Skilled Nursing Facility Uses Standardized Assessments, Palliative Care Consults, and Root-Cause Analysis to Reduce Readmissions and Improve Staff Morale

Service Delivery Innovation Profile

Skilled Nursing Facility Uses Standardized Assessments, Palliative Care Consults, and Root-Cause Analysis to Reduce Readmissions and Improve Staff Morale

Snapshot

Summary

The recuperative services unit within Hebrew SeniorLife's rehabilitation center provides short-term, skilled nursing care to patients requiring rehabilitation services after an acute hospital stay. To reduce the risk of hospital readmissions, staff use a three-part protocol consisting of a standardized assessment at admission to identify those with multiple prior hospitalizations, palliative care consults and care plans for those who have had three or more hospitalizations in the past 6 months, and multidisciplinary staff conferences to examine the root causes of inpatient readmissions when they occur. The program has significantly reduced readmissions and improved staff morale.

Evidence Rating

Moderate: The evidence consists primarily of a comparison of the inpatient readmission rate among patients cared for on the recuperative services unit before implementation (June 2008 through May 2009) to the same rate after implementation (June 2009 to May 2010). Additional evidence includes post-implementation feedback from staff collected anecdotally and via survey.

Developing Organizations

Hebrew SeniorLife; Harvard Medical School, Beth Israel Deaconess Medical Center, Division of Gerontology

Boston, MA

Date First Implemented

2009

Problem Addressed

Elderly patients who come to skilled nursing facilities (SNFs) after an inpatient stay are often readmitted to the hospital quite soon after their initial discharge. Many of these readmissions may be preventable.

  • Many readmissions: In 2006, nearly a quarter (23.5 percent) of hospitalized Medicare patients discharged to a SNF were readmitted to the hospital, either while still at the SNF or shortly after discharge. Patients with certain conditions such as congestive heart failure and those with specific clinical indicators (e.g., elevated carbon dioxide levels in those with chronic obstructive pulmonary disease, poor renal function) are at greatest risk of readmission. 
  • Often preventable: Many readmissions result from medical conditions that could have been prevented, such as infections and fractures. Conducting geriatric assessments and getting nurse practitioners more involved in patient care appear to help in keeping readmission rates low. 

Description of the Innovative Activity

The recuperative services unit within Hebrew SeniorLife's rehabilitation center uses a three-part protocol to reduce the risk of hospital readmissions. The protocol consists of a standardized admission assessment that documents prior hospitalizations, palliative care consults and development of care plans for those with multiple recent hospitalizations, and multidisciplinary staff conferences to examine the root causes of readmissions. Key program elements are described below:

  • Standardized assessment to identify those with multiple readmissions: All physicians use a standardized template to assess those newly admitted to the SNF after an inpatient stay. The template covers various topics, including care guidelines for common geriatric syndromes, medicine reconciliation, and care goals. It also collects information on recent inpatient admissions. The physician arranges a palliative care consult for anyone with more than three hospitalizations in the last 6 months (including the hospitalization that preceded the current SNF admission), as described in the bullet below.
  • Palliative care consultations and care plan: The palliative care team—made up of a board-certified palliative care physician, geriatric nurse, geriatric social worker, and chaplain—consults with the patient and family members to clarify care goals and determine whether a future readmission would be consistent with those goals. As part of this process, the team explains various options and potential alternatives to inpatient care if the patient's symptoms should worsen (e.g., remaining in the SNF, transferring to a long-term care facility, or going home to receive palliative care). After the consultation, patients and family members prepare a list of questions and concerns in preparation for a meeting with SNF staff to further discuss their options and develop a formal palliative care plan. The plan addresses numerous items, including treatment goals, the type of treatment and medications the patient would like to receive, whether the patient remains at the facility or goes home, and possible discharge options.
  • Multidisciplinary root-cause analysis of readmissions: The medical director and other facility leaders hold bimonthly, 30-minute conferences (known as “TIPS” or Team Improvement for the Patient and Safety conferences) to examine the root causes of selected cases where patients have been readmitted to the hospital. Before each meeting, physicians speak with the care team at the readmitting hospital to gain insights into problems that staff might have missed. During the session, nurses, nurse aides, physicians, therapists, social workers, and a nursing home administrator discuss the selected cases, focusing on the root-cause problems that led to the readmission. Depending on the nature of the case, they may be joined by family members, on-call physicians, and/or representatives from security, maintenance, home care, inpatient and outpatient pharmacy, information technology, psychiatry, recreation therapy, dietary, admissions, respiratory therapy, and the laboratory. After each conference, all attendees receive an e-mail documenting the lessons learned from the case.

Context of the Innovation

Hebrew SeniorLife is an integrated, eight-site system of health care, housing, research, and teaching that serves seniors in the Boston metropolitan area. The organization's Hebrew Rehabilitation Center offers a variety of health care and rehabilitation services, including a recuperative services unit that provides short-term skilled nursing care to patients after an acute hospital stay. The impetus for this program came from Dr. Randi Berkowitz, the medical director of the unit. With the support of the chief executive officer, chief of medicine, and president of Hebrew SeniorLife, she applied for a 2-year fellowship from The Practice Change Fellows Program, which provides opportunities for nurses, physicians, and social workers to develop leadership skills and content expertise, with the goal of improving care for older adults. After being awarded the fellowship in 2008, she formed a steering committee to finalize program design and assist with implementation of the three-part protocol.

Results

The program significantly reduced inpatient readmissions and improved staff morale.

  • Fewer inpatient readmissions: Inpatient readmission rates among SNF patients on the recuperative services unit fell by nearly 20 percent, from 16.5 percent before implementation to 13.3 percent a year later.
  • Improved staff morale and quality of work: Data from the Agency for Healthcare Research and Quality Patient Safety Survey and staff feedback suggest that the program has reduced staff stress levels and improved overall teamwork and quality of work.

Evidence Rating

Moderate: The evidence consists primarily of a comparison of the inpatient readmission rate among patients cared for on the recuperative services unit before implementation (June 2008 through May 2009) to the same rate after implementation (June 2009 to May 2010). Additional evidence includes post-implementation feedback from staff collected anecdotally and via survey.

Planning and Development Process

Key steps included the following:

  • Obtaining endorsement: Introducing new patient care procedures requires management approval. Before applying for her fellowship, Dr. Berkowitz obtained support from all key Hebrew SeniorLife leaders, including the chief of medicine.
  • Forming advisory committee: Dr. Berkowitz formed an advisory committee that met twice before implementation of the program and twice a year to guide the project. The committee includes nurses, secretarial staff, aides, therapists, nurse practitioners, doctors, and administrators from Hebrew SeniorLife and an acute care hospital, along with the daughter of a patient who had experienced multiple hospitalizations.
  • Developing admissions template: Dr. Berkowitz developed the standardized admissions template based on the American Medical Directors admissions history and physical template, with additional input from members of the Hebrew SeniorLife department of medicine and nurse, administrative, and social service leaders.
  • Introducing program and multidisciplinary conferences: With full support from the director of nursing and other advisory committee members, Dr. Berkowitz introduced the program to unit staff and explained the rationale for the bimonthly staff conferences.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing personnel incorporate it into their everyday responsibilities.
  • Costs: The program requires a modest financial outlay to cover overtime pay for night-shift staff who participate in the multidisciplinary meetings, along with additional minor expenses.

Funding Sources

In 2012, Commonwealth Care Alliance received funding by the Hartford Foundation and the Atlantic Philanthropies Foundation to build the program in partnering skilled nursing facilities across the state of Massachusetts. The program expansion is ongoing as of 2013.

Tools and Resources

Would-be adopters can compare their patient population to that served by this program using a resource from the Shaping Long Term Care in America Project, available at http://ltcfocus.org/.

Getting Started with This Innovation

  • Obtain leadership and management approval: This type of program cannot proceed without approval for procedural changes from senior leaders and managers.
  • Arrange for palliative care consultations: Palliative care consults represent a key element of the program. Would-be adopters without in-house access to palliative care specialists should consider contacting hospice organizations for assistance.
  • Identify staff champions: Successful implementation depends on the support of front-line staff, who will drive the change process, organize multidisciplinary meetings, and ensure that new lessons are incorporated into practice.
  • Create positive environment for change: Staff will not be willing to examine factors that may have contributed to a patient's readmission in the absence of a collegial environment that looks to find solutions, not assign blame. To that end, Hebrew SeniorLife staff positioned the program as an opportunity to promote teamwork and establish mechanisms for positive staff interactions that contribute to patient safety and quality of care.

Sustaining This Innovation

  • Follow up with patients: Information on patients' status after leaving the unit can help to maintain and enhance program effectiveness. As noted earlier, physicians at Hebrew SeniorLife make followup calls to obtain information about readmitted patients, and then present this information at the multidisciplinary conferences.
  • Maintain multidisciplinary conferences: These conferences provide an opportunity to report successes, discuss challenges, and identify care alternatives, thus helping to create an environment that recognizes the contribution that all staff make to quality and safety.
  • Inform new staff about program protocols: Would-be adopters should integrate information about the program into guidelines for employment interviews and new staff orientation sessions.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Randi Berkowitz, MD
Commonwealth Care Alliance
Medical Director
30 Winter Street
Boston, MA 02108
Phone: (617) 426-0600
E-mail: rberkowitz@commonwealthcare.org



Innovator Disclosures

Dr. Berkowitz has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. [PubMed]

Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010 Jan-Feb;29(1):57-64. [PubMed]

Footnotes

  1. Berkowitz RE, Jones RN, Rieder R, et al. Improving disposition outcomes for patients in a geriatric skilled nursing facility. J Am Geriatr Soc. Epub 2011 Jun 7. [PubMed]

Funding Sources

Hartford Foundation
Atlantic Philanthropies Foundation

Developers

Hebrew SeniorLife, Harvard Medical School, Beth Israel Deaconess Medical Center, Division of Gerontology

Boston, MA

Original Publication: 08/31/11

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 07/30/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 06/26/13

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

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