Bethany Model of Care

1
Bethany Model of Care

• Sister Jacquelyn McCarthy, CSJ, RN
• CEO/Administrator
• Bethany Health Care Center

2
Faculty Disclosures

• Sister Jacquelyn has disclosed that she has no
  relevant financial relationships.

3
Learning Objectives

• By the end of the session, participants will be
  able to
• Understand the importance of daily collaboration
  of interdisciplinary nursing and support teams
  who provide timely intervention and
  implementation of medical care.
• Understand the importance of adherence to
  institution organizational improvement plans.
• Understand that providing a comprehensive array
  of in-house medical services and an in-house
  education program tailored to enhance the
  delivery of quality care requires a willingness
  of the staff to change from the traditional way
  of caring for our residents to a
  resident-oriented approach.
• Understand the impact of low employee turnover on
  care given to residents.

4
Facility Demographics

• Bethany Health Care Center
• Framingham, Massachusetts
• Total of Beds 101
• A Non-profit Facility Sponsored by the
• Sisters of St. Joseph of Boston

5
Bethany Model of Care Program

• Initiated formal study beginning January, 2003
  program was in place to a degree prior to this
  date.
• We wanted to have a treat in place modality of
  care.
• We believe we could reduce the number of
  unnecessary admissions to the acute care setting.
• We had historically followed this mode of care,
  but had not studied outcomes.
• Our objective was to verify that treat in place
  philosophy could be an option for residents who
  reside in long term care facilities and have
  positive outcomes.
• Efficacy - the degree to which a test, procedure
  or service meets the individuals needs, desired
  or projected outcome(s).
• Appropriateness - the degree to which care and
  services are relevant to the individuals needs,
  given the current state of knowledge.

6
Bethany Model of Care Program (Continued)

• Availability - the degree to which appropriate
  care and services are available to meet the
  individuals needs.
• Timeliness - the degree to which the care and
  services provided to the individual are at the
  most beneficial or necessary time.
• Effectiveness - the degree to which care and
  services are provided in the correct manner,
  given the current state of knowledge, to achieve
  the desired or projected outcome.
• Continuity - the degree to which the individuals
  care and services are coordinated among
  practitioners, among organizations and over time.

7
Project Timeline

• Study was conducted over 5 years 2003 2007
• Planning and Research
• Data compiled included
• Age of Residents Currently Bethany residents 85
  years old and over is 73. Compared to
  Massachusetts state average of 45 and national
  average of 41.
• Number of hospitalizations 29 in 2003 to 8
  in 2007
• Number of infections 129 in 2003 to
  74 in 2007
• Number of deaths 33 in 2003 to 21 in
  2007
• Average number of medications residents receive
• 40 - 9 medications or less
• Positive contributing factors
• Low turnover of direct caregivers
• RNs 31 in 2003 - 9 in 2007
• LPNs 7 in 2003 - 0 in 2007
• CNAs 15 in 2003 21 in 2007
• Care hours provided 3.5 to 3.8 hours per
  resident Massachusetts standard is 2.6.
• Reviewed Contracted Vendor use looked for ways to
  improve in-house service to residents.

8
Project Timeline (Continued)

• Issues encountered
• How do we bring as many services to the facility
  as possible so that residents do not have to
  leave the building.
• Added Mobile Barium Swallow Capability.
• Added Psychiatrist to Bethany Staff.
• Added INR Testing On Site.
• This is an on-going study monitored by our QI
  team that meet monthly.

9
QI Planning Implementation

• Committee Members meet monthly
• CEO/Administrator Pharmacy
• Assistant Directors of Nursing Lab
• Director of Nursing X-Ray
• Medical Director Rehabilitation
• Department Heads Human Resources
• Nurse Managers Pastoral Care
• Social Services
• Interdisciplinary members meet daily.
• Meetings Results communicated to Staff at QI
  meeting
• Collaboration with committee to look at best
  practice.
• Identify high risk issues such as falls, weight
  loss, infections, change of condition promptly at
  daily interdisciplinary meetings.
• Continue to monitor to see if factors changed and
  effect on resident care.
• Plan Review
• Staff
• Quality Assurance Committee
• In addition
• Each month the information regarding fall, weight
  loss, infections is communicated to Staff.
• Each day information regarding changes in
  condition is shared with Nursing Staff, Social
  Service and Administration.

10
Issues Found/Communicated

• Residents preferred to be treated in their own
  home at Bethany.
• Families/Health Care Proxies are in agreement
  with residents preference to be treated at our
  facility.
• Longevity of staff builds relationships with
  residents. Consistent care assignments of CNAs
  Medical Director at Bethany more than 20 years
  NP more than 5 years DON 19 years ADON 15
  years Administrator 12 years.
• Quick assessment of health issue and intervention
  reduced need for hospitalization. Staff
  recognizes subtle changes in residents condition
  allowing for quick assessment of health issues.
• Five days per week visit by facility Physician
  and Nurse Practitioners. 24 hour availability of
  Primary Medical Director and Nurse Practitioners
  allows for immediate intervention and
  implementation of care to reduce need for
  hospitalization.

11
Tools Used to Affect Change

• Tools used
• In the beginning
• Committed Medical Director whose philosophy is to
  treat in place when at all possible and who
  practices evidenced-based medicine.
• Five day per week visits by on-site Primary Nurse
  Practitioners. Five days per week visits to the
  facility by Medical Director to those who are
  experiencing health decline.
• As time progressed
• Round table discussions with contracted
  psychiatrist to discuss behavior modification.
• On-going training of nurses on physical
  assessment of residents by Education Coordinator,
  NPs, Pharmacy, Rehabilitation, and Audiologist.
• Monitoring of turnover rate of staff at facility
  and compare with State average.
• On-site monitoring of necessary hospitalization
  and number of MLOA days.
• Proactive fall reduction program to reduce
  unnecessary hospitalizations.
• Rehab rounds weekly.
• Daily discussion of falls and high risk residents
  with interdisciplinary team.
• Walking club.

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Tools Used to Affect Change (Continued)

• Tools used
• As time progressed (continued)
• Monitoring of meal consumption. Adequate
  nutrition reduces skin breakdown and reduces
  admissions for those who are diabetic.
• Watch your weight group (for residents who are
  trying to lose weight)
• Food group meetings (for all residents to discuss
  menu choices and favorite foods)
• Monthly weight management meetings.
• Weight changes discussed at weekly
  interdisciplinary meeting.
• Prevention of infections through vaccinations of
  staff and residents, education of staff and
  residents.
• Tools created
• Use of on-site Barium Swallow
• INR testing in-house

13
Facility Expenses

• No additional costs were incurred because
  planning and execution were done during normal
  work hours. However, the cost of on-call
  psychiatrist was 1500 per month and use of
  coagucheck was 156.25 per month. Supplies for
  the coagucheck were about 250 per month.
  Facility receives reimbursement of about 5.95
  per INR. Average number of INR tests done 105
  per month.
• The BMCP "treat in place" modality of care has
  resulted in cost savings associated with
  decreased hospitalizations, testing, medication
  costs and transportation services.

14
Outcomes

• Reduction in hospitalization and infection
• 29 residents hospitalized in 2003 7 residents
  hospitalized in 2007.
• Decreased days in hospital 102 in 2003 to 34 in
  2007.
• Reduction in infections from 129 in 2003 to 74 in
  2007, with the most notable reduction in urinary
  track infections 53 in 2003 to 26 in 2007.
• A fall reduction program that included weekly
  rehab rounds that reduced the number of
  hospitalizations.
• Average number of medications prescribed
  decreased.
• 40 of Bethany residents take fewer that 9
  medications.
• Deficiency free DPH survey rating 11 consecutive
  years.
• One of 33 homes in the United States to receive a
  5-Star rating from the Federal Government.
• 100 referral recommendation from residents and
  families who responded to a Massachusetts
  Department of Public Health Survey.
• Reduction in turnover rate of employees
• 2003 2007
• RN 31 7
• LPN 7 0
• NA 15 21
• Reduced recruitment and training costs.
• Consistent resident care assignments have brought
  benefit to residents who have their issues
  addressed quickly and staff who have strong
  relationships with residents.
• Staff satisfaction with job improved.

15
Closing Thoughts

• This model of care can be easily replicated.
• Essential Elements Needed
• Dedicated Medical Director.
• Nursing Department with strong assessment and
  collaborative skills.
• Quality Improvement Program that meets regularly
  and resolves issues across departments.
• Salary and benefit package that will keep
  turnover rate low.
• Common understanding and acceptance among
  employees and families that treating in place
  can prevent hospital acquired conditions.
• Treating in place can and does improve quality
  of life!