON, nursing leadership from each unit, and the medical director • DON: Meetings have helped change the nursing mindset from immediately calling the doctor for a hospital transfer, to a more analytic assessment of change of condition • DON: INTERACT training helped change the nursing culture; gave a new and clear set of expectations • DON: Collaboration with hospital on CHF protocol helped

12. Facility B Results

13. Facility B Results Hospitalization Rate – Year 1: 5.15Year 2: 3.24 30-day Rehosp Rate – Year 1: 34%Year 2: 16.5% COMMENT: Facility B showed dramatic improvement from Year 1 to Year 2 in both hospitalization and rehospitalization rates, with the trend line reversal corresponding temporally with the INTERACT webinar series starting April 2011 and initiation of the IDT hospitalization review meeting in May 2011.

14. Facility C Results

15. Facility C Results Hospitalization Rate – Year 1: 3.95Year 2: 4.70 30-day Rehosp Rate – Year 1: 12.7%Year 2: 16.9% COMMENT: • Significant leadership turnover (DON) throughout Year 2 hindered the introduction and limited the sustainability of interventions • Spike in hospitalizations correlated with a 2-3 week Norovirus outbreak

16. Summary and Discussion • Measuring and reviewing hospitalizations from a NF can identify systemic factors to be targeted for quality improvement. • Interventions such as sustained interdisciplinary hospitalization reviews and engagement with INTERACT training and tools are associated with some improved measures in this CQI project. • Hospitalization rates are likely due to a complex interplay of many factors, including but not limited to case mix, local referring hospital readmission rates, degree and frequency of physician presence in the NF, and nursing skill in assessing a resident’s change of condition. • Medical directors and attending physicians can make a difference by promoting high-quality subacute care and assisting the nursing staff in improving response to clinical change of condition in the NF.