Category Archives: Process Improvements

The important role nurses play in care transition and reducing readmissions

By Denise Barbera, RN, BSN, MA, chief nursing officer at HealthSouth  /  24 May 2017

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires that transitional care processes are under constant evaluation.

Nurses are the linchpin in the coordination of patient care, and thus are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand a great deal more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend to the patient high-value care beyond organizational boundaries.

Nurses create transitional care plans by compiling all the pertinent patient information and creating instructions to be followed. Then they share the plan in detail with all members of the new care team so that the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition of care is communication during the handoff process.

What to communicate and when

The goal of the handoff is to safely transfer the patient from one care setting to another (or to discharge the patient from the hospital completely) by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and either the new team of clinicians or the family prepares them in such a way that they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and especially in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

Many times, nurses on the receiving team care for patients for whom they lack pertinent health data. For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay extra close attention to medication communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences.

However, defective handoffs are also known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

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KEY RESOURCES: NURSES AND CARE TEAM COLLABORATION
Nurses are vital to effective care team collaboration. Read on for resources you can use to build your own strategy.

What to expect from MACRA: The early years

By Caitlin Greenbaum, Director of Health Policy & Strategy, The Health Management Academy   /  09 May 2017

MACRA legislation passed in April 2015. When the initial version of the rule came down, the industry collectively braced for declining revenues, the avalanche of administrative paperwork and the increase in overhead costs that would be required to comply.

When the final rule was issued in October 2016, the tempered requirements seemed to point toward fewer projected negative payment adjustments in 2019, the target year for MACRA’s first Quality Payment Program distributions, and the tension subsided a little.

Even with the new allowances in reporting and threshold scores, the MACRA structure makes clear that there’s an abundance of work to be done, especially around efforts to promote care coordination and communication.

Year 1: 2017-2018

Now that we’re already into 2017, the first official reporting year, tensions are rising again because, even though most physicians acknowledge they are going to participate, the majority have not yet plotted their course or defined a compliance strategy.

And if you’re in the group that hasn’t figured it all out yet, the good news is you’re not alone.

According to a recent poll conducted by The Health Management Academy, almost half of the physician and practice leaders who participated are not moving very quickly toward adopting value-based payment models. In fact, only 4% claimed to be moving “very quickly” while almost 40% admitted to moving “very slowly” toward value-based care.

Somewhat surprisingly, the same is true even for large hospital systems. These organizations are perceived to be the driving force, the ones moving the fastest toward the end goal of value-based care, and yet, per a similar poll, few of the large systems are moving very quickly.

Only 8% of large hospital systems polled are moving swiftly toward implementing value-based payment models. – The Health Management Academy, 2017

The Quality Payment Program, however, is going to be the catalyst for healthcare organizations, both large and small, moving more aggressively toward these models in the next couple of years.

The MACRA structure and how you fit in

By now, you know that reimbursements are going to be variable based on performance, even if you’re still practicing in a fee-for-service structure and, like most, have not yet begun practicing in the more advanced tracks.

There are four participation categories, which fall underneath two broad tracks—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) track.

The four MACRA Quality Payment Program participation categories. – The Health Management Academy, 2017

The two categories in the middle of the chart are bridge areas, and won’t apply to many providers right now, but they can be considered as stepping stones from MIPS to the Advanced APM track.

The MIPS track equates to fee‑for‑service, and most physicians will, at least initially, fall into this track. They’ll balance their steps toward embracing more downside risk by continuing to practice fee-for-service medicine, and so they must prepare to report performance metrics and have payments adjusted based on those metrics in 2019.

On the other end of the spectrum is the Advanced APM track. To reach “Advanced APM Qualifying Clinician” status, physicians must engage significantly in certain downside risk-bearing payment models. In this track, participating physicians will enjoy fewer reporting requirements and more financial incentives, while still being held accountable for delivering high-value care. The only way to sustain a profitable practice in this track is to eliminate wasteful workflows that result in inefficient and unreliable communication processes among all members of the broader care team, even if they are not directly affiliated with your practice.

Year 2: 2018-2019

In the first months of 2018, physicians practicing in the MIPS track—again, that will be most of you—will be required to report metrics in three performance categories based on at least 90 consecutive days of work. This should come as more good news, because if you haven’t started measuring yet, or you’re not impressed by your initial metrics, you still have time to pivot before the data is due in early 2018.

CMS will use that data to give each physician a composite score, which will determine the payment adjustment he or she receives in 2019.

The Quality Payment Program’s initially proposed rule was accompanied by disheartening projections in terms of payment adjustments, particularly for solo physicians and small practices. While the finalized October 2016-issued rule basically guaranteed that all physicians who submit any performance data will receive at least a neutral payment adjustment, physicians are still bracing themselves for less-than-average profit margins.

As MIPS is largely a budget-neutral program, less risk equals less reward. Since fewer physicians will be subject to negative payment adjustments in 2019 (see Image 3 below), fewer dollars will be available to distribute to those who perform well.

Only 20%—versus 87%—of physicians in smaller practices are projected to experience negative payment adjustments in 2019. – The Health Management Academy, 2017

Simply put, the best way to ensure your adjustment is as high as possible is to garner a high composite score.

Effectively coordinating care with your patients’ broader care teams as accurately and efficiently as possible to reduce waste and unnecessary overhead costs is a good first step toward achieving high scores in all four MIPS performance categories.

Back to the present

One of the goals of MACRA is to drive the costs out of treatment while still providing high-value care. Physicians will be in a much better position to deliver this dichotomy, and advance to a more rewarding reporting track, when the barriers to real-time care coordination have been broken down.

Seamless care team communication and collaboration among interdisciplinary, and often disparate, providers will be a foundation on which you can lay the groundwork for improved care coordination, which leads to less waste, improved efficiencies, and ultimately better outcomes, all of which underlie value-based care and the successful reduction of healthcare costs.

Source: “Making Sense of MACRA” webinar. The Health Management Academy and PerfectServe. March 2017. 

Watch the full webinar to learn even more about MACRA and how it applies to your practice.

Terry Edwards

3 takeaways from HIMSS17

By Terry Edwards  /  28 Feb 2017

More than 41,000 healthcare IT and clinical leaders converged on Orlando last week for the annual HIMSS Conference & Exhibition. This event generates a lot of industry buzz and, for some organizations, sets the stage for the year in terms of strategic focus and planning.

As I looked through the educational sessions offered in this year’s curriculum, I found it striking that nearly half of the 20 education tracks elevated the need for secure, real-time and reliable clinical communication and collaboration.

From “The Business of Healthcare and New Payment Models” track to the “Quality and Patient Safety Outcomes” track, attendees received an abundance of information pertinent to the strategic goals the industry will focus on in the year to come — goals that need a foundational infrastructure of secure clinical communications.

Here are three areas that I see most affected by the need for improved care team collaboration:

  1. Care coordination, value-based care and population health

The level of care coordination needed to successfully adapt to value-based payment models requires interdisciplinary clinicians to easily and securely communicate within — and beyond — the walls of the hospital. Regardless of affiliated organizations or geographical locations, these clinicians need instant access to the broader care team — and the patient — and they must have the ability to quickly send and receive critical PHI. This will enable hospitals and large systems not only to succeed in value-based care, but also to reduce costs and lay the necessary foundation for true clinical integration and population health.

(I talk more about this in my blog post “Healthcare is ripe for tools to enable value-based collaborative care” — read it here.)

  1. Technology, infrastructure and security

To achieve the level of care coordination required to truly address value-based payment models, organizations have to build a secure and compliant technological infrastructure that supports device standards and the communication protocols of the various workgroups that make up dynamic care teams.

Privacy, security and compliance will continue to be important objectives; the foundation of these objectives is an infrastructure that meets requirements without impeding communication and collaboration. This means automatically and seamlessly sharing information through mobile applications that are easy to use and easy to incorporate into existing workflows. Only then will we have tools that will achieve the levels of adoption necessary to make them truly impactful.

It seems like an arduous task, but it’s one we cannot shy away from.

  1. Analytics, process improvement and clinician engagement

As a result of the digitization that has occurred over the past decade, the industry has amassed a significant amount of clinical data. The farther we go down the road toward clinical integration and real value-based care, even more data will be created. To make lasting improvements and affect positive change, we have to harness this data and make it useful.

By gathering and analyzing data related to patient conditions and behaviors, intelligent decisions can be made automatically via technologies that reduce the cognitive load on clinicians by presenting only the information that is relevant to them and requires their actions. This will support value-based care and patient compliance and experience, as well as reduce costs by streamlining workflows and better engaging physicians.

In the same vein, HIMSS17 attendees were heavily focused on the topics of cognitive healthcare and actionable intelligence. Keynote speaker Ginni Rometty, CEO at IBM, spoke about this new era of medicine and challenged healthcare leaders to step up and “build this world.”

“We’re in a moment when we can actually transform pieces of healthcare. It’s within our power,” Rometty said during her HIMSS17 keynote. “This era that will play out in front of us can change the world for the better.”

The industry is changing at a speed that we haven’t seen before. This really is the time for healthcare leaders to make their voices heard and to take part in shaping the future healthcare landscape.

And it’s exciting to know that PerfectServe is in the thick of it with you — building a foundation of secure and immediate clinical communications across the broader care continuum that’s needed to achieve the goals discussed in the majority of the educational tracks at this year’s event.

Looking forward to seeing you all again next year.

HIMSS18
March 5-9, 2018
Las Vegas, Nevada

Terry Hayes

Optimize rapid response team efforts with automated, real-time communication

By Terry Hayes, MSN, CPNP, CNOR  /  12 Jan 2017

Agnes Cappabianca worked as a stroke nurse manager at NYU Lutheran Medical Center, a Brooklyn-based teaching hospital. She was in the middle of a shift when the unthinkable happened—she suffered a stroke and found herself admitted to the hospital as a patient in her own ward.

The hospital’s rapid response team (RRT)—one that Agnes had helped train and prepare for these critical situations—sprang into action. Within 30 minutes, the team had final results of her CT scan and blood tests and began to administer tPA treatment.

Her role in advocating advances in stroke care within the hospital seems to have saved her life.

The primary goal of rapid response

The American Heart Association and the American Stoke Association® have warned since 2010 that “the benefits of tPA in patients with acute ischemic stroke are time-dependent.” The associations’ guidelines recommend a door-to-needle time of 60 minutes or less for the treatment to be effective.

In most hospital settings, the process for communicating the needs of a newly admitted stroke patient to care team members is manually intensive. These workflows usually have many steps, numerous decision points and multiple handoffs—creating many opportunities for communication breakdowns and delays in a situation in which every second counts.

One of the primary goals all RRTs strive for should be to reduce the number of steps in the communication process—including the number of decision points, communication handoffs and number of people involved in transmitting the information.

Some hospitals have achieved this goal by implementing a unified communication and collaboration solution that automates many of the steps in the RRT process, such as sending notifications to all team members—including team leadership—at the same time. With just one call, schedules are analyzed and the appropriate care team members are identified and contacted simultaneously—based on their preferred contact method.

This eliminates numerous steps and players from the communication processes and makes significant strides toward improving patient outcomes by speeding time to treatment.

Building an effective rapid response protocol

Pre-planning is required for a communication platform to optimize the capabilities of RRTs. Evidence based guidelines and individual hospital protocols determine the number and composition of responding teams. Some hospitals assign different care team members to different teams depending on urgency levels.

For example, Henry Ford Macomb Hospital in Clinton Township, Michigan, has two RRTs. One is dedicated to Level II traumas and does not include an anesthesiologist in the alert system because Level II trauma patients rarely require advanced airway management. However, the Level I trauma RRT—the team assigned to the most critical cases—does include an anesthesiologist.

Deciding whom to alert depending on the urgency of the situation is a key factor in RRT success.

Another important factor is identifying timelines for each care team member’s arrival at the patient’s bedside. For St. Rita’s Medical Center, a 419-bed hospital in Lima, Ohio, the pre-set arrival time for the rapid response nurse is three minutes; it’s five minutes for their 4A nurse. St. Rita’s also set guidelines for both the physician arrival and ordering of the CT scan at 10 minutes.

An effective communication platform feature that aids RRT outcomes is an automated callback and escalation process. This eliminates critical minutes being wasted on resending notifications and manually escalating the issue to another provider when team members do not arrive on time.

The proof is in the results

St. John Hospital and Medical Center (SJHMC) in Detroit aimed to comply with the guidelines set by The Joint Commission and the American Heart Association/American Stroke Association, all of which call for having CT scans interpreted within 45 minutes of the patient’s arrival and having treatment administered within 60 minutes.

SJHMC implemented PerfectServe Synchrony™ and used the flexibility of the platform to develop its stroke team protocol. The protocol called for alerts to a multidisciplinary team of nurses, physicians and staff from neurology, the ED and neurosurgery, as well. Each team member’s preferred method of contact was configured in PerfectServe Synchrony so that when a stroke alert is sent from the ED, each member (or their on-call counterpart) is contacted via their preferred method.

The ability to contact team members directly on their personal mobile devices, as opposed to using overhead paging systems, eliminates the potential for missed pages.

After the system and process were implemented, SJHMC saw significant improvements in time to treatment for its stroke patients. The on-call neurologists’ response times dropped 90%, from 22 minutes to just 2 minutes.

Graph 1

Their door-to-CT scan completion time decreased 41%, from 78 minutes to 46 minutes.

Reduce communication times

 

 

 

 

 

 

Additionally, SJHMC was able to administer life-saving tPA to three times more stroke patients than they were before.

Making lasting, life-saving process improvements

Most hospitals in the Unites States have some version of an RRT in place for major medical events. Some hospitals have even included local EMS organizations in their rapid alert processes in order to improve speed-to-treatment times.

There’s no question that streamlined and automated communication aids RRTs in their work to lower mortality rates for stroke patients and other traumatic injuries.

Rapid response alerts have proven benefits for clinicians, too. Having a rapid response alert program in place eliminates stress and frustration for the ED staff, which usually has the primary responsibility of initiating treatment to stroke and trauma patients.

In addition to simultaneous instant alerts to appropriate response team members, PerfectServe Synchrony’s rapid response alert system also sends activation notices to hospital leadership. These notices include the time the alert was activated and the time each care team member arrived (as input by the nurses involved). This additional insight into rapid response operations gives healthcare leaders the opportunity to identify problem areas and make lasting process improvements that ultimately save more lives.

 

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When communications work, patients win
In every hospital, communication is at the heart of what care teams do. Physicians need to communicate with one another for consultations; nurses need to reach physicians to update them and receive treatment order. Case managers need to communicate with nurses and physicians to ensure on-time discharges and proper care transitions.

Terry Edwards

Healthcare is Ripe for Tools to Enable Value-Based Collaborative Care

By Terry Edwards  /  29 Dec 2016

Game-changing value-based reimbursement models are radically altering the healthcare landscape. CMS’s new program, Medicare Access & CHIP Reauthorization Act of  2015 (MACRA), along with the expanding Bundled Payment for Care Improvement Initiative (BPCI) are dominating headlines, calling into question physician and organizational readiness and the ability to address complexities that impact the revenue cycle.

These new payment models will require clinicians to collaborate around their patients in ways that they have not done so in the past. Increased collaboration is necessary to effectively coordinate a patient’s care among care team members who cross ambulatory, acute and post-acute care settings and organizations. To quote one esteemed health system nursing executive, “If you can’t communicate and exchange information with all of the people involved in an ACO or other new risk-sharing model, you can’t deliver quality care.”

However, many obstacles exist – brought about by healthcare’s fragmented cottage-industry structure – which critically hinder efficient care team collaboration. Inefficiencies are inherent in this siloed work culture, which if left unaddressed can lead to compromises in patient safety and employee relationships. The inevitable lack of communication, coordination and access to critical information points to our most prevalent problems with patient care.

Collaborating under one payment model, one price

This concept is best illustrated by Michael Porter and Robert Kaplan in an article from the July-August 2016 Harvard Business Review in which they offered a simple analogy between buying a car and paying for healthcare services. According to the authors, consumers do not buy the motor, the brakes, the seats, the wheels and other individual parts from different suppliers. Instead, “They buy the complete product from a single entity.”

Like the automotive industry, our healthcare system comprises different suppliers – different healthcare professionals employed by different organizations who provide components of care in a single episode of care. However, unlike the automotive industry, patients rarely, if ever, pay for all of these services from a single entity. Bundled payment aims to change this paradigm.

However, numerous navigational barriers exist in provider-to-provider communication, primarily because each organization possesses different workflows optimized around their own needs for how they receive communications. This ranges from identifying and coordinating the right specialist for a consult, to arranging physical therapy and tests.

To echo Porter and Kaplan, it just makes good sense to collaborate under one model and one price where all suppliers unite to assemble a car—or administer care—in the most efficient manner for the consumer/patient, which is where value-based payments come into play.

Rethinking strategies and tools for bundled payments

Under the new bundled payment model for as many as 48 clinical conditions, CMS will disperse one lump sum to the health system or hospital covering a patient’s entire episode of care. This means that organizations must rethink the most effective strategies and supporting tools to coordinate care activities among a network of acute and post-acute provider participants in a community—and pay them.

Without a doubt, efficient care team collaboration and patient-centered coordination are the nexus of transformative change. To accelerate this level of collaboration, innovative communication technologies are necessary to support this new era of incentivized care. But these communication technologies must be purposefully designed and extend beyond the EHR (and the hospital).

Transforming care with communication technology

The level of collaboration required means that providers need communication technology that transcends geographic and organizational barriers. It must enable and expedite contact among care team members who work in and across multiple coordinating facilities and locations.

In addition, this communication technology must be able to identify and provide immediate connection to the “right” care team member for a given clinical situation. This type of logic requires that—for every single communication by every care team member—the contextual variables of each interaction must be analyzed in real time to ensure communications are routed to the correct individual based upon the recipient’s workflow.

Bottom line: MACRA, BPCI and other market forces are imposing high demands on the care team in making clinical communication and collaboration even more critical for success under value-based care. Leaders in medical practice can take heart in the creation of a permanent impetus that meets the needs of the patient to achieve stronger correlation of the best health outcomes, while rewarding their care services. Assessing communication technology and business processes is a logical place to start.