OUR STORY

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OUR STORY

• STAAR
• STATE ACTION ON AVOIDABLE REHOSPITALIZATIONS
• Cherelyn Roberts, RN, BSN

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Holyoke, Massachusetts

• Alcohol and Drug related illnesses are 246 above
  the state average
• 5th highest rates of suicide
• 2nd highest rate of teen births
• 48.5 of population is Latino, primarily Puerto
  Rican
• 36 prefer a language other than English

• Income is 61 below the state average
• Cardiovascular disease is 278 above the state
  average
• Poorest municipality in Massachusetts
• 30 of community are tobacco users

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Our Hospital

• Holyoke Medical Center is the largest provider of
  inpatient and outpatient healthcare services to
  the poorest community in Massachusetts
• 80 of adult patients admitted to the hospital
  from the community are cared for by a Hospitalist
• 189 Beds consisting of a MedSurg Unit including
  Orthopedics , ICU , Telemetry , Birthing, and a
  Psychiatric Unit
• Our average readmission rate was 14.8 for all
  causes all payors

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STAAR PROGRAM

• HMC began working on the STAAR Program actively
  in August of 2011.
• The STAAR Program perfectly aligned with other
  work being done such as Patient Centered Medical
  Home and Care Transitions
• Four Key Changes were addressed
• 1.Perform and Enhanced Assessment of Post
  Hospital Needs
• 2. Provide Effective Teaching and Facilitate
  Enhanced Learning
• 3. Ensure Post Hospital Care Follow up
• 4.Provide Real Time Handover Communications

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Our Partners
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• Holyoke Health Center.

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http//www.rebhc.org/
Soldiers Home In Holyoke
HOLYOKE HEALTH CARE CENTER (M) 282 Cabot Street

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PCP/Medical Home Providers

• WMPA ( Western Mass Physician Associates)
• Holyoke Health Center
• Valley Medical PCP Offices ,Amherst

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Current Members

• 7 Different Home Health Agencies
• 14 Facilities consisting of Acute Hospitals ,
  Skilled Nursing Facilities and Acute Rehabs
• Several PCP Offices and Health Clinics
• 2 Patient/Family Members
• Other stakeholders such as Pharmacists, RT, IT as
  needed per project

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Understanding the Continuum of Care

• Primary Care
• Acute Care Hospital
• LTAC Long Term Acute Care Hospital
• IRF Inpatient Rehabilitation Facility
• SNF/sub-acute/Skilled Nursing Facility / Nursing
  Home
• LTC Long Term Care
• ALF Assisted Living Facility
• VNA Home Health Care / Visiting Nurse
• Hospice Care End of life care in various
  settings

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The Eyes of the Patient

• The PFAC members keep us tuned in to how the
  patient is feeling
• We had predicted that waiting for paperwork to be
  completed was the delay in getting a patient out
  the door but quickly learned through them that
  it was something totally different!

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OUR TEAM
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Rules of Engagement

1. Throw out your old attitudes about work
2. Dont think of reasons Why it Wont Work, Think
   of Ways to Make the New Ideas Work
3. Dont Make excuses, and Dont Accept Excuses.
   Dont say, We cant
4. Dont wait for perfection 50 ,is fine for
   starters
5. Correct Problems Immediately
6. Wisdom Arises from Difficulties
7. Ask Why at least 5 times until you find the
   root cause.
8. Better the Wisdom of Ten people then the
   Knowledge of One.
9. Improvements are Unlimited. Dont Substitute
   Money for Brains.
10. Improvement is Made at the Workplace NOT from the
    Office.

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OUR AIM STATEMENT

• HMC will decrease the monthly readmission rate by
  20 from 14.8 and maintain that rate by Dec 2013
  by improving the handoff of critical information
  to the next provider

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May 2010 thru Oct 2013
CHF program
CTEP
COPD
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Holyoke Medical Center
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Accomplishments

• Heart Failure and COPD Redesigned Educational
  Tools shared across the Continuum
• Teach Back taught and used across the Continuum
• Heart Failure Protocol established in One SNF
  with Resource RN and spreading to other SNFs
• Identification for High Risk For Readmit
• Warm Handoffs
• Care Transitions Education Project
• Pharmacy Education at the Bedside of HF patients
• PCMH work
• Appts prior to discharge
• Follow up calls
• Priority to HF patients for Home Health Visits

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How we established our CCT

• Networking
• Visiting Facilities
• Offering to introduce the STAAR program at the
  Health Clinic, PCP, offices, VNAs and SNFs
• Asked for frontline staff to join us as they have
  the most access to our patients and they were the
  ones that would keep this going and know what
  needed to be done

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Sharing of Information

• Relationships were formed
• Resource RN visited the facility
• Respect for each others environment was
  established
• Realization that we cared for the same patients
  but with different goals
• How could we, while working together, help the
  patient succeed?

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We started with a Site Visit

• HGA, a long term care facility that also provides
  short term rehab and adult day care for our
  patients agreed to trial a Resource Nurse
• Hospital RN spent the day at the Nursing Home
  after the facility had sent 2 RNs and 2 nurse
  aides to shadow here on the cardiac unit

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Barriers Identified

• Poor Health Literacy
• Time and Access to front line staff
• Inconsistent communication between hospital
  providers (MDs, RNs) and PCPs
• Limited electronic registers and tools for
  communication and tracking patients

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CHF TOOLS FOR SNF
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SNF TOOL FOR CHF PATIENT
2GM NA DIET
2GM SODIUM DIET
2GM SODIUMDIET
Intake/output
Daily weight Same way/same time
HF ZONE Check every shift Green-yell-red
Notify MD if Yellow zone per protocol
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Enhanced Educational Tools
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ZONE EDUCATION
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CCT MEETINGS

• ALL members meet monthly now at different sites!
• We discuss case reviews, each organization
  presents a readmit and the group brainstorms on
• What went wrong? what went well?
• Was the readmission avoidable?
• What are we doing to prevent readmits?

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Recent Evidence of Success of CCT

• Holyoke VNA Project Heart Failure Boot Camp 5
  day program
• Marys Meadow Warm handoff progress
• Home Health Transition Coach Tracer
• Care Transitions Education Project
• Forum held with Hospitalists and Community
  Physicians (next one being planned)

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Care Transitions Education Project
Complement and Leverage Existing Care
Transitions Efforts
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Care Transitions Education Project
Grantee MA Senior Care Foundation Timeline Sept
1, 2011 Aug 31, 2014 Budget 450,000 Partners 3
2 organizations
Project Co-Investors

• Partners Investing in Nursings Future --
  Collaborative of Robert Wood Johnson Foundation
  Northwest Health Foundation
• Massachusetts Senior Care Foundation
• Irene E. George A. Davis Foundation
• Home Care Alliance of MA
• Regional Employment Board of Hampden Co.
• Healthcare Workforce Partnership of Western MA
• United Way of Pioneer Valley
• Commonwealth Corporation

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Care Transitions Education Project
Nurses are in unique position at every step of
the patients journey
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Equipping nurses to lead effective
patient-centered care transitions
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Care Transitions Education Project
Year 1 9/11-9/12
Year 2-3 9/12-12/13
Year 3 1/14 - 8/14
Project Objectives

1. Increase competency to lead and improve care
   transitions
2. Increase mutual respect across care settings
3. Improve coordination and collaboration
4. Demonstrate nurse-led quality improvement

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What Causes Adverse Events During Care
Transitions?
Care Transitions Education Project

• We fail to communicate critical information about
  a persons care, safety, medications, advance
  directives, in-home support services and social
  situation
• We fail to identify issues such as health
  literacy, cultural barriers and educational
  issues

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The OpportunityWhy This Why Now?
Care Transitions Education Project

• Improving care transitions can save lives and
  reduce adverse events and disability due to gaps
  or omissions in care.
• Massachusetts Strategic Plan for Care Transitions

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Cross Continuum Team Branches
COPD team
PulmonaryRehab Team
Partnering with RT and Pharmacy
Teach back sessions
Heart failure program
Community partners
Chronic Disease Patient Education Tools
Resource Nurse
Care Transitons Project
Tobacco education committee
PCMH
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Our Relationships Allow Us to

• Reach across the Barriers and open up the lines
  of communication to provide more
• patient centered care that is improving the
  lives of our patients especially those with
  chronic illness

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CCT in the Community

• Assisted a Public Housing Corporation with
  smoking cessation support and education sessions
  in Senior Housing Communities
• Other members of our CCT did the same in their
  community
• Public Housing was going smoke free and asked us
  to help
• Great opportunity to reach out to our elders in
  the community and establish realtionships

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STAAR Bursts

• We feel the STAAR program has laid the groundwork
  and ground rules for this Transition Program to
  take place.
• Everything we have been working on is going to
  become real as the frontline nurses make it
  happen!
• We are excited to be Pioneers in providing
  Patient Centered Care

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Solutions to Organizing a CCT

• Start at the top
• Approach the Organization you want to partner
  with and explain the importance of transition
  work and what it will mean for the patient and
  their organization.
• Always bring it back to the patient. We all want
  what is best for the patient
• Offer to share your knowledge, expertise , time
  and materials
• Develop tests to trial together
• LISTEN to each other

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Future Plans

• Sustain
• Spread
• THANK YOU!

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Questions?