Collaboration: The KEY Link to an Integrated Care Continuum Carol G. Pray, RN, MA, Program Director Care Coordination, Clinical and Fiscal Integration and Jo Wahl, RN, MS, FACHE, Director Frisbie Memorial Hospital, Rochester, New Hampshire
Frisbie Memorial Hospital is an 84-bed acute care hospital based in Rochester, New Hampshire. To ensure Frisbie is positioned to effectively carry out our mission of providing excellent care throughout the care continuum, we implemented performance improvement initiatives that focused on prospective discharge planning and creating a “safety net” of clinical management of our patients with continuity throughout the patient journey.
Project Goal
Data and Outcomes
Using key performance indicators such as excess days and length of stay, we determined our priorities for improvement. We purposefully collaborated with our physicians and ancillary clinical, ambulatory and community partners to create an integrated approach that focused on process redesign in the three pivotal and dynamic parts of care: 1. Acute care 2. Ambulatory post-discharge follow up 3. Community skilled nursing facilities.
Improvements in these three areas directly led to a reduction in length of stay and excess days. Specifically: • Reduction of 50 Total Med/Surg. excess days • 12% reduction in excess days per discharge • 0.5-day reduction in observation hours • Excess days reduction yielded $252,000 in annual savings Clinical Scorecard Metric
Approach
Target / Budget
1.02 41% 3.87 3.73 4.40 230 175 55 225 29.1 1.332
0.81 NA NA NA NA 183 139 44 225 24.0 1.390
Care Management Excess Days per Discharge % DCs with Excess Days Overall Med/Surg LOS Medical LOS Surgical LOS Total Med/Surg Excess Days Med Excess Days Surg Excess Days Total Discharges Observation LOS (hours) Case Mix Index** Baseline - August 2017 through January 2018 *CMS FY2018 Table 5 used for all months **CMI Target is January through Septmeber 2018
Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019
1.13 37% 4.14 3.92 5.44 211 160 51 187 29.4 1.441
0.68 30% 3.51 3.56 3.35 153 121 32 226 29.1 1.471
0.86 38% 3.53 3.51 3.62 186 154 33 217 28.1 1.358
0.70 35% 3.49 3.28 4.71 133 103 30 191 24.5 1.317
0.93 38% 3.81 3.47 5.43 199 129 70 214 27.2 1.387
1.11 40% 3.98 3.93 4.12 242 185 57 218 25.8 1.465
0.73 31% 3.59 3.48 4.09 150 138 12 205 30.3 1.424
1.00 44% 4.04 3.69 5.68 247 171 76 248 25.6 1.429
0.90 38% 3.80 3.59 4.69 166 116 50 185 24.2 1.392
Current Month Variance to Target
0.08 NA NA NA NA -17 -23 6 NA 0.2 0.0
Frisbie - Average LOS vs. GMLOS by Month 4.5
4.25
4.14 3.90
4
3.5
3.51
3.53
3.49
Jul 18
Aug 18
Sep 18
4.04
3.98
3.80 3.59
3
2.5
2 May 18
Jun 18
ALOS
Oct 18
Nov 18
Dec 18
Jan 19
Feb 19
GMLOS
Frisbie - Excess Days and Excess Days per Discharge 1.40
300
1.20
250
1.00
200
Excess Days
Acute Care: We developed best practice standards of care in discharge planning through implementation of daily Interdisciplinary Rounding and Early Discharge rounding. • Interdisciplinary rounds (IDR) provide a means to assemble hospital team members and improve collaboration. Case Management, Nursing, and Hospitalists collaborated in conjunction with other professional clinical departments (including rehabilitation therapies, nutrition, pharmacy) to assure each patient was discussed, focusing on addressing and resolving risks and barriers to a safe discharge most appropriate to meet the patient’s needs • Early Daily Discharge Rounds were initiated first with Charge RNs and unit-based RN Case Managers to facilitate the rounding and discussion that combines the patient’s pre-discharge plan of care and post-discharge interventions. • We provided Anticipated Date of Discharge education for all Case Managers and bedside RNs to assure patient/family discussion on day 1 and consistent documentation on all patient room whiteboards. • We implemented unit whiteboards to show progress of each patient’s care, their multidisciplinary referrals, their discharge planning, barriers to progress and their destination after hospital.
Quality Improvement
Monthly Baseline
0.80 150 0.60 100
0.40
50
Post-Discharge Ambulatory Care: • Ambulatory Practice Clinical RNs and Inpatient Nursing and Case Management created Post Discharge Standards of Care for ambulatory follow up. These standards assure prioritization of post-discharge appointments and interventions using the LACE Index Scoring Tool and Electronic Medical Record (EMR) interface to review discharge medication lists and patient discharge instructions and education. • We developed processes to ensure post-discharge appointments are scheduled prior to discharge, information is transmitted within the EMR prior to the patient discharge and pertinent clinical information is available to the ambulatory care team to best meet the patient’s needs. Skilled Nursing Facility Collaborative: We created a partnership between Frisbie and community skilled nursing facilities (SNF) as an innovative solution to ensure smooth transitions and excellent quality of care across the continuum. Keys to success include: • Developing communication standards for clinical hand-off processes for all Frisbie patients admitted or readmitted from the selected SNF’s. These include nursing and physician communication. • Aligning the LACE readmission risk assessment tool used in the acute care setting with tools used in our collaborative SNF facilities. • Creating a collaborative clinical scorecard to monitor and improve readmissions for high-risk patient populations • Designing processes to increase efficiency of acceptance and post-discharge transfer of patients to community SNF partners.
Excess Days/DC
Introduction
0.20
0
0.00 Mar 18
May 18
Jun 18
Jul 18
Aug 18
Sep 18
Excess Days
Oct 18
Nov 18
Dec 18
Jan 19
Feb 19
Excess Days/DC
Implications • These initiatives proved to be beneficial in not only metric improvement but assured a safe and efficient transition between levels of care. • Beyond the clinical metric improvement, this initiative enhanced professional relationships among all clinical disciplines and the patients and their families. • It also enabled effective collaboration and integration of the team to deliver safe and effective care from the acute setting through the post-acute care continuum.
Critical Success Factors • Consistent reinforcement and support of executive and physician leadership • Focus on IDR facilitation and format around the patient’s progression, with participation from all clinical disciplines • Flexibility, negotiation and consistent communication with providers to attain buy-in and validation of the process • Clinical management presence, particularly early on, to facilitate change and coach staff • A patient-centric vision to align all disciplines to common goals and outcomes