Recommended Practices to Maximize Reimbursement: Colo-Rectal Bundle Sunil

Recommended Practices to Maximize Reimbursement: Colo-Rectal Bundle Sunil

Recommended Practices to Maximize Reimbursement: Colo-Rectal Bundle Sunil (Sunny) Eappen, MD,Chief Medical Officer and Chief of Anesthesia Massachusetts Eye & Ear Fleurette (Flo) Kiokemeister, RN, MSN Project Manager for the Perioperative Surgical Home/ERAS/ RRP Advocate Lutheran General Agenda Case Study Client logo placeholder Getting Started Informati on Governa nce / Steering Committ ee Clinical Redesign

Advocate Lutheran General Hospital 638 bed hospital Level 1 Trauma Center Tertiary care referral hospital 1,303 physician representing 51 specialties and subspecialties 25 operating rooms / over 19,000 surgeries per year Part of Advocate Health Care, Illinois largest health care system and one of the nations top 10 health care systems 3 What is the Main Goal? Client logo placeholder The main goal is to enhance value while achieving the Triple Aim: a better patient experience, better health outcomes and lower costs Specific Goals and Objectives Client logo placeholder Provide a portal of entry to perioperative care

Ensure continuity of coordinated care throughout the surgical experience Reduce Cost of care LOS Complication rates Readmissions Promote optimal patient safety Standardization using evidence based practices and research Improve the patient and caregiver experience and satisfaction Provide quality and improvement measures demonstrating success and outcomes Perioperative Surgical Home: Who, Where, When, How Multidepartment al Initiative Continuity of Care Throughout Surgical Experience Surgic al Home Transform Surgical

Care Developing a Standardize d Set of Evidenced Based Protocols 6 Getting Started First Step: The Most Important One Assemble anesthesia champions Select 1 surgical service line High Cost / High Complexity / High Volume Procedure with ERAs protocol Enthusiastic surgeons Obtain senior leadership support Allocate money and support personnel Obtain benchmark data on performance 8 Steering Committee

Anesthesia Lead Anesthesiologist Surgeons Surgeon in Chief Ad HOC Nutrition Geriatric MD Nursing Education Administration Care Managers IT Marketing Post Op Project Team Post Discharge AHH and PAN

Pharmacy Service Intra-op PACU Hospitalists Finance Physical Therapist PreSurgical Testing Project Manager Ostomy RN Research and Quality 9 Next Steps

Interview Staff Assemble Steering Team Gather Literature Collect Quality Baseline Data Trial and Carry Out Plan and New Pathways Gather List of Protocols Learn About Current State Develop New Pathways

Analyze Data Finalize Protocols and Pathways Roll Out New Protocols 10 Information Retrieval is Challenging Information Needed: How Best To Obtain: EHR Nomenclature to Schedule Financial Cost Per Case Hospital Financial System ICD10 L.O.S.

NSQIP Database Quality SSI DVT Crimson NSQIP HCAHP Press-Ganey/NRC 11 Lean Methodology Act Act Study Study Step 9 Step 8 Analyze the pathways and Trial protocols

Step 6 protocols and new And Clinical Workflows Develop Pathways and protocols handoffs. and clinical Monitor pathways Data Step 7 Plan Plan + + Step 5 Step 4 Step 3 Step 2 Step 1 Interview Staff Assemble steering

teamchoose a physician leader for each phase and its members Gather literature. Collect quality baseline data Collect list of protocols for each phase Observe current state. Value stream Mapping. Step 10 Finalize protocols, processes

and clinical pathways. Develop Physician Scorecards and Colorectal dashboard. What changes are to be made? Next cycle? Act Plan + Study Do Analyze data

Compare results to predictions Summarize what was learned Implement finalized processes and clinical pathways. Finalize physician scorecards and dashboard Reason for action Current state Ideal state Gap analysis Causal Analysis Possible solution Carry our plan Document observations Record data 12 How Did We Educate Ourselves? ASA

Learning Collaborati ve Attend Conferenc es Literature Reviews Networkin g ERAS Project Manageme nt Group 13 Bundled Payment Overview Physician Director of Perioperative Services PSH

Preoperative Patient engagement Assessment and triage Optimization Education Transitional care planning Surgical Home Leadership Intraoperative Multimodal pain therapy GDFT Supply chain Operational efficiencies Reduced variations

Management Team Postoperative Right level of care Integrated pain management Prevention of complications Quality Improvement Analytics Long-Term Recovery Coordination of discharge plans Education of patients and caregivers Transition to appropriate level

of care Rehabilitation and return to function Return to PCP/Medical Home expectations met Health Care SUPPORTING MICROSYSTEMS Human Resources Resources Nursing Pharmacy Laboratory Radiology Central Supply Information

Technology Social Services Home Health ECF Nutrition *Figure develop by Daniel J. Cole, M.D. 14 Perioperative Phase: Surgeons Office, PST and the Perioperative Optimization Clinic for Risk Reduction Surgeons Offices Surgery Colonoscop y Checklist Form Scheduling to Identify the PSH

Patients Introduce New Perioperati ve Optimizatio n Clinic Introduce Patient Technology Engageme nt App Twistle 16 SAMPLE: Surgery Colonoscopy Checklist Form 17 Perioperative Optimization Clinic (POC) Multidisciplinary Clinic: One Stop Shopping Concept Hospitalist Anesthesiologist Nurses

Additional Clinicians AD HOC Discharge Consultant Nutritionist Skilled Nursing Home Rep or Home Health Ostomy Nurse 18 Opportunities of the POC Develop Preoperative Risk Assessment for all surgical patients Preoptimize patient 2-3 weeks before surgery Serve as home base for patient and point of contact before and after surgery Allow for proactive planning for post-discharge and transitional care Active follow-up with high-risk patients Patients will be well prepared for discharge before admission Patients will be educated on postop expectations and their healing process 19

POC Requires Support From Administration Building Blocks Anesthesiologists Primary Care MDs/Hospitalists Surgeons (some) Staff Goal is Standardization 20 Anchors of Best Practice in Preoperative Preparation Benchmark cost/patient preparation <$50/patient RNs is the POC manages patient preparation, education, and clearance processes Charts completed at least 3-5 days prior to day of surgery Surgeons office supplies timely H&P, Orders, Consents and faxes to POC Anesthesia assists in the POC with patient preparation/clearance Developing Preparation Algorithms Staffing POC most common only with physician-extender/hospitalist (relationship) Seamless, efficient paperwork or use of IT system 21

What Elements Are Needed to Create A Successful POC Center? Accurate surgical scheduling Immediate triage-as soon as patient scheduled for surgery Tool Box Pre-registration (telephone screen completed within 2448 hrs. of scheduling for surgery) Pre-op Order sets for surgeon and or anesthesiafuture orders completed for surgery History tool (more complete triage) Lab/EKG on-site Matrix for labs required for surgery 22 What Elements Are Needed to Create A Successful POC Center? MD/DO Review of all abnormal tests (Hospitalist/ Anesthesiologist) Medications to hold with updated list (250 plus) prior to surgery Tool Box Communication with Primary and Surgeons Office (after visit within 72 hours) Hospitalists/charge capture Tracking form for all patients- who were identified

as high risk Evening before phone call /scripted instructionsautomated reminders from APP Incomplete chart summary performed 2-3 days before surgery 23 SAMPLE: POC Risk Screening Form 24 SAMPLE: POC Risk Screening Form Continued 25 Risk Reduction Management Tools Anemic / Blood Count Protocol Depression Screening Diabetes Assessment Nutritional Status Evaluation

PONV Screening Tool Cardiac Risk Calculator Delirium Screening (Mini Cog) Frailty Assessment OSA Screening (Stop Bang) POP Risk Calculator Chronic Pain/ Multi-Modal Pain & Narcotic Use DVT Risk Analysis Morse Tool for Falls

Pacemaker and ICD Management Risk of Readmission Tool 26 Additional Screening Tools in Clinic Alcohol Use Smoking Cessation Social Screen Precondition ing / Exercise 27 ERAS (What) A multimodal perioperative care pathway

designed to achieve early recovery for patients undergoing major surgery by minimizing organ dysfunction and reducing the profound stress response brought on by surgery 28 Components of ERAS for Colorectal Education and prehabilitation of patient Clear fluids and a carbohydrate beverage up to 2-3 hours prior to surgery Narcotic sparing, multimodal pain therapy Goal directed IV fluid therapy GDFT Active intraoperative warming

Routine administration of prophylactic antiemetic Minimally invasive surgical technique No drains or nasogastric tubes Early ambulation and enteral nutrition 29 Intra-Operative Phase POCU, OR, PACU Intraop Anesthesia Protocols Day of Surgery Home NPO after midnight for solids and non-clear liquids Clear liquids up to 4 hrs High carbohydrate up to 3hrs before surgery

***Epidurals not indicated for right hemi-colectomies ***If in doubt, ask surgeon Client logo placeholder POCU PO meds to be given 2 hrs before surgery Celecoxib 400mg PO (hold for epidurals or impaired renal function) Pregabalin 75 mg PO Alvimopan 12mg PO (hold with opioid usage of 7 days pre-op) Tylenol 1000mg PO Scopolamine patch for a PONV risk score of 3 or 4 Avoid Versed and Scopolamine with positive screen for delirium/frailty/falls Fluids 1ml/kg/hr for laparoscopic; 3ml/kg/hr for open Epidurals if ordered by surgeon it will be placed in the OR T7-10 epidural for all left sided procedures such as LAR Intraop Dexamethasone Fluids

Ventilation Epidural Dosing Titrate Opioid Administration Toradol Ondansetron 8mg IV at induction (4mg w/DM or borderline DM) Initial PIV on infusion pump in POCU at basal rate: Aim to ventilate at 8ml/kg IBW PF 1% Lidocaine 5ml bolus dose 20 min prior to incision to test placement Minimize PONV Usual dose 30mg,

decrease to 15mg with moderate kidney disease 4mg at emergence 1ml/kg/hr for laparoscopic cases; 3ml/kg/hr for open cases To assure analgesia postop, dose epidural intra-op intermittently or at conclusion of case with 0.25% Bupivacaine; or initiate standard infusion of 0.125% Bupivacaine with 2mcg Fentanyl Administer 30 minutes prior to end of procedure IV rate based on lean body weight with max of 80kg

Bolus dose may result in a decrease in SVR treat with vasopressors Hold with epidural, severe renal impairment, Crohns, Ulcerative Colitis 2nd PIV on Fluid warmer to be used for GDFT; place in OR Fluids 1mg/kg/hr in PACU 32 Goal Directed Fluid Therapy SVV Guided Wait 10-15 Fluid minutes Intervention: following If SVV < 12% Clearsite of Flo- epidural bolus, Fluid status stable; no therapy

Trac used with abdominal all major cases insufflation or indicated If SVV > 12% to optimize changes in Fluid deficit vs SVR fluid patient position decrease administration to assure SVV If fluid deficit infuse 250-500 ml value is stable bolus of crystalloid and nor an If SVR decrease aberration administer vacopressors Reassess status every 15 minutes Factors that may affect SVV accuracy: Monitor SVV trends Cardiac arrhythmias (more

than 4 times a minute) Spontaneous ventilation Change in intraabdominal/thoracic pressures Frequent cardiac arrhythmias negate the use of Flo-Track / Clearsite 33 Post-Operative Delirium & Miscellaneous Avoid Versed in patient who screen positive for delirium/frailty/fall risk Give muscle relaxant at beginning of case and reverse at the end of case with as little reversal as needed OG tube removed at the end of the case; no NG tubes 34 Additional Intra-Op Identified Colorectal anesthesia and OR nursing team

Colorectal SSI Bundle July 2014 Sage wipes the night before surgery full body Sage wipes the morning of surgery site specific Dedicated closing tray and changing gloves and gowns Maintenance of Normothermia 35 Post-Op Phase Post-Op Protocols No PICC line delays Patient screened POD 1 to determine PICC line necessity All ostomy patients will be seen on POD 1; additional floor nursing staff

trained to educate patients on ostomy care Early feeding and diet Early removal of Foley catheter PT all colorectal patients will be consulted on POD 1 Activity and early mobilization Post-op analgesia Daily goals developed for

patients 37 Readmission Prevention Tools Education Video Links and Patient Engagement Provide Education Video Links Build patients expectations and prepare them for entire surgical experience Patient Technolo gy Engagem ent App Twistle- used to remind patients pre-op and to monitor and

surveillance patients up to 30 days post discharge Can be viewed on tablets 39 Twistle Patient Engagement Platform (Pre and Post-Discharge Reminders) Reminders Cadence Reminder Content Post-Op Monitoring Notifications 3 days and 1 day before clinic visit Pre-op reminders send 7 days before surgery Stop taking blood thinners Arrive to pre-op dept. on 1st floor Bowel prep

instructional video SAGE wipes instructional video NPO reminder Clearfast or G.E.D. high carbohydrate drink reminder Sent daily questions for the first 3-5 days up to 30 days postdischarge -HIPPA compliant -Patients can send pictures Alerts RN or surgeon if having any fever, hydrating, visit from Home Health RN Follow-up appointment reminders for PCP and surgeon Patient outcome 40 Post-Discharge Phase Home, Home with HH or ECF

Post-Discharge Developed handoff process Care management to home health Identified 6 preferred PAN SNFs Develop Protocols for colorectal Patients with colostomy, lleostomy, open incision, closed incision patients In-services home health staff and 6 SNFs on the PSH Educated on ostomy care & protocols Implementation of Automated Patient Engagement System 42 ProtocolsBefore and After

Preoperative Phase Protocols / Clinical Care Pathways Current Standard of Care (Before the PSH) Perioperative Surgical Home Patient Education No formal education provided to patients Videos and written education for patients what to expect during the entire surgical experience Pre-operative Testing Lack of pre-operative testing Perioperative clinic visit Rick reduction clinical with lab testing and EKG testing. Multi-disciplinary team (hospitalists, anesthesiologist, RN) Nutrition No nutritional screening Nutrition screening performed in PSH clinic.

Nutritionist is consulted NPO Guidelines NPO for solids and liquids after midnight NPO for solids after midnight. Carbohydrate drink taken 3 hours before surgery Standardized Order Sets Lack or pre-op order sets Order sets of PONV, diabetes, VTE, pain Risk Assessments Lack of assessments for co-morbidities Risk assessment screenings performed by hospitalists for cardiac, pulmonary, delirium, frailty, falls, OSA, nutrition Pre-habilitation None Pre-screening for exercise, alcohol use and smoking Automated Patient Reminder

None Use for pre-op. Remind patient regarding bowel prep, NPO, antibiotics, CHG bath, when to arrive to POCU Discharge Planning Delayed discharge planning. Starts at admission to inpatient unit Case manager consulted based on social screening tool. Post discharge care identified (home with AHH vs. SNF) Introduction to home health and agencies if needed. Stoma teaching performed if needed. 44 Intraoperative Phase Protocols / Clinical Care Pathways Current Standard of Care (Before the PSH) Perioperative Surgical Home Anesthesia

Anesthetics and fluid management based on individual anesthesia providers preference Standardized anesthesia protocols use of thoracic epidurals Standardized goal directed therapy protocols Anesthesia Staff No dedicated team Dedicated OR Colorectal Anesthesia team developed Pain Management Opioids given Multi-modal pain protocols utilized Equipment Equipment used per surgeon preference Standardized set-up OR Nursing Staff

No dedicated team Dedicated OR Colorectal team developed Surgical Site Infection (SSI) No formal protocol SSI Protocol developed. Separate closing mayo utilized, gowns, gloves, cautery and suction changed 45 Post-Op Phase Protocols / Clinical Care Pathways Current Standard of Care (Before the PSH) Perioperative Surgical Home Education Generic education provided to patient

Specific post-op education developed for Colorectal patients video links for education Pain Management Use of opioids and PCA Multimodal pain management protocols with an emphasis on oral medication. Avoidance of opioids Nutrition / Diet Based on patient passing gas POD #0 tea and coffee, POD #1 full liquid for breakfast and lunch, at dinner soft diet Activity Up in chair POD #1 Up in chair POD #0, ambulation starting POD #1 Physical Therapy No standard protocol PT Consultation on all colorectal patients within

24 hours post-op PICC Line Placement No standard protocol All ileostomy patients will have a PICC placed within 48 hours post-op Ostomy Education Patient may receive first education 1 week before surgery and 48 hours post-op if available on the weekend Patient will receive first teaching in PSH clinic if he/she is unable to meet ostomy RN. An RN on the floor will be available to provide additional education on the unit if needed before discharge Discharge Planning Discharge plan developed POD #1 by care manager. Updated / revised on POD #3 or when patient is scheduled for discharge Care manager and / or social worker meets with patient daily. Disposition may change based on patient status

46 Post-Discharge Phase Protocols / Clinical Care Pathways Current Standard of Care (Before the PSH) Perioperative Surgical Home Automated patient reminder None To be re-activated when patient is discharged from hospital Education Lack of post discharge education for patients Written and video education materials for patients wound care, ostomy care, nutrition and hydration, activity Protocols of Care No standard protocols

Hand-off form will be completed by care manager. Form and protocols given to home health or SNF Pain Management No standard protocol Standardized pain management protocol Patient follow-up Follow-up with surgeon within 1-2 weeks Follow-up with surgeon. RN phone call, automated reminder calls with Twistle 47 Perioperative Surgical Home Protocols Preoperative Phase(Scheduling from office & PST) Nutrition Skin Prep (SSI Bundle) Lab orders

Pre-op Analgesia Bowel Prep Visit by Care Coordinator Home visit by Home Health Identify Risk Factors Anemia evaluation/management Intraoperative Phase Postoperative Phase (POCU/MOR) (Phase 1 PACU, 7 Tele) Education & Expectation Management Pain Management Diabetes Optimization Early feedings /diet Anesthesia clinical pathways Intraop Analgesia- Epidurals Early Ambulation Fluid Balance/Therapy Physical Therapy MD preference lists PIC Line Nausea and vomiting control Early removal of NG tubes/catheters Standardize nursing care

Transfusion Therapy Stoma Education Post-op Analgesia D/C of Antibiotics Chemical Prophylaxis Post Discharge Phase (Home/Facility) Wound Care Stoma Care Prescriptions Primary Care Follow-up Arrangements made for SNF/LTC if needed Transition Phone Call Center Inclusion of Primary Med MD Each phase of care has a well-defined series of care elements and protocols- each with an emphasis on patient centered care and shared decision making 48 Metrics Source: Crimson Clinical Advantage 49

Patient Satisfaction / Experience Satisfaction has also increased, since implementing the PSH with support from the Patient Engagement Technology support from Twistle. The following are a few of the questions that were asked 30 days after discharge: 50 Lessons Learned and Barriers Client logo placeholder Get everyones feedback early on current state to understand where opportunities and barriers exist Difficult to collect baseline data; found in multiple places: Midas, Crimson and Cerner Procure data analyst to help with data collection and automate it Handoffs missing from discharge to post-discharge Inconsistencies in SNF ostomy care even after in-service by ostomy nurse Difficult to ensure protocols are being followed with patients that transition to a non-PAN SNF or a non-AHH. Care managers ensure the protocols are attached in EMR If patient is discharged early, based on the ERAS protocols, he or she has higher risk of readmission if patient is not managed properly post-discharge Need to monitor patient 30,60 and 90 days post-discharge to determine if patient is back to normal activity Program is essential for bundled payments ****TIME The Future

Palliative care involvement Readmissi on Prevention Collaborative , comprehensi ve shared decision making process Better identification of patients likely to fail and pre-op counseling Service line expansion: breast, spine, joints, Hepatobiliary and Gyneoncology

52 Questions 53 Surgical Directions 541 N. Fairbanks Court Suite 2740 Chicago, IL 60611 T 312.870.5600 F 312.870.5601

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