TRANSFORMING HEALTH CARE: A SYSTEMS APPROACH

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TRANSFORMING HEALTH CARE A SYSTEMS
APPROACH Presented by Carolyn Holder MSN
CNS Karen Robinson MSN CNS

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Objectives

• Describe the need for change in the quality of
  care in a healthcare system to ensure every
  person receives all the care for which they are
  eligible every time.
• Discuss program interventions designed to
  transform hospital systems to deliver quality
  care.
• Review quality core measure performance before
  and subsequent to the changes in the hospital
  systems.

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The Changing Health Care Environment

• 50 percent of US population has one chronic
  illness
• 37 percent of people over 65 have three or more
  chronic illnesses
• Increasing hospital expenses
• Diagnosis-Related Group-Adjusted Hospital Costs
  are Higher in Older Medical Patients with Lower
  Functional Status. JAGS 51 1729-1734, 2003

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Chronic Care in America A 21st Century
Challenge

• One in six Americans has a chronic condition that
  inhibits daily life
• 80 percent of hospital days and 69 percent of
  admissions
• 83 percent of prescriptions
• 66 percent of physician visits
• 56 percent of ER visits

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1980sSearch for the Well Seniors
Age 65 years
Age 73 years
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1990s Realization Era
Well elderly are not the hospitals clients
Must provide services to manage the walking
wounded and frail populations
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Health System Fails Seniors

• Wenger NS et al. Annals of Internal Medicine
  2003 Nov 4139(9)740-7

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The Nature of Chronic Conditions Requires a New
Mind-set
Public Health
Primary Care
Acute Care
Long-term Care
Condition Onset
Normal Aging
Progressive Conditions
Disability
Complex care management
Acute Event
Time
Obesity Tobacco and Alcohol Pollution
Hypertension Rapid Weight Gain/Loss
Hyperglycemia Hip Fracture Stroke CHF
COPD Incontinence Confusion Caregiver
Burnout ADL/IADL Decline
Interrelated needs require ongoing, coordinated
care interventions
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The Acute Care for Elders (ACE) Model of Care

• Meeting the Challenge
• of Providing Quality
• and Cost-Effective Hospital Care
• to Older Adults

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Traditional Acute Care Model
Functional Older Person
Acute Illness Possible Impairment
Hospitalization Hostile Environment Depersonaliza
tion Bed Rest Starvation Medicines Procedures
Depressed Mood Negative Expectations
Physical Impairment
Dysfunctional Older Person
ACE Acute Care for Elders
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Functional Model of Care -- ACE
Functional Older Person
Acute Illness, Possible Impairment
Hospitalization
Depressed Mood Negative Expectations
ACE Unit
Prehab Program Continued on next slide
ACE Acute Care for Elders
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Functional Model of Care -- ACE (Cont)
Prehab Program Prepared environment Patient-cente
red, interdisciplinary care Multi-dimensional
assessment and non-pharmacologic
prescription Home planning/informal
network Medical review
Improved Mood Positive Expectations
Decreased Iatrogenic Risk Factors
Reduced Impairment
Functional Older Person
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ACE Unit Benefits

• Improved ADL function
• Decreased discharge to long-term care
• Patient, Nurse, Physician Satisfaction
• Decrease in restraint use
• Changes in process of care (less bed rest, early
  discharge planning, fewer high risk medications,
  depression recognized and treated)
• Reduced expense to hospital

C.S. Landefeld et al., NEJM 1995, Counsell SR et
al. JAGS. 2000, K.E. Covinsky et al., JAGS 1997.
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How does ACE work?

• ACE is a nursing model of care
• Patients at risk for decline are identified upon
  admission by staff, PCPs, the APN
• At risk patients are presented and followed
  during the entire stay with the interdisciplinary
  team rounds.
• Suggestions/communication from the team shared on
  an informal communication sheet
• The ACE team provides academic detailing to
  suggestions for improving care direct and
  immediate QI
• The APN role is as facilitator, consultant, care
  manager, educator and support for QI

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Elders at Risk

• Age 70 or greater
• Impaired 2 or more ADLs/IADLs
• Presence of Geriatric Syndromes (delirium,
  dementia, depression, falls, incontinence, poor
  nutrition, polypharmacy)

• Use of high risk medications
• Lives alone/limited social support
• Frequent readmissions
• Suspected abuse or neglect

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ACE Interdisciplinary Team

• Geriatrician
• Geriatrics Clinical Nurse Specialist
• Patients Nurse
• Patient Care Coordinator
• Social Worker
• Clinical Review Nurse

• Physical Therapy
• Occupational Therapy
• Dietitian
• Pharmacist
• Home Care
• Spiritual Support
• Area Agency on Aging Nurse

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Dissemination of the ACE Model

• Viable method for changing care delivery in
  multiple settings
• Improves quality and cost effectiveness for
  targeted populations
• Can be modified for other disease specific states
• Requires leadership and persistence
• Utilizes a defined process improvement method
  Agree, Build, Build, Commence, Document,
  Evaluate, Feedback

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The ABCs of ACE Unit Implementation
Grow
Agree
Build
Feedback
Evaluate
Commence
Document
ACE Acute Care for Elders
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Care Management for Health Plan
Home Care-ACE Team
SNF GEM Units
ACE for Readmits-GRIP
ACE - Heart
AD-LIFE Trial
ACE
ACE -Ortho
ACE -Pulmonary
Unit
Key
ACE Unit Replications Gero-pysch
TEAM Project
Hospital
Stroke Unit
Community
S.A.G.E. Project
NIH-STEPS CARE Trial
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The ACE of Hearts

• Adaptation of ACE to the Management of Heart
  Failure Patients

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Agree

• Involvement of key stakeholders
• Decreased length of stay
• Improved quality and coordination of care
• Increased patient and family satisfaction
• Improved staff and physician satisfaction
• Education and research opportunities

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Build

• Identify Cardiologist and CNS
• Determine admission criteria
• Develop CHF Unit Team
• Admission orders/Discharge orders
• Team communication sheet/HF meds
• CHF plan of care
• ACE/CHF protocols
• CHF patient education materials
• Training for CHF Unit staff
• Monitoring tools

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Commence

• ACE of Hearts officially began with team rounds
  on May 12, 2004
• ALOS was 5.2 days
• Readmission rate for DRG 127 within 1-31 day
• was 25
• CMS composite score was 67.3
• Patient education compliance was 38.87

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Readmission Rate DRG 127
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References

• ACE
• Counsell S, Holder C, Liebenauer L, et al.
  Effects of a multi-component intervention on
  functional outcomes and process of care in
  hospitalized older patients A randomized
  controlled trial of acute care for elders (ACE)
  in a community hospital. J Am Geriatr Soc
  2000481572-1581.
• Stroke
• Allen K, Hazelett S, Palmer R, Jarjoura d,
  Wickstrom G, Weinhardt J, Lada R, Holder C,
  Counsell S. Developing a Stroke Unit Using the
  Acute Care for Elders Intervention and Model of
  Care. J Am Geriatr Soc 2003511660-1667.
• Stroke Transitional Care
• Allen K, Hazelett s, Jarjoura D, et al.
  Effectiveness of a post-discharge care management
  model for stroke and transient ischemic attack A
  randomized trial. J Stroke Cerebrovasc Dis
  20021188-98.
• Allenk , Jarjoura, D, Hazelett S et al. STEPS
  CARE Trial. NIH/NINDS funded. Complete April
  2005