Outcomes 2018 by BARLOW

Outcomes 2018

In this issue: OUTCOMES | MASTER PLAN

DEAR COLLEAGUE, Barlow Respiratory Hospital is proud to present our annual Outcomes Book. This publication highlights our unique role in the continuum of adult acute respiratory care. We are the only not-for-profit long-term acute care hospital in California. We serve chronically critically ill and medically complex patients referred to us by esteemed medical professionals at the finest hospitals in California. Our commitment to provide the highest quality care for our patients is illustrated by the exceptional outcomes we report. As pioneers in the care of the chronically critically ill, Barlow Respiratory Hospital has treated and liberated more patients from prolonged mechanical ventilation than any other hospital in the nation. This high volume has helped us build expertise and develop innovative approaches to treat ventilator-dependent patients, most notably our published TIPS© weaning protocol. For ventilator-dependent patients, to regain the ability to breathe on their own is the most important outcome. For family members, the gift of having more time with a loved one is precious beyond measure. For any medical condition, no single outcome captures the details or the nuanced results of the care our

WE HAVE REDESIGNED OUR BARLOW LOGO This new look honors our legacy and underscores our commitment to excellence.

patients receive. For many conditions we treat here at Barlow, defining a set of comprehensive outcomes is a process that our interdisciplinary team develops over time. Organizations like the International Consortium for Health Outcomes Measurement (ICHOM) continue to inform and inspire those processes.

Patients still benefit from the same personalized expert care at Barlow Respiratory Hospital. Families still experience a welcoming inclusive atmosphere at Barlow Respiratory Hospital.

Improving outcomes and value is central to all we aspire to. Our team partners with patients and their

Now, you’ll see it all in a new light with our new logo and our ongoing visual transformation.

families to focus on the needs of the patient. Our commitment to value and transparent reporting of accurate, timely information about patient care reflects Barlow Respiratory Hospital’s culture of continuous improvement and is designed to help referring physicians, patients, and families make informed decisions. We hope you find this information valuable. We welcome your feedback, questions, and ideas for collaboration. Please contact us at info@barlowhospital.org. Sincerely,

A M I T M O H A N , P H D, FAC H E , FAC M P E PRESIDENT & CHIEF EXECUTIVE OFFICER

DAV I D R . N E L S O N , M D MEDICAL DIRECTOR

BARLOW OUTCOMES BOOK 2018

CONTENTS

/ OUTCOMES 2018 /

Outcomes 2018

4 BARLOW RESPIRATORY HOSPITAL GROUP & HOSPITAL BOARD OF DIRECTORS Michael D. Berger CHAIR Diane Naegele VICE CHAIR

In this issue: OUTCOMES | MASTER PLAN

Jason Zayon, CPA SECRETARY/TREASURER Amit Mohan, PhD, FACHE, FACMPE PRESIDENT

Eric Kleerup, MD Richard F. Seiden

E: info@barlowhospital.org W: www.barlowhospital.org

the facts of proper lung health Enias qui non pliqui quamet fuga. Ovidenis re nemo bea volut que siment laccusdae non natque dipsapis

ESTABLISHED EXPERTISE – VOLUME MATTERS

VENTILATOR WEANING PROGRAM

CONTINUOUS IMPROVEMENT

Daniel Weinstein

OUTCOMES AT-A-GLANCE

John Van Dyke, MD

the facts of proper lung health Enias qui non pliqui quamet fuga. Ovidenis re nemo bea volut que siment laccusdae non natque dipsapis

KEY POPULATION METRICS AND QUALITY MEASURES the facts of proper lung health Enias qui non pliqui quamet fuga. Ovidenis re nemo bea volut que siment laccusdae non natque dipsapis CENTER FOR OUTCOMES AND VALUE

OUTCOMES AT 23 A GLANCE

Earl E. Gales, Jr.

ORGANIZATIONAL OVERVIEW

Bradford M. Bolger

the facts of proper lung health Enias qui non pliqui quamet fuga. Ovidenis re nemo bea volut que siment laccusdae non natque dipsapis

David R. Nelson, MD MEDICAL DIRECTOR

WHO WE ARE

ONE TEAM ONE GOAL – BEST OUTCOMES

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BARLOW OUTCOMES BOOK 2018

Barlow Respiratory Hospital is the longest continuously operating respiratory hospital in the United States. The hospital was founded in 1902 by Dr. Walter Jarvis Barlow as the premier sanatorium for the treatment of tuberculosis.

ORGANIZATIONAL OVERVIEW:

Dr. Barlow transformed a personal brush with death into a visionary life-saving legacy. He contracted tuberculosis in New York City in 1895 and journeyed west for the dry and sunny climate. His recovery inspired him to help others. The Barlow Sanatorium opened its doors in 1902 and transitioned to a full-service respiratory hospital starting in the late 1960’s. With the advent of intensive care units and critical care medicine, Barlow transitioned again, assuming its current mission as a regional specialty center for weaning chronically critically ill patients from mechanical ventilation.

WHO WE ARE: MISSION:

At Barlow Respiratory Hospital, patients with complex re-

long-term acute care hospitals serving the chronically criti-

spiratory conditions benefit from the expertise of an in-

cally ill. We are the destination of choice for weaning patients

terdisciplinary medical team of clinicians who specialize in

from prolonged mechanical ventilation. Patients are referred

pulmonary medicine, critical care medicine, and internal

to Barlow from nearly 100 hospital intensive care units (ICUs)

medicine and who work in close collaboration with physi-

in the Los Angeles metropolitan area and Southern Califor-

cians in a variety of medical practice specialties.

nia. With multiple locations in Los Angeles County, our specialized services are accessible to patients and families.

ACADEMIC PARTNER Barlow serves as a teaching hospital for medical students at

In 2018, Barlow Respiratory Hospital was recertified and

the Keck School of Medicine of USC and the David Geffen

awarded the Gold Seal of Approval® for Disease Specif-

School of Medicine at UCLA. Barlow Respiratory Hospital

ic Certification for Respiratory Failure, the only one on the

also acts as a clinical training site for respiratory therapy,

VISION:

West Coast and among fewer than two dozen hospitals

nursing, physical, occupational, speech therapy and clinical

nationwide to attain this elite certification. Barlow was also

nutrition allied health professionals. Educating medical pro-

To be the best in the care of individuals with complex respiratory conditions in the post-acute setting.

awarded the designation as the only West Coast Passy-Muir

fessionals of the future to care for the chronically critically

Center of Excellence, recognized for treating patients with

ill is a vital role Barlow plays in our community, and one in

tracheostomies, on and off the ventilator.

which we take great pride.

To make a positive difference in the lives of individuals with chronic critical illnesses and complex respiratory conditions in post-acute settings.

VALUES: Continuous Improvement – to deliver best outcomes Collaboration – to improve patient care Efficiency – in clinical services delivery Respect – for patients, families and co-workers

Barlow Respiratory Hospital is among the nation’s leading

BARLOW OUTCOMES BOOK 2018

Since 1902

The partnership between physicians and our interdisciplinary team promotes communication and coordination of care, informs treatment decisions, and supports patient centered goal setting.

BARLOW OUTCOMES BOOK 2018

94%

Overall Satisfaction With Care Provided

17%

Higher Survival Rate

BARLOW OUTCOMES: AT-A-GLANCE

55%

Weaning Success Rate

42%

Decrease in Time to Wean

39%

Increase in Overall Mobility Score For Ventilator Patients

67%

Reduction in Hospital-Acquired Pressure Ulcers

78%

Reduction in C. Difficile Rate 6

BARLOW OUTCOMES BOOK 2018

ESTABLISHED EXPERTISE – VOLUME MATTERS

Barlow Respiratory Hospital admits and treats more than twice the national percentage of mechanically ventilated patients discharged from long-term care hospitals. (Data Source: Medicare Payment Advisory Commission (MedPAC), March 2018)

2017

Barlow Respiratory Hospital is a high-volume regional weaning center. In a true value-based system, volume matters. Volume of a condition treated is positively correlated with the outcome for that condition. For over three decades, Barlow Respiratory Hospital has focused on serving chronically critically ill patients with complex respiratory conditions. Clinicians who treat a high volume of patients with the same condition become expert in treating those conditions. Pulmonologists, internists, nurses and respiratory therapists currently at Barlow have combined to treat over 1,000 ventilator-dependent patients at each of our three locations.

Total Patients 891 Ventilator Weaning Program 305 Weaning Success Rate 55%

2008-2017

Total Patients Ventilator Weaning Program Weaning Success Rate

1988-2017

Total Patients Approximately 20,000 Ventilator Weaning Program 6,308 Weaning Success Rate 52%

BARLOW OUTCOMES BOOK 2018

7,941 2,983 55%

“Higher–volume hospitals have better outcomes.” – Dr. David Shahian Professor of Surgery, Harvard Medical School

BARLOW OUTCOMES BOOK 2018

VENTILATOR WEANING PROGRAM

17% decrease in length of stay

More than 50% weaned each year

Length of stay is defined as number of days from admission to discharge.

61%

2017 2017

2016 2016

2015 2015

2014 2014

30 50% DAYS

Time to Wean (median days)

patients who wean do so within the first two weeks of admission.

19 55%

13 61%

12 54%

12 58%

11 55% 13 DAYS

2017 2017

13 DAYS

17 57%

2016 2016

2016

2014

2013

2012

2015

6 Year Median

2017

55%

6 Year Median

2015 2015

Barlow Respiratory Hospital has consistently weaned more than 50% of patients each year for the last six years decrease while decreasing the to 42% in time number of days to wean and wean. More than half of length of stay.

2014 2014

58%

Weaned is defined as patient being free of invasive mechanical ventilation at least one full calendar day prior to day of discharge.

2013 2013

17 13

2012 2012

54%

PERFORMANCE OVER TIME

42% decrease in time to wean

Days to Wean

BARLOW OUTCOMES BOOK 2018

Barlow Respiratory Hospital has consistently decreased length of stay with 17% decrease over six years.

55%

Length of Stay

Time to wean is tallied from day of admission through last day of ventilator support.

2017

2016

2015

50%

TIME TO WEAN (MEDIAN DAYS) More than half of patients who wean do so within the first two weeks of admission.

55%

57% 36

2013 2013

54%

58%

LENGTH OF STAY (MEDIAN DAYS)

2012 2012

61%

2014

Weaned is defined as patient being free of invasive mechanical ventilation at least one full calendar day prior to day of discharge.

55%

2013

Barlow Respiratory Hospital consistently liberates over half of all chronically critically ill patients admitted for weaning from mechanical ventilation.

57%

2012

WEANING SUCCESS RATE

Time to wean is tallied from day of admission through last day of ventilator support. Weaned

Days to Wean

Length of Stay

BARLOW OUTCOMES BOOK 2018

CONTINUOUS IMPROVEMENT We are driven to achieve superior value in the eyes of our stakeholders. We take pride in our work. We believe that excellence in our delivery of patient care and services distinguishes us from others. We focus on personal and professional development. We pay vigilant attention to detail to assess risks and reduce negative impacts.

Hospital-Acquired and Worsened Pressure Injuries Stage 2-4

Reduced by 67%

CAUTI Rate per 1,000 Urinary Catheter Days

Reduced by 69%

7.0 6.0

25%

UCL

5.0 20% 4.0 15%

3.0

UCL

10%

1.0

CL 5%

Q4 17

Q3 17

Q2 17

Q1 17

Q4 16

Q3 16

Q2 16

Q1 16

Q4 15

Q3 15

Q2 15

Q1 15

Q4 14

Q3 14

Q2 14

Q1 14

Q4 13

Q3 13

CLABSI Rate per 1,000 Central Line Days

Reduced by 78%

Reduced by 83%

7.00

UCL

30.0

DEC – 17

NOV – 17

OCT – 17

SEP – 17

AUG – 17

JUL – 17

JUN – 17

MAY – 17

APR – 17

MAR – 17

FEB – 17

JAN – 17

DEC – 16

NOV – 16

OCT – 16

SEP – 16

AUG – 16

JUL – 16

JUN – 16

MAY – 16

APR – 16

MAR – 16

FEB – 16

JAN – 16

DEC – 15

NOV – 15

OCT – 15

C. Difficile Rate per 10,000 Patient Days

Q2 13

Q1 13

0.0

35.0

2.0

6.00 25.0 5.00 20.0

UCL

4.00

15.0 3.00 10.0 2.00

LCL

5.0

1.00

BARLOW OUTCOMES BOOK 2018

Q4 17

Q3 17

Q2 17

Q1 17

Q4 16

Q3 16

Q2 16

Q1 16

Q4 15

0.00 Q3 15

Q4 17

Q3 17

Q2 17

Q1 17

Q4 16

Q3 16

Q2 16

Q1 16

Q4 15

Q3 15

Q2 15

Q1 15

Q4 14

Q3 14

0.0

BARLOW OUTCOMES BOOK 2018

Catheter-Associated Urinary Tract Infections Barlow Respiratory Hospital’s ratio of reported to predicted catheter-associated urinary tract infections (CAUTI) of 0.68 was no different than the national benchmark. (Confidence interval (range) 0.295, 1.335) 0.68

0 1 2 3 4 5 CONFIDENCE INTERVAL

Source: CMS LTCH Facility-Level Quality Measure Report 2017

National Benchmark = 1

Central Line-Associated Blood Stream Infections Barlow Respiratory Hospital’s ratio of reported to predicted central lineassociated blood stream infections (CLABSI) of 0.55 was no different than the national benchmark. (Confidence interval (range) 0.224, 1.149) 0.55

0 1 2 3 4 5 CONFIDENCE INTERVAL

Source: CMS LTCH Facility-Level Quality Measure Report 2017

National Benchmark = 1

Clostridium Difficile Infections Barlow Respiratory Hospital’s ratio of reported to predicted Clostridium difficile (C. difficile, CDI) infections of 0.44 is better than the national benchmark. (Confidence interval (range) 0.270, 0.667)

0.44

0 1 2 3 4 5 CONFIDENCE INTERVAL

Source: CMS LTCH Facility-Level Quality Measure Report 2017

National Benchmark = 1

BARLOW OUTCOMES BOOK 2018

KEY POPULATION METRICS AND QUALITY MEASURES Compared to all other long-term care hospitals in Los Angeles County, Barlow treats patients with the highest severity of illness.

19 INTENSIVE CARE UNIT DAYS PRIOR TO LTCH ADMISSION Patients admitted to Barlow Respiratory Hospital spend more than one week longer in acute care hospital intensive care units compared to all other long-term care hospitals in Los Angeles County. (Source: KNG Health Consulting, LLC analysis of 20122016 Medicare claims)

CASE MIX INDEX (CMI) CMI of a hospital reflects the diversity, clinical complexity, and the needs for resources in the population of all the patients in the hospital.

Barlow Respiratory Hospital

1.51

Other LTCHs

1.22

NEW OR WORSENED PRESSURE ULCERS Barlow Respiratory Hospital’s rate of pressure ulcers that are new or worsened was lower than the national average comparison group.

88% 73%

Barlow Respiratory Hospital

Other LTCHs

1.5%

1.1%

(Source: CMS LTCH Facility-Level Quality Measure Report 2017)

Barlow Respiratory Hospital Barlow Respiratory Hospital

BARLOW OUTCOMES BOOK 2018

Despite a higher patient acuity, Barlow Respiratory Hospital has a 21% higher survival rate compared to all other long-term care hospitals in Los Angeles County. When adjusted for patient complexity, our survival rate is 24% higher than others. (Source: KNG Health Consulting, LLC analysis of 20122016 Medicare claims)

(Source: KNG Health Consulting, LLC analysis of 20122016 Medicare claims)

SURVIVAL TO DISCHARGE

Other LTCHs

BARLOW OUTCOMES BOOK 2018

Functional Abilities: Mobility From admission to discharge, Barlow patients realize gains in seven measured activities, including ambulation. 38% 35% 33%

32%

34% 30% 26%

Roll L&R

Sit to lying

Lying to sitting

33%

Mobility Scores Gain All Patients

Sit to stand

Chair/bed to chair transfer

Toilet transfer

Ambulation

39%

Mobility Scores Gain Ventilator Patients

33% increase in overall mobility score (all patients) 39% increase in overall mobility score for ventilator patients 57% increase in overall number of ambulatory patients from admission to discharge Source: Barlow internal data from LTCH CARE Data Set – Version 3.0

BARLOW OUTCOMES BOOK 2018

Experience of Care Better patient care experiences are associated with higher levels of adherence to treatment processes, better clinical outcomes, and better patient safety. Barlow Respiratory Hospital is committed to providing care that is respectful of and responsive to individual patient preferences, needs and values.

94% Patient and Family Satisfaction with Care Overall satisfaction with care at Barlow Respiratory Hospital was ranked in the top tier by over 90% of patients and families.

Source: Patient and Family Satisfaction with Care Inpatient Survey Report 5/2017-5/2018

Very Satisfied/ Satisfied

Likelihood of Recommending Barlow

Other Responses

91%

The likelihood of recommending Barlow was ranked at the top of the scale by over 90% of patients and families.

Source: Patient and Family Satisfaction with Care Inpatient Survey Report 5/2017-5/2018

Highly Likely

BARLOW OUTCOMES BOOK 2018

Other Responses

BARLOW OUTCOMES BOOK 2018

CENTER FOR OUTCOMES AND VALUE PUBLISHED ABSTRACTS Brock J, D’Souza G, Nelson DR, Hassenpflug MS. Sepsis screening in a long-term care hospital: improving timely identification and effective treatment. Am J Respir Crit Care Med 2018;197:A3627 Barlow Respiratory Hospital maintains the largest longitudinal dataset in the nation with reported outcomes of chronically crit-

Hassenpflug MS, Nelson DR, Steckart J. Outcomes in

ically ill patients admitted to an LTCH for weaning from pro-

chronic critical illness: continuous improvement at a

longed mechanical ventilation. The Ventilation Outcomes Data-

regional weaning center. Am J Respir Crit Care Med

set (VOD), a performance improvement dataset, includes data

2018;197:A5154

on more than 6,300 patients over 30 consecutive years. The advantage of our rich longitudinal dataset is that we can measure change.

Shah M, Mohan A, Nelson DR, Hassenpflug MS. Chron-

The dataset allows us to analyze the impact of various processes,

ic critical illness: improving efficiency of care using

protocols, and policies on improvement in patient outcomes.

time-driven activity-based costing methodology. Am J Respir Crit Care Med 2018;197:A684

Barlow leads LTCHs in outcomes reporting with over 80 publications – book chapters, peer-reviewed journal articles, editorials and abstracts – and numerous national and international conference presentations.

By reporting its outcomes, Barlow Respiratory Hospital serves as a valuable resource for patients who become ventilator-dependent and have weaning and rehabilitative potential, the chronically critically ill, those with chronic lung and medically complex disease processes, their families, and the medical community challenged with their care.

CONFERENCE PRESENTATIONS Improving Timely and Effective Sepsis Care for Long-Term Acute Care Patients Using The Surviving Sepsis Campaign International Guidelines In the thematic poster session, “Enhancing Practice Environments, Patient Safety, and Outcomes.” American Thoracic Society (ATS) International Conference, May 21, 2018, San Diego, CA Outcomes in Chronic Critical Illness: Continuous Improvement at a Regional Weaning Center In the thematic poster session, “Critical Care: Every Breath You Take – Acute Respiratory Failure and Mechanical Ventilation.” American Thoracic Society (ATS) International Conference, May 22, 2018, San Diego, CA

BARLOW OUTCOMES BOOK 2018

ONE TEAM ONE GOAL – BEST OUTCOMES Barlow Respiratory Hospital is committed to providing the highest quality post-acute intensive care for chronically critically ill and medically complex patients. We serve Los Angeles County with award-winning expertise from three convenient locations that allow patients and families the comfort of access to their home community.

MASTER PLAN The Master Plan to ReBuild Barlow Respiratory Hospital is a multi-phased plan that begins with a required seismic retrofit and culminates in an expanded, state-of-the-art hospital.

The project begins with the retrofit of Barlow’s historic hospital building on the main campus in Los Angeles. This will uphold the hospital’s longstanding commitment to protect the historic 1927 hospital building while ensuring

BARLOW RESPIRATORY HOSPITAL

uninterrupted exceptional patient care.

MAIN CAMPUS IN LOS ANGELES 2000 Stadium Way Los Angeles, CA 90026

BARLOW RESPIRATORY HOSPITAL AT VALLEY PRESBYTERIAN HOSPITAL 15107 Vanowen St. Van Nuys, CA 91405

The plan to ReBuild Barlow creates a completely new higher-capacity

BARLOW RESPIRATORY HOSPITAL AT PIH HEALTH HOSPITAL WHITTIER 12401 E. Washington Blvd. Whittier, CA 90602

modern hospital from the inside out, constructed entirely within the walls of the existing hospital building. This enables Barlow to provide care in our current building while construction of the new hospital moves forward in an adjoining space. This will significantly expand services on our Los Angeles campus – for a much lower cost than building a new hospital from the ground up. This also builds upon our legacy and our promise to serve patients and families for generations.

Barlow Respiratory Hospital has three locations in Los Angeles County. • Our original, “main” facility, near downtown Los Angeles is an iconic site with a history of providing specialized care since 1902. • Our Whittier location, at PIH Health Hospital, serves patients in the San Gabriel Valley.

www.ReBuildBarlow.org

• Our Van Nuys location, at Valley Presbyterian Hospital, serves patients in the San Fernando Valley. We are grateful for the trust that referring physicians, patients, and family members place in Barlow Respiratory Hospital.

BARLOW OUTCOMES BOOK 2018

With a legacy of care, compassion and hope, Barlow Respiratory Hospital welcomes patients from all over California, the West Coast and beyond. If you have a patient who requires the experience and expert care only Barlow can offer, contact us today. With locations in Los Angeles, Van Nuys, and Whittier we are accessible. Admissions and Referrals Info Line: 833–4–BARLOW www.barlowhospital.org www.rebuildbarlow.org

LOS ANGELES

VAN NUYS

WHITTIER

2000 Stadium Way

15107 Vanowen St.

12401 E. Washington Blvd.

Los Angeles, CA 90026

Van Nuys, CA 91405

Whittier, CA 90602