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Improving Care Transitions: Standardizing Discharge Care Plans from Hospital to Nursing Home
Quality Improvement / JAMDA 16 (2015) B16eB25
Background: Hospital admissions for the Long-Term Care (LTC) patient are predominantly frail elderly with multiple chronic disease. They are the most vulnerable to hospital associated complications as well. These complications may include, falls, delirium, nosocomial infections, adverse drug reactions, pressure ulcers and death. This population represents only 12 percent of our population, but utilize 1/3 of all hospitalizations. They also utilize a disproportionate share of health care costs. The Affordable Care Act (ACA) includes a readmission reduction program. The goal is to reduce unnecessary hospital admissions and readmissions to improve patient outcomes and reduce costs. Objective/Aim: The goal of this study was to review quality improvement factors that reduce hospital admissions and readmissions. The group studied was our LTC patients, enrolled in a United Healthcare (UHC) Nursing Home Plan (NHP). The goal for the outcome of this study was to improve quality care, and reduce overall costs. Quality Improvement Methods: This study utilized a 100 percent retrospective design. All participants where enrolled in the UHC NHP in Florida. The study was multi-centered in nursing home sites throughout the State of Florida . An expert panel which included a nurse practitioner and physician reviewed all cases sent to the hospital on a twice weekly basis. This review is the Transfer Alternative Program (TAP). Specific factors are identified which caused the admission. The admissions are then assigned as preventable and potentially preventable, and appropriate. Results: The data was compared to the National Medicare readmission rate which is 18%. The UHC NHP data prior to implementation of design was 16%, and post implementation was 10%. The decrease in cost will also be estimated in the poster. Conclusion: Hospitalizations, both admissions and readmission rates for the UHC NHP patients, are significantly lower due to the utilization and implementation of our TAP model. Quality of patient care has improved and costs have decreased. Multiple factors were identified that may affect patient care and hospitalizations and cost. Author Disclosures: All authors are full time employees of Optum, a division of United Health Group, and provide care for patients in this model.
Improving Care Transitions: Standardizing Discharge Care Plans from Hospital to Nursing Home
B17
dictated discharge summaries not being transcribed and uploaded into the medical chart within a timely manner; and 2) nurses not completing discharge instructions for nursing home patients. The improve phase consisted of a new process intervention developed and piloted with a sub-group of physicians and nurses that centered on creating a nursing home discharge process and packet to include the discharge summary, discharge instructions, and an updated medication reconciliation form. The pilot intervention included various educational elements for both physicians and nurses on the new processes and forms, and the addition of a new dictation option which would ensure that discharge summaries were transcribed and entered within 4 hours of dictation. The intervention was then piloted in 27 resident physicians and the nurses of 2 care units over 7 weeks. Results of the pilot intervention on the number of discharged patients with complete and timely discharge information for these 27 resident physicians and the nurses of the two units included a 300% improvement in the proportion of nurses completing discharge instructions for nursing home patients (z ¼ -4.57, 0.000), and a 30% reduction in the DPMO (z ¼ 6.18, 0.000). Conclusion: The intervention is currently being implemented in all nursing care units, and data being collected on the outcomes. In the future we plan to report on hospital-wide outcomes, including standard quality of care indicators, readmission rates and costs associated with the implementation of this intervention. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Improving the Appropriate Use of Proton Pump Inhibitors: A Skilled Nursing Facility Based Quality Improvement Project Presenting Author: Darshan J. Patel, MD, University of Arkansas for Medical Sciences Author(s): Darshan J. Patel, MD, Jasmine A. Brathwaite, MD, Kristin Wheeler, MD, MPH, Tiffany M. Shelton, MD, Kimberly K. Garner, MD, JD, MPH, Kalpana Padala, MD, MS, Prasad R. Padala, MD, MS; and Dennis H. Sullivan, MD
Background: The overuse and misuse of PPIs are concerning and very Presenting Author: Venkat Banda, MD, Tulane School of Medicine, Baton Rouge Satellite Campus Author(s): Venkat Banda, MD, Trisha Guidry, OT, Lisa Beal; and Michelle Lacour
Background: Prior to implementing this project, zero percent of patients discharged from these units to a nursing home left our facilities with a standardized discharge care plan that included a discharge summary, discharge instructions, and a medication reconciliation. Inaccurate and untimely communication of the discharge care plans to nursing homes likely resulted in poorer care, higher costs, increased readmissions and penalty risks, and may have also decreased the utilization of our facilities. We estimate that this lack of standard discharge information could be affecting up to 1100 patients a year. Objective/Aim: The overall aim of this project is to improve the accuracy and timeliness of communicating discharge care plans from our acute care, rehabilitation, skilled nursing, and psychiatric units to nursing homes. Quality Improvement Methods: The Baton Rouge General Medical Center is a full-service community hospital with 527 licensed beds between two campuses. Our institution uses Lean Six Sigma (LSS) methodologies to implement quality improvement projects, and for the current project utilized the 5-phase LSS Define, Measure, Analyze, Improve, and Control (DMAIC) model to improve our performance on standardizing discharge care plans to nursing homes. Data collected on the number of discharged patients with complete and timely discharge information on the 4 care units of interest over a 16-week baseline period indicated 462 defects, 892 opportunities, a DPMO (defects per million opportunities) rate of 517,937, and a sigma of 1.4. Results: A root cause analysis indicated three critical elements: 1) physicians not dictating the discharge summary prior to discharge; 2)
prevalent in skilled nursing facilities. While PPIs cause few adverse effects with short-term use, long-term PPI use has been associated with an increased risk of all-cause mortality. Proton pump inhibitors have potential adverse effects in that they are associated with an increased risk of fractures of the hip, wrist and spine, increase the risk of C. difficile infection and of community-acquired pneumonia. Objective/Aim: The aim of this QI project was to decrease inappropriate prescribing of PPIs in skilled nursing facility (SNF) patients by 20% with the goals of avoiding negative health outcomes including side effects, hospitalizations, resource utilization and higher costs. Quality Improvement Methods: West Markham Skilled Nursing and Rehabilitation facility is a non-profit facility affiliated with the University of Arkansas for Medical Sciences. QI project leaders received training in Plan, Study, Do, Act (PDSA) quality improvement methods to implement a project and initiate a baseline chart review for patients who were on PPIs. A list of appropriate indications with time durations was created after completing a literature search and guidelines review. In defining the problem, demographic data and the number of patients with inappropriate use of PPIs were recorded. Following this the implementation, team was identified and comprised the geriatrics attending, geriatric fellows, residents, APNs, pharmacists, registered nurses and certified nurse assistants. The goal was to have patients on the lowest appropriate, effective dose of the safest drug for the shortest amount of time. The team analyzed the process, created a tapering/ discontinuation algorithm and implemented lifestyle modifications and dietary interventions. Education was provided through periodic meetings, flyers, pamphlets, reminders to patients, family, providers and stockholders. Results: At baseline, we identified 76% of patients with inappropriate use of PPIs. Inappropriately prescribing occurred by using an inappropriate dosage and/or prolonged dosing time without a valid indication. Patients
Background: Hospital admissions for the Long-Term Care (LTC) patient are predominantly frail elderly with multiple chronic disease. They are the most vulnerable to hospital associated complications as well. These complications may include, falls, delirium, nosocomial infections, adverse drug reactions, pressure ulcers and death. This population represents only 12 percent of our population, but utilize 1/3 of all hospitalizations. They also utilize a disproportionate share of health care costs. The Affordable Care Act (ACA) includes a readmission reduction program. The goal is to reduce unnecessary hospital admissions and readmissions to improve patient outcomes and reduce costs. Objective/Aim: The goal of this study was to review quality improvement factors that reduce hospital admissions and readmissions. The group studied was our LTC patients, enrolled in a United Healthcare (UHC) Nursing Home Plan (NHP). The goal for the outcome of this study was to improve quality care, and reduce overall costs. Quality Improvement Methods: This study utilized a 100 percent retrospective design. All participants where enrolled in the UHC NHP in Florida. The study was multi-centered in nursing home sites throughout the State of Florida . An expert panel which included a nurse practitioner and physician reviewed all cases sent to the hospital on a twice weekly basis. This review is the Transfer Alternative Program (TAP). Specific factors are identified which caused the admission. The admissions are then assigned as preventable and potentially preventable, and appropriate. Results: The data was compared to the National Medicare readmission rate which is 18%. The UHC NHP data prior to implementation of design was 16%, and post implementation was 10%. The decrease in cost will also be estimated in the poster. Conclusion: Hospitalizations, both admissions and readmission rates for the UHC NHP patients, are significantly lower due to the utilization and implementation of our TAP model. Quality of patient care has improved and costs have decreased. Multiple factors were identified that may affect patient care and hospitalizations and cost. Author Disclosures: All authors are full time employees of Optum, a division of United Health Group, and provide care for patients in this model.
Improving Care Transitions: Standardizing Discharge Care Plans from Hospital to Nursing Home
B17
dictated discharge summaries not being transcribed and uploaded into the medical chart within a timely manner; and 2) nurses not completing discharge instructions for nursing home patients. The improve phase consisted of a new process intervention developed and piloted with a sub-group of physicians and nurses that centered on creating a nursing home discharge process and packet to include the discharge summary, discharge instructions, and an updated medication reconciliation form. The pilot intervention included various educational elements for both physicians and nurses on the new processes and forms, and the addition of a new dictation option which would ensure that discharge summaries were transcribed and entered within 4 hours of dictation. The intervention was then piloted in 27 resident physicians and the nurses of 2 care units over 7 weeks. Results of the pilot intervention on the number of discharged patients with complete and timely discharge information for these 27 resident physicians and the nurses of the two units included a 300% improvement in the proportion of nurses completing discharge instructions for nursing home patients (z ¼ -4.57, 0.000), and a 30% reduction in the DPMO (z ¼ 6.18, 0.000). Conclusion: The intervention is currently being implemented in all nursing care units, and data being collected on the outcomes. In the future we plan to report on hospital-wide outcomes, including standard quality of care indicators, readmission rates and costs associated with the implementation of this intervention. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Improving the Appropriate Use of Proton Pump Inhibitors: A Skilled Nursing Facility Based Quality Improvement Project Presenting Author: Darshan J. Patel, MD, University of Arkansas for Medical Sciences Author(s): Darshan J. Patel, MD, Jasmine A. Brathwaite, MD, Kristin Wheeler, MD, MPH, Tiffany M. Shelton, MD, Kimberly K. Garner, MD, JD, MPH, Kalpana Padala, MD, MS, Prasad R. Padala, MD, MS; and Dennis H. Sullivan, MD
Background: The overuse and misuse of PPIs are concerning and very Presenting Author: Venkat Banda, MD, Tulane School of Medicine, Baton Rouge Satellite Campus Author(s): Venkat Banda, MD, Trisha Guidry, OT, Lisa Beal; and Michelle Lacour
Background: Prior to implementing this project, zero percent of patients discharged from these units to a nursing home left our facilities with a standardized discharge care plan that included a discharge summary, discharge instructions, and a medication reconciliation. Inaccurate and untimely communication of the discharge care plans to nursing homes likely resulted in poorer care, higher costs, increased readmissions and penalty risks, and may have also decreased the utilization of our facilities. We estimate that this lack of standard discharge information could be affecting up to 1100 patients a year. Objective/Aim: The overall aim of this project is to improve the accuracy and timeliness of communicating discharge care plans from our acute care, rehabilitation, skilled nursing, and psychiatric units to nursing homes. Quality Improvement Methods: The Baton Rouge General Medical Center is a full-service community hospital with 527 licensed beds between two campuses. Our institution uses Lean Six Sigma (LSS) methodologies to implement quality improvement projects, and for the current project utilized the 5-phase LSS Define, Measure, Analyze, Improve, and Control (DMAIC) model to improve our performance on standardizing discharge care plans to nursing homes. Data collected on the number of discharged patients with complete and timely discharge information on the 4 care units of interest over a 16-week baseline period indicated 462 defects, 892 opportunities, a DPMO (defects per million opportunities) rate of 517,937, and a sigma of 1.4. Results: A root cause analysis indicated three critical elements: 1) physicians not dictating the discharge summary prior to discharge; 2)
prevalent in skilled nursing facilities. While PPIs cause few adverse effects with short-term use, long-term PPI use has been associated with an increased risk of all-cause mortality. Proton pump inhibitors have potential adverse effects in that they are associated with an increased risk of fractures of the hip, wrist and spine, increase the risk of C. difficile infection and of community-acquired pneumonia. Objective/Aim: The aim of this QI project was to decrease inappropriate prescribing of PPIs in skilled nursing facility (SNF) patients by 20% with the goals of avoiding negative health outcomes including side effects, hospitalizations, resource utilization and higher costs. Quality Improvement Methods: West Markham Skilled Nursing and Rehabilitation facility is a non-profit facility affiliated with the University of Arkansas for Medical Sciences. QI project leaders received training in Plan, Study, Do, Act (PDSA) quality improvement methods to implement a project and initiate a baseline chart review for patients who were on PPIs. A list of appropriate indications with time durations was created after completing a literature search and guidelines review. In defining the problem, demographic data and the number of patients with inappropriate use of PPIs were recorded. Following this the implementation, team was identified and comprised the geriatrics attending, geriatric fellows, residents, APNs, pharmacists, registered nurses and certified nurse assistants. The goal was to have patients on the lowest appropriate, effective dose of the safest drug for the shortest amount of time. The team analyzed the process, created a tapering/ discontinuation algorithm and implemented lifestyle modifications and dietary interventions. Education was provided through periodic meetings, flyers, pamphlets, reminders to patients, family, providers and stockholders. Results: At baseline, we identified 76% of patients with inappropriate use of PPIs. Inappropriately prescribing occurred by using an inappropriate dosage and/or prolonged dosing time without a valid indication. Patients