Leveraging Evidence-based Plans of

Care in Interdisciplinary Rounding to

Optimize Outcomes

October 24, 2013

Kathy S. Menefee DNP, RN, NEA-BC, CPHQ

Administrative Director for Patient Care Operations

Riverside Health System

Moderator:

Michele Norton MS, RN

Director Product Marketing and Strategy

Zynx Health

Patient Engagement, Process and

Technology Unite to Create Positive

Outcomes

Kathy S. Menefee DNP, RN - Administrative Director

Riverside Health System

Dr. Menefee does not have any conflicts of interest.

At the conclusion of this presentation participants should be able to:

Describe basic process steps in an optimization effort around

interdisciplinary plans of care.

Understand the importance of a defined process for patient-focused

interdisciplinary collaboration.

Appreciate the positive patient, organization and team impact that can

result from such an approach.

Objectives

Outline

About Us

The Problem

The Innovation

Technology

Process

Results

End Notes

“To care for others as we would care for those we love –

to enhance well-being and improve health”

Riverside by the Numbers

People Physicians = 1000+ (392 Employed by the Riverside Medical Group) Employees = 9000+

Hospitals Hospital Beds = 984 Acute Care, Community Hospitals = 5 Behavioral Health/Substance Abuse - Children, Adolescent, Adult (1) Physical Rehabilitation (1) LTACH (1) Discharges = 27,136 Patient Days = 141,858 4 ED/Trauma Centers = 118,976 Visits Births = 2,941

Outpatient Visits = 107,000 (excludes diagnostics)

PACE Centers = 6

Long Term Care Centers = 10 Resident Days = 303,405 Beds = 978

Retirement Communities = 3 Assisted Living Units = 306 Independent Living Units = 350

Total Post Acute Beds = 2,306

2012 Data

Where We Live

Our Locations

Who is Riverside? We are.

The Problem

A Plan of Care (POC)

A communication and documentation tool

Promotes communication between team members

Meets documentation needs and requirements

Contains

Patient problems

Plans to address those problems

Interventions to be implemented in patient care

Patient response to interventions

The Plan of Care

2012 Goal: Implement

POC in eHR

IPOC = 7 + Pages of

Paper

Inconsistent Use &

Process

Little to No Patient/Family

Involvement

TJC and MU

But it was much more

than just paper….

The Problem

<30%

The Importance

Value Based Purchasing (VBP) =

Reimbursement model where

hospitals are paid based upon

performance criteria

Affordable Care Act (2010) =

A law that puts in place

comprehensive health

insurance reforms that will roll

out over four years and

beyond

Pay for Performance (P4P)=

Financial incentives to health care

providers to meet defined targets.

VBP

P4P

The Innovation

The Evidence

Studies have shown that an interdisciplinary approach to care can assist in reducing readmissions, mortality, costs and length of stay while simultaneously increasing communication, collaboration and satisfaction of care providers and patients (Preen et al., 2005) (Vazirani, Hays, Shapiro, & Cowan, 2005).

Preen, D. B., Bailey, B. E., Wright, A., Kendall, P., Phillips, M., Hung, J.,…Williams, E. (2005). Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. International Journal for Quality in Health Care, 17(1), 43-51.

Vazirani, S., Hays, R. D., Shapiro, M. F., & Cowan, M. (2005, January). Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71-77.

The Framework

The Plan of Care

Interdisciplinary (IPOC) = Care Managers, Nurses,

Physicians, Rehab Services, Respiratory Therapy,

Nutrition, Pharmacy & others

The Patient is Engaged = Inclusion of Patient’s Daily Goal

Evidence-Based = Zynx Health & Mosby

Includes Transition Goal = Setting of Care

Process as Important as Documentation = Rounding &

Conferencing

Guided Rounding

Project Elements

Steering Council

Clinical Leaders

End Users

Support – IT, Project Management, Process Improvement

Workgroup

End Users

Nurses

Physicians

Ancillary

Mission

Goals – Steering Council

Guiding Principles – Workgroup

Key Concepts

Collaboration vs. Communication

Transition vs. Discharge

Process, process, process

Nurse as Integrator

Guiding Principles - Workgroup

Subject Matter Experts

(SMEs) must be open to the

ideas/suggestions of other

facilities represented.

“This is the way we have

always done it ” is not what

we need.

Keep in mind what is

important when caring for

YOUR patients in your

experience.

This will be a collaborative

effort of our facilities.

Subject Matter Experts for

your area and facility, you

are representing the

viewpoint of your entire

clinical discipline throughout

the design process.

In the event of a discussion

where two or more

members cannot come to an

agreement, the evidence will

prevail.

Getting It Done

Development Process Similar to Order Sets

Use of Zynx Health Evidence (ZynxCare) & Mosby Consult

Workgroup Sessions (chose “live” as preferred venue)

Seek input and expertise of team members in ‘local’ area

Start with “problems”, then diagnosis-based plans

Zynx AuthorSpace off-line review and comment

Approval –

Workgroup

Core Team

Ancillary Advisory Group

Nurse Executive IT Group

Physician Advisory Council (PAC)

Technology

Patient/Family Goals

Anticipated Transition Date

Anticipated Transition Date

07/25/12

IPOC Rounding Participation

IPOC Rounding Prompters

Use of Triggers in the IPOC

Tied to Assessment Findings & Order Sets

Result = Care Gets to Patient Faster

EXAMPLE:

Respiratory Care Screening Trigger

Assessment Finding:

SaO2 </= 93% with or without O2

General Respiratory Care Screen

Identify Problem R/O Problem & Dismiss

Establish POC with Care Team

Implement Interventions

Resolve Problem

Process

Role of Entire Care Team

Assess & Screen

Communicate & Collaborate

Identify IPOC Problems & Interventions

Screen & Intervene

Educate

Revise IPOC and Chart

Advocate

Anticipate

The Difference…….

Communication

The imparting or

interchange of thoughts,

opinions, or information by

speech, writing or signs.

Collaboration

Individuals assuming

complementary roles and

cooperatively working

together, sharing

responsibility for problem

solving, and making

decisions to formulate and

carry out plans.

IPOC Rounding Script (Prompts)

Cadence – IPOC Rounds

1. Begin with the current patient/family goal

2. Review patient status (use Rounding Tool*)

3. Review all current patient problems, interventions

and goals

4. Adjust ATD as needed

5. Revise IPOC adjusting goals, interventions, etc.

6. End with the patient/family goal – verify

consistency with IPOC

Results

Measures

Baseline Data – Ongoing Monitoring

IPOC Presence, Use, Individualization (eHR Audit)

Length of Stay (ALOS, All)

Readmission Rate (30-Day All Dx, All Payer)

Patient/Family Satisfaction

Staff Satisfaction

Physician Satisfaction

Transition Setting (Referrals to Home Health)

Key Clinical Quality Indicators (NDNQI – Falls)

Adverse Events (Midas – patient/procedural)

Average Cost Per Patient Day/Stay

Pilot Hospital: Has the IPOC

been reviewed at least daily?

75%

Pilot Hospital: Readmissions

30-Day, All Cause Readmissions

Pilot Hospital: Patient Satisfaction –

Patient Included in Treatment Decisions

Data Source: Press Ganey Online

Pilot Hospital - Readmissions

0

10

20

30

40

50

60

2012 Number

2012 Rate

2013 Number

2013 Rate

30-Day, All Cause Readmissions

Source: Riverside DSS

Pilot Hospital : Patient Satisfaction

Patient Included in Treatment Decisions

10 3

31

6 14

6

18

3

42 47

92 92 90

41

98

23

41

12

25

8

0

20

40

60

80

100

120

Score

AHA Region 3 Rank

AHA Region 3 Mean: 85.4

Data Source: Press Ganey Online

52.1

35.6

45.7 46.5

33.3

39.5 41.9

48.9

40.9

51.2 50 50.9 48.1

60.5 62.5

54

65.7

57.6

42.4

60.6

0

10

20

30

40

50

60

70

Pilot Hospital HCAHPS Survey Question: "Would you recommend this hospital to your friends and family?"

Desired

Trend:

Outcomes & Results:

Qualitative

Theme Exemplar Theme Exemplar

Improved

communication

“I not only feel free,

but obligated to

state my opinion

and ideas” (RT)

Consideration of

multiple viewpoints

“The team helps me

consider options” (MD)

Strength and

equality of the

team

“All of us are greater

than any one of us”

(RD)

Identification of

care gaps

“We make discoveries

that make a

difference” (RPh)

Team focus on

the patient

“Our patients

deserve this- all of us

together on the same

page” (PT)

Streamlined care “I don’t have to hunt

everyone down

anymore” (RN)

Proactive,

anticipatory

model

“Things don’t come

to a head anymore

– we are more

proactive” (MD)

Holistic approach “Aligns us with the

patient & family’s

wishes” (CM)

Identification of social and

support needs – air conditioning,

meals on wheels, caregivers

Screenings ordered and

completed earlier in stay (as much

as 1-2 days earlier)

Correcting conflicts between

patient-team goals and plans

Just a Few of the “Catches”…

Summer on the Shore (Outside

Temp = 102) patient with COPD,

almost returned patient home to

trailer with no fan or A/C…..

Pediatric patient not eating, team

determined he was grieving over

the loss of his mother…..

Patient “noncompliant” with home

respiratory treatment while

“compliant” in hospital – needed

different mask at home…..

Patient needed information on

losing weight in preparation for

surgery, team focused on

admission diagnosis…..

Maturity & Evolution

Screenings ordered and done earlier in stay (as much as 1-2 days earlier)

Clarification of end of life care wishes

Correcting conflicts in patient-team goals and plans

When “gut” assessment findings/feelings are shared “something’s just not right”

Staff time savings– “entire team is together to share information and make decisions right there”

“In the interdisciplinary team’s

care planning process, all

team members are not only

expected to, but obligated

to, cross over disciplines and

ask questions of each other,

while adding the perspective

of the patient.”

~Kyle Allen, DO,

Medical Director for Geriatrics

and Lifelong Health, RHS

End Notes

Senior Leadership support

invaluable

Champion (CNO)

Kick Off (CEO)

IPOC Rounding (COO)

Discipline of Measurement

Strong Project Management

Find the Champions

Constantly Learn and

Respond

Other Good Things will Follow

IPOC “Coach”

Patient Goal Dialogue

Nurse as Integrator

Patient Advocate

Information Source

Information Giver

Coordinator of care

Coordinator of care team

“Pulls it all together for the

patient”

IPOC Facilitator or Coach

Enforces mandatory attendance

Ensures timely, efficient meetings

Suggests when to take discussion “offline”

Elicits all patient information from team

Uses eHR to reference and update information

Eliminates sidebar conversations

Delegates responsibility for follow-up

Ensures information on Rounding Tool is covered

What does this really mean?

Patient/Family Goal = “I want to go home”

Care Team Goal = “I want them to go home”

What does the patient need to be able to DO before they

can go home (or transition to the next level of care)?

When do they want or need to be home?

How do they want to feel when they go home?

What can we do as a care team to help them get home?

In the patient’s own words…. “ wife’s birthday”, “pain in

my right knee”, “use the bathroom by myself”, “go

dancing”, “breathe”

Future

Bring patient (physically) into rounds

Give patient daily IPOC

Involve patient in developing IPOC

Diagnosis-specific IPOCs

Continue to update and enhance existing problems, add triggers

Continue to revise plans and process based on measurement results

LIPOC =

Longitudinal Plan of Care

Summary

Implementation of electronic plans of

care is an opportunity to improve

patient and organizational outcomes.

The process component is perhaps

more important than the technology or

documentation component.

Foundational elements must be in

place in order for this effort to be

successful.

Outcomes important to the patient,

interdisciplinary team and facility can

be positively impacted through the

IPOC process.

• Medical care is care provided by an individual physician or provider.

• Multidisciplinary care is provided by multiple care providers who all chart in

the same place.

• Interdisciplinary care is provided by multiple providers who actually talk to

each other and know what the other is doing.

~ Shared by a Riverside Dietician (Source Unknown)

Questions ?