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PRISMUnderstanding risk and aligning resources to improve outcomes

September 2017

Slide2

©2014 Trinity Health - Livonia, MI

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Overview for today

Background on PRISM

PRISM bundles: risk based interventions

Impact of PRISM bundles

Where are we going with all this?

Slide3

Recap – today’s challenges

©2014 Trinity Health - Livonia, MI

3

Health care is complex, fragmented, expensive

Hand-offs, communication failures

Inpatient: Change in units, shifts, rotations

Across sites of care: outpatient, inpatient,

SNF

Discharge summaries, referral letters

Mass General survey – 59%

housestaff

reported patient harm due to suboptimal handoffs

(

Kitch

Jt

Comm

J

Qual

Pat

Saf

2008)

Only modest level of agreement of the patient’s clinical risk between check-out physicians and incoming physicians

Kappa .19 - .44 (

Brannen

J Patient Safety 2009)

ICC .42 - .51 (

Ratelle

J Gen Intern Med 2014

)

HCAHPS doctor communication

scores worse for high risk

patients

Failure to recognize, rescue

Delays, gaps in care

Clinician alert fatigue

Slide4

Recap – today’s challenges

©2014 Trinity Health - Livonia, MI

4

Imbalance between needs and type of care provided for patients with multiple, chronic conditions

C

linical practice guidelines may conflict with each or not pertain to patients with multiple conditions

(Boyd JAMA 2005,

Lugtenberg

PLoS

One 2011)

Patients admitted for one condition often readmitted for a different condition

(Jencks NEJM 2009)

25 – 33% patients die with pain, shortness of breath, emotional needs

(

Teno

JAMA 2004)

C

ancer screening performed for 31 – 55% of those at high risk of dying

(Royce JAMA

Int

Med 2014)

ICU ventilator use for advanced dementia patients doubled from 2000 – 2013

(

Teno

2016)

Health care resources are finite

Nurses, hospitalists, ICU beds, transition coaches, time for patient teaching (inhaler technique – 2 minutes versus 6 minutes for teach back

Press J Gen

Int

Med 2012

)

Slide5

Look to make complex simple

Look for patterns

Look for common denominator

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Pareto Principal:30 % of patients > 80% deaths > 40% readmissions

PRISM 1 and 2 patients will likely need more than “usual care”

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PRISM is a counter influence

©2014 Trinity Health - Livonia, MI

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Simple

construct – pay extra attention to high risk subgroup

Pareto principle – small proportion of patients (inpatients AND outpatients) have disproportionate number of adverse events

High risk patients need higher nursing staffing levels

High risk patients may have golden hour - physicians

should see

early and often

High risk patients have needs anticipated by other team members (

eg

. Rapid response team, nutrition, pharmacy, palliative care,

etc

)

Understand

explicit

risk of dying – Which goals are most important to the patient right now?

(Fried Arch

Int

Med 2011,

Tinetti

JAMA Cardiology April 2016)

aggressive life-saving efforts right now

?

Living longer at all costs?

Time spent living independently?

Control bothersome symptoms (pain, SOB, anxiety, depression) irrespective of survival time?

Use remaining time to repair personal relationships?

Creates

common

clinical language for hand-offs and communication

Knowing a patient is PRISM 1 provides an immediate array of information

Framework transportable to home care and local SNFs to initiate risk-based interventions

Outpatient version - No

longer “inpatient silo” versus “outpatient silo”

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©2014 Trinity Health - Livonia, MI

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What is PRISM?

Prediction rule that generates a probability of a patient’s risk of dying (mortality risk) within the first 30 days of admission based on information known at the time of admissionProbabilities are distilled into a single score ranging 1-5PRISM 1 – Highest Risk PRISM 5 – Lowest RiskInforms initial placement into the appropriate nursing unit, timeliness of initiating treatment, surveillance and response activities of the clinical team, and transitions of care

AROC

30-day

mortality (0.88)

180-day mortality (0.89)

Palliative status (0.89)

Unplanned Transfer (0.74)

30-day readmission (0.69)

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©2014 Trinity Health - Livonia, MI

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PRISM Risk Factors

Provided by Clinician

Current or past history of: Cognitive Defect Other Neurological Atrial Fibrillation Cancer Metastatic Cancer LeukemiaCurrently have: Respiratory failure Injury Heart Failure Sepsis Medical vs Surgical Admission

Obtained Electronically

Age

Gender

BUN

WBC

Platelet Count

Lactate

Hemoglobin

Albumin

Arterial pH

Arterial pO2

Troponin

Hospitalized at SJMHS within past year

Emergent

Admission

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©2014 Trinity Health - Livonia, MI

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PRISM Inputs

Slide11

30-day Outcomes by PRISM StrataSJMAA Adult Inpatients, CY2015

11

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Need to institute treatment early

Need to institute life-saving measures quickly

Need to account for persistent

level of risk after discharge

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Disposition and PRISM:Informs Work of Case Managers, Social Workers

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©2014 Trinity Health - Livonia, MI

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PRISM 1 patients sent

home experience a similarlevel of events as their counterparts in SNF, home care

Slide15

©2014 Trinity Health - Livonia, MI

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15

PRISM 1 and 2 patients provide lower scores for Doctor Communication and Staff Responsiveness (adjusted for age, gender, language, self-reported health, educational level and service)

15

Journal of Hospital Medicine,

September 2016

More Favorable Responses

Less

Favorable

Slide16

Look for common patterns in our daily work

Some root causes (To Err Is Human):Delay in diagnosis, treatmentFailure to respondFailure to preventFailure of communication

Some remedies:Care within “Golden hour”Nurse staffingTeam workCommunicationStandard work

©2014 Trinity Health - Livonia, MI

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PRISM Across the Continuum: Standardized Process & ExpectationsIdentify Vital Few Items to Customize Level of Intensity, andSupport Appropriate for Risk Level

Assign PRISM Score and Pre-Admit Work

Identify Appropriate setting for care, Initiate Care and Bundles

Transition & Discharge

Post DischargeFollow up

PRISM Score 1PRISM Score 2PRISM Score 3PRISM Score 4/5

Placement

& Admission

Admit & Placement Guidelines include risk and acuityPrioritize order entry and initiation for high risk patientsHeightened vigilance for high risk patients in first 24 hrs

Progressing Care

Early Screening of high risk patients for Case Management, Palliative Care and Nutrition

Addressing Advance Directive and Goals of Care proactively for high risk patientsAppropriate frequency of nursing assessments for low risk pts

Reducing

MortalityReducing Complication Improving Evidence Based Care and Patient ExperienceReducing Readmissions, ED Utilization

Discharge & Transition

Scheduling of follow up appointments for high risk patientsDifferentiated Handoffs by risk/complexity levelStandardized, Minimum Home Care support for high risk patientsDischarge med rec, education/support

Copyright©Saint Joseph Mercy Health System,

Ann Arbor Michigan

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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Example how concurrent processes of care can be launched (PRISM 1 Acute Care Bundle)

18

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PRISM Bundle: Interventions for Care Coordination and Transitions

PRISM Score

Select Interventions

PRISM 1

Palliative Care Consult for goals of care and symptom management

Verbal IP to PCP provider handoff attempted

Discharges

to Home include Home Care at minimum

HomeCare

Bundle

inplace

, includes first visit within 24-36

hrs

Discharges to ECF targeted

to occur prior to 1pm

ECF Bundle, includes all assessment completed within 24-36

hrs

and

HomeCare

and PCP appointment when d/c from ECF

PRISM 1 & 2

Pharmacy provides medication review and counseling (while admitted or with post discharge phone call)

PRISM 1, 2 & 3

Schedule follow-up appointment for within 3 - 7 days after discharge to home/homecare (PRISM 1 & 2 attempt closer to 3 days)

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©2014 Trinity Health - Livonia, MI

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Primary

Bundle Elements - Assessment for Regional Standardization in Progress July 2017

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©2014 Trinity Health - Livonia, MI

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PRISM 1 Patients:

Higher nursing staffing levels (not GMB)

Start treatment quickly (“golden hour”)

Respond quickly, bedside evaluation if new symptoms because mortality risk increases greatly

Include PRISM score with handoffs

Palliative Consult – goals of care, symptom control

Home care (if PRISM 1, non-SNF)

Attempt communication with PCP (or SNF doc) at discharge

Slide22

Post Hospital

©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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PRISM 1 ECF Bundle (Each team member plays a role)regional collaborative

23

Working on expanding to include interventions for PRISM 2 & #

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©2014 Trinity Health - Livonia, MI

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PRISM 1 Home Care Bundle: Ann Arbor Example

24

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©2017 Trinity Health

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Process Metrics

and Outcomes

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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30 Day Mortality Actual # Deaths / Expected # Deaths

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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30 Day Readmissions (Actual / Expected). Reflects statistically significant decreases in

Pneumonia, most Medical Discharges, however, trends for HF, COPD, AMI, Stroke, Surgery were non-significant with this particular risk-adjustment method

Slide28

Slide29

75th percentile - Time from order placement to Nurse Review (hours)

Numerator

Denominator

Time from diet order placement by physician to RN review (

dietorderrnreview_hr

) - 75th percentile (in hours)

Scored in ED

Slide30

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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Associations with Early Assessment and Inpatient Care Orders*

©2014 Trinity Health - Livonia, MI

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Length of Stay

PRISM 1: (vte advisor) Shorter average LOS by 0.37 days (p = .003)PRISM 2: (vte advisor) Shorter average LOS by 0.16 days (p = .01)30 day mortalityPRISM 1: 18% fewer deaths (vte advisor or diet order), p = .03PRISM 2 : 13% fewer deaths (vte advisor or diet order), p =.07CHF patients 30 day mortality borderline lower (vte or diet order) 19.8% versus 31.7% (p = .05)Severe infections (sepsis) 30 day mortality lower (vte or diet order) 39.1% versus 47.0% (p = .0498)Unplanned transfers to ICU in first 24 hoursPRISM 1: 46% fewer unplanned transfers if diet order or vte advisor completed within 75 minutes (p = .03)Top 3 clinical conditions having unplanned transfer regardless of PRISM score: Serious infection (33% of transfers), Pneumonia (9.8% transfers), Alcohol-related (6.1%)

…mortalitysite 8/1/13 – 3/31/16

*As measured by launching VTE advisor (or diet order if noted) within 75 minutes of floor arrival in non-surgical cases (cannot determine causal relationships)

Slide31

Nutrition Screen for PRISM 1, non-ICU

Discharge MonthMeasure201611201612201701201702Target Pop: PRISM 1, admit unit Not ICU86959397Any Intervention Criteria Met - Count69747077Any Intervention Criteria Met - % Target Pop80%78%75%79%Individual Intervention Criteria - Count:Nutrition Consult Order entered w/i 48 20202019Nutrition Note entered w/I 48 hrs63686269Review in TeamFlow w/I 48 hrs24192730

Prospective PRISM scored,

disch

as IP or TC

Slide32

PRISM Bundle and HCAHPS Dashboard for Prospective PRISM Scores

PRISM 1PRISM 2PRISM 3PRISM 1 &PRISM 2

Slide33

PRISM 1 Follow Up Appointments Kept (IHA)

©2014 Trinity Health - Livonia, MI

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Slide34

Current state

©2014 Trinity Health - Livonia, MI

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All 5 SE Michigan Trinity hospitals + Grand Rapids St. Mary are generating inpatient scores (see next slides for details)

CNOs working across the region to standardize PRISM-related care bundles

Outpatient PRISM scores generated and delivered to IHA practices monthly (more detail at a later time)

“Check-in PRISM

” launched. Before the ED evaluation takes place, an initial PRISM score is calculated at the time of ED registration

[NEW] There is now a separate prediction rule in place in all EDs to identify patients at high risk for repeated future ED visits

Slide35

[NEW] Prediction Rule to Identify Those at Risk for Frequent ED utilization

©2014 Trinity Health - Livonia, MI

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Prediction rule for determining patients likely to return to the ED 2 or more times in the 30 – 120 days following the index visit developed

Allows 30 days for interventions to be put in place

3 Risk Categories (high, medium, low) for returning to the ED

Implemented

in 6 Trinity Hospital Emergency

Departments

Scores visible in the ED PRISM web application

No standard bundles yet

Permits

control charts to

evaluate effectiveness of

interventions (observed / expected)

Slide36

Other new uses of inpatient PRISM scores

©2014 Trinity Health - Livonia, MI

36

Ann Arbor Pastoral Care visiting PRISM 1 patients in the Emergency Department

Working on a patient pathway for PRISM 1 patients

Slide37

Your Care Path starts as soon as you arrive at St. Joe’s and continues beyond….

When you arrive to your in-patient roomDuring your stayDuring your stayAs you prepare to leaveThe nursing team will greet you when you arrive in your room and will make you comfortable. They will assess your immediate needs. Your Hospitalist doctor will see you within 1 hour and develop with you the right treatment plan to get you better. The nursing team will make sure the tests, medications and plan are carried out and will inform you and your family of next steps.Your “My Important Papers” folder is where all your new information will be kept. Your team will review the material often with you.Good nutrition is important for healing, so healthy meals and snacks will be provided.We begin planning for your discharge from the hospital the day after you are admitted since a safe transition takes time to put into place. The Care Coordination Team will work with you and any family to determine the type of support you will need once you leave the hospital.Sitting in your bedside chair and walking a few times a day are important steps to get you better. We will always assist each time to keep you safe.Nursing team will check on you every hour. Your doctors will see you once or twice a day and review your care plan with you.Sometimes it can be difficult to manage troubling symptoms, like pain or fatigue; while at home and in the hospital. Our Palliative Care staff are part of the team that help you learn how to better cope with your illness and its impact on your daily life.Your active participation in all discussions and decisions are so important. We will help you make the plan that is right for you, and respect your wishes.Other physician consultants and therapists might also be involved in your care, but your Hospitalist is the one in charge. Ask any one of your healthcare team when you have questions or need help. Your care team will ensure you have the support necessary for a safe transition from the hospital:We will help you schedule a follow up appointment with your own doctor, if you are going home.Your hospital physician will update your primary care physician with a summary of your hospital stay.If you have a family member or support person, it is best to include them in all of your health teaching ,or as often as they can visit you while you are at St. Joe’s, since sometimes it is hard to remember once you get home.

Skilled Nursing FacilityOur goal is to have you transferred earlier in the day and once your arrive, you will be seen by the nurse within 1 hour.The physician as well as members of the social work, therapy and nutrition teams will meet to discuss your plan of care by the second day.When you are ready to go home, your skilled nursing facility team will :Schedule a follow up appointment with your Primary Care physicianPlan for Home Care to follow up with you after you leave

HomeTalk with your team about what to expect when you go homeA nurse or pharmacist will review your medications with you before you leave the hospital. When arrive home, a Home Care nurse will call to schedule a home visit2 – 3 days after discharge, a pharmacist will call you to answer any question you may have about your medications.

Patient Pathway Draft (

pg

1)

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Your Care Path: After the Hospital

What to Expect if you are going Home In the HospitalWe will help you schedule follow-up appointmentsA nurse or pharmacist will review your medications with you beforeAt HomeHome Care nurse will call to schedule a home visitA Pharmacist will call you 2-3 days after discharge to answer any question you may have about your medications.

Before I Leave the HospitalDo I:Understand the purpose and the common side effects of my medicationsHave all the medications I needHave all the equipment I needFeel comfortable getting up and moving aroundWhat else do I need to know or learn What other questions do I have?

What to Expect if you are going to a Skilled Nursing FacilityIn the HospitalOur goal is to have you transferred earlier in the dayWhen you arrive at the FacilityA nurse will see you within 1 hourThe physician as well as members of the social work, therapy and nutrition teams will meet to discuss your plan of care by the second dayWhen you are ready to go home, your skilled nursing facility team will :Schedule a follow up appointment with your Primary Care physicianPlan for Home Care to follow up with you after you leave

Patient Pathway Draft (

pg

2)

Slide39

If your patient asks about PRISM

©2014 Trinity Health - Livonia, MI

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http://infonet.trinity-health.org/clinical/prism/docs/Infosheet_Talking_about_PRISM_with_Patients.pdf

Slide40

We are Building Coordinated, Risk-based Care Across the Continuum

©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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©2014 Trinity Health - Livonia, MI

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Our Vision:

Every patient will get timely, anticipatory, appropriate care based on the level of risk/need

Every patient will received better-coordinated care wherever they

are (home, physician office, hospital, emergency department, skilled nursing facility or

other) because all care providers communicate the level of risk (“handoffs”) using the same language

Every patient in our population will have a PRISM

score

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©2017 Trinity Health

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PRISM Understanding risk and aligning resources to improve outcomes - Description

September 2017 2014 Trinity Health Livonia MI 2 Overview for today Background on PRISM PRISM bundles risk based interventions Impact of PRISM bundles Where are we going with all this Recap todays challenges ID: 776078 Download Presentation

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