Volume 25
Number 11
May 30, 2014
Hospital of the University of Pennsylvania
`` GRNs Krista Walsh (r) and Colleen Hogan of Founders 14 walk with patient John Fitzpatrick to help him prevent losing physical strength during hospitalization.
A new focus on
Elder Health Care
providing individualized care
Hospitalization has a greater cognitive and physical impact on geriatric patients than on those who are younger. Indeed, more than 40 percent of the elderly suffer from delirium while in the hospital. And even a short hospital stay could result in enough physical deconditioning so that a once-independent person will require assistance for basic activities after discharge. “The change in environment is especially hard on these patients,” said Rebecca Trotta, PhD, director of Nursing Research and Science.
for a safe hospital stay and
A new initiative at HUP focuses on this group of especially vulnerable patients, using specially trained geriatric resource nurses (GRNs) to address these issues and more.
transition, and, hopefully,
A New Comprehensive Training
The GRN supports both the patient and family,
preventing readmissions.
Inside Speaking with HUP’s Leaders...........................2 “Best Practice” Tournament.....3 New Mandatory HIPAA Training...........................3
Providing specialty care for the geriatric patient is not new at HUP. In 2010, Nursing brought NICHE (Nurses Improving Care for Healthsystem Elders) on board, a nationwide program that helps meet the needs of older patients with proven programs and protocols. It was piloted on Founders 9, Silverstein 9 and the Emergency Department. The GRN initiative takes this care to a new level. “The GRN supports both the patient and family, providing individualized care for a safe hospital stay and transition, and, hopefully, preventing readmissions,” said Trotta, who created the GRN program at HUP with a $1.5M grant from the Health Resources and Services Administration, a federal agency. Training to become a GRN requires 20 hours of evidence-based geriatric training available on the NICHE website and completion of a two-day class on the comprehensive geriatric assessment, which Trotta developed. “The NICHE course provides a foundation for caring for geriatric patients,” she explained. “The classes focus on the fundamentals of clinic assessment and care planning for these patients.” (Continued on page 4)
Lab Professionals Celebrate!...3
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Speaking with HUP’s Leaders In today’s digital age, risks to privacy and security are becoming more common. To help keep patient information better protected, HIPAA (Health Insurance Portability and Accountability Act) is requiring health-care organizations to strengthen efforts to monitor compliance. “Up until now we’ve been reactive – investigating if someone makes a complaint,” said Garry Scheib, HUP executive director, at this month’s Meal with an Administrator. “Now we’ll be doing more proactive screening.” Every employee who accesses private patient information leaves a computer trail – his or her name, where and when the search took place, and how deep the person went into the file (ie, just demographics or getting a lab result). “We can now use a computer to do the monitoring,” he said. “It will look for trends,” for example, looking for employees who have accessed information on patients in their hometown, or an employee working in heart failure looking in an obstetrics/gynecology file. “It looks for links and can check thousands of possibilities.” Employees who are found to have accessed patient information inappropriately and used it in some way can be terminated. “There is zero tolerance,” Scheib said, “Even if it’s for a family member, it’s not allowed unless that person has health-care power of attorney or is the patient’s caregiver.” All employees must complete new HIPAA education, said Denise Mariotti, HUP’s chief HR officer. “This is especially important since we want our employees to use Penn physicians. We need to make sure we’re protecting our employees’ medical information as we do for all our patients.” (Read more about the mandatory training on page 3).
A Good Year Financially
In financial news, “we’re substantially beating our targets,” Scheib said. Although admissions are down, the increase in outpatient activity and selected inpatient services more than offsets this decline.” UPHS has done well for several reasons, he said. First, our patient-case mix index – which is a measure of how sick our patients are – is high. “Revenue tends to follow case mix,” he explained. “Caring for critically ill patients costs more but we receive higher reimbursements.” UPHS has also seen significant growth in certain areas of surgery, such as neurosurgery, cardiac surgery and transplant, which offsets lower admissions. In addition, our malpractice costs are lower since we’ve had fewer malpractice cases. He noted that our mortality rate is more
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than 30 percent less than expected based on the complexity of our cases, and also credited clinical staff members’ hard work toward eliminating bloodstream infections, patient falls, and ventilator-associated pneumonias. “Penn is doing better than most hospitals in this region,” he said, noting that, on average, admissions to hospitals in this region have dropped 10 to 12 percent in the past few years versus 4 to 5 percent at Penn. The prime reason for this decrease is observation status, a category of care used by all payers. Patients receive the same care as an inpatient – sometimes the cost of care is more – but stay less than 24 hours. Medicare is now requiring that these patients stay for two midnights in order to count as an admission.
Financially, it’s been a strong year for both HUP and the Health System. Although admissions are down, the increase in outpatient activity and selected inpatient services more than offsets this decline. “We see critically ill patients who require a lot of care for most of the day they’re here but they’re out by the next day,” said one attendee. “We take care of more patients than we get credit for.” Scheib said about 12 percent of all UPHS patients fall into the observation status category. “That means we’re losing 80 percent of revenue in 10 to 12 percent of our patients.” In our region, though, other hospitals average 25 percent and more. Because patients have more out-of-pocket costs for observation status than for an admission, this new class of care is a “major patient dissatisfier,” Scheib said. “They get annoyed with the hospital but we have no control. This is not about improving patient care, but just how we are paid by the insurance companies.”
New Mandatory HIPAA Training A new mandatory HIPAA privacy training has been released to update all Penn Medicine employees on privacy and security rules under HIPAA. The training module can be completed online through Knowledge Link. The interactive format addresses current, high-risk issues regarding patient privacy. The e-learning course, which takes about 20 minutes to complete, replaces prior versions of HIPAA training in order to ensure that all members of the Penn Medicine workforce are up-to-date regarding privacy and security safeguards. It is of utmost importance that Penn Medicine ensures patient privacy.
`` Members of the winning Heart Transplant team included (front, l. to r) Susan Chambers, Christine Gearhart, and Patricia Poderis and (back, l to r) Donna Chojnowski, Mary Williams, Mieke Maslanek, and Maria Molina. Missing from photo are William Wynne and Patricia Stutman.
“Best Practice” Tournament March Madness isn’t always about basketball. The AP Practice Committee challenged its advanced practice providers to compete in a “best practices” tournament. Weekly winners competed against one another for the top position. Congratulations to the Heart Transplant team for scoring the most votes in the final match! The team’s winning entry — Transitioning Heart Transplant Patients from Inpatient to Outpatient — uses nurse practitioners to improve continuity of care for these patients. The transition to outpatient is eased through appropriate consultations, safe discharges, and follow-up appointments and continued care by the inpatient nurse practitioner from the time of discharge until the patient’s first outpatient follow-up. The initiative resulted in a considerable reduction in readmissions and improved patient satisfaction scores.
New software will also be in use to proactively monitor electronic patient information to help detect inappropriate access to records. Consequences for violations can include all forms of discipline, including termination. The software will strengthen the HIPAA compliance program and increase patient security and privacy. All of our patients, including employees who often are patients, deserve to have their privacy protected. Information about the software is included as part of the new training course. All employees must complete the online module by June 30, 2014. If you have any questions or concerns, please contact your Entity Privacy Officer (Karen Anderson at HUP and Denise Reynolds at CPUP) or the Penn Medicine Privacy Office at privacy@uphs.upenn.edu.
Lab Professionals Celebrate! Last month, Penn Med observed Medical Laboratory Professionals Week to celebrate the hard work and dedication of the 600-plus lab professionals in more than 30 laboratories across the Health System. HUP Pathology and Laboratory Medicine held a variety of activities for its staff, including the popular dessert competition which brought in “lab” cupcakes complete with double-helices, atoms, and Erlenmeyer flasks, as well as “Perfect Streak Technique” cookies. Fourteen labs participated in the new Rock Your Pride: Lab Week Door Decorating Contest. First prize went to the Microbiology Lab, whose door featured the insect “Mike Roach” presenting the “savory side of microbiology” for those people who are usually “grossed out when they think of bacteria or fungus.” The department also continued its annual tradition of candygrams and a gift basket raffle to raise money for good causes. This year, it raised more than $5,500 for the Metropolitan Area Neighborhood Nutrition Alliance (MANNA) and the Peoples Emergency Center (PEC), two Philadelphia charities.
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A new focus on
Elder Health Care
(Continued from page 1)
Trotta consulted with Marie Boltz, PhD, an expert in geriatric nursing care and NICHE research director, to create the program. “Ours is customized for our setting and our older patients,” she said. The expanded initiative was launched in the three patient-care units with the most geriatric patients — Silverstein 11 and Founders 12 and 14. Silverstein 9 and the ED also continue NICHE initiatives in their specialized settings. `` Rebecca Trotta is the driving force behind HUP’s geriatric resource nurse program.
How Does it Work? Every weekday, one GRN focuses care on specific geriatric patients on the unit. “For that day, the GRN has no other clinical assignments,” Trotta said. Each GRN spends, on average, two days a month in this role. The remainder of time is spent as a primary nurse. Traditionally, GRNs target the oldest patient on the floor. “Age alone is one of the highest risk factors for adverse events,” Trotta said, but cognitive impairment and other factors are also considered. The initial comprehensive geriatric assessment comprises several components, include sensory (such as vision and hearing), cognition (delirium, depression, and dementia), functional status (activities of daily living), nutrition, and medication adherence.
Benefits for Patients, Caregivers and Staff Caregivers are very much part of an elderly patient’s world and as a result they are part of the GRN’s focus as well. “The patient’s success at home — and whether he or she is readmitted — is largely based on the caregiver’s ability and state of mind,” Trotta said. A caregiver strain index can help determine if the person seems overwhelmed. “We’ll try to put interventions in place or provide suggestions to help eliminate some of the stress.” Benefits of the GRN initiative extend beyond the daily care of geriatric patients. “It gives these nurses an opportunity to do something different…a day when they’re not running around with a million things to do,” Trotta said. “And the other clinical nurses on the floor appreciate the help with this population. GRNs also do consults on other patients. Because the GRN also works as a primary nurse, other nurses on the unit learn about caring for the elderly as well. “It’s a diffusion effect,” Trotta said. The GRN program addresses a key component of Penn Medicine’s Blueprint for Quality (Transitions in Care/Coordinating of Care). “Transitions is a critical issue for older patients,” said PJ Brennan, MD, chief medical officer and senior VP for UPHS. “This program is a complement to what we’re trying to do and will bring greater patient satisfaction.” The HRSA grant funding runs through June 2016. “By that time, our hope is to have developed an effective care model that meets the needs of our older adult patients and families, keeping them safe and facilitating successful transitions,” Trotta said.
This thorough assessment often brings to light important issues that might not otherwise be known. “Three weeks ago, a 79-year-old patient of mine was driving, cooking and caring for his wife who has Parkinson’s,” said GRN Joan Brower, BSN, of Founders 12. Since being hospitalized, “he needs a wheelchair and can’t even lift his arms above his head. If we can get him physical therapy, maybe we can preserve some function.… The team didn’t originally have this on their radar.” Part of the cognitive assessment is the ability to recall three words and correctly draw the time 11:10 on a drawing of a clock (an executive function). “You can have a normal conversation with a patient but if the patient can’t correctly draw the time, there’s a problem,” said Vic Gatmaitan, BSN, of Silverstein 11. Trotta said this deficit could have a significant impact on everyday activities, such as the patient’s ability to know which medications to take when. GRNs also follow up on other patients who have already received the initial assessment. Part of this is a daily delirium assessment, and addressing pain and mobility issues. After the assessment and follow-ups, the GRN participates in interdisciplinary rounds to share findings and make recommendations to the team. “As a social worker, I feel that I have gained a partner in coordinating complex discharges for our older adult patients,” said Christine Chevallier-Holmes, LSW, of Clinical Resource Management & Social Work. “The information that they collect during their assessments is greatly appreciated and valued by all the members of our multidisciplinary team.”
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