1. Texas Regional Template: Readmissions Workgroup Organization: Texas Children’s Hospital

2. The Texas Regional Hospitals
Baylor Scott & White McLane Children’s Medical Center
Children’s Health, Children’s Medical Center
Children’s Memorial Hermann Hospital
Cook Children’s Medical Center
Covenant Children’s
Dell Children’s Medical Center of Central Texas
Driscoll Children’s Hospital
Medical City Children’s Hospital
Texas Children’s Hospital (Houston)
The Children’s Hospital of San Antonio

3. Readmissions Bundle Elements
Details
Discharge instructions contain a plan on potential problems and what to do if they arise (as in who to call)
• Discharge instructions contain a plan including:
o Accurate medication list and instructions
o How to recognize and respond to the patient’s clinical changes
o Escalation contact relevant to the situation
Schedule follow-up medical and post discharge tests/labs appointments prior to discharge
• For weekday discharges: Patient’s 1st follow up appointment scheduled prior to discharge including an exact time, date, location, and care provider.
• For weekend and holiday discharges: The patient’s discharge instruction to list the follow up appointment provider, their phone number, and the time frame for the appointment
Provide feedback to clinicians on any readmission
• Timely notification to discharging physicians of the readmission
• In a non-judgmental fashion, invite the discharging physician to review the case and make recommendations, if appropriate, as to how this readmission might have been prevented.
Identify high risk populations
• Each hospital will identify a population at high risk for readmission.
• Develop and implement readmission risk mitigation plan for the identified patient population.
• Measure adherence to the plan at the time of discharge.
Post-discharge follow-up call to reinforce discharge instructions with a standardize script
• A follow up phone call within 72 hours of discharge using a standard script and providing direct access to a medical professional, if needed.
• A second attempts on a different day should be made if the first call is unsuccessful.
• Parents not wanting to talk is considered a successful call.
Language Assistance
(Not required by SPS bundle. Specific to TCH.)
• Ascertain need for and obtain language assistance for discharge instructions.

4. Readmission Data Collection Methods
Population
Population list is generated by QlikView app
Numerator: Number of readmissions that occur within 7 days of discharge (<=7)
Denominator: Total number of discharged patients during time period
Inclusion: All patients are included who are defined as inpatient or under observation at the hospital
Exclusion: Readmitted for planned scheduled procedures (i.e., psychiatric and rehab units for scheduled procedures or for planned and scheduled chemotherapy
Trigger Tools –We are looking at how to leverage Epic to trigger bundle use
Chart Review Tools
20 randomized charts from all discharges
Captured on Excel worksheet

5. Readmission InterventionsP S D
Goal: 2.78% D S P A
Cycle 6: Data Transparency
Readmission reports by Service
Bundle compliance to Units A P S D
Improvement
Cycle 5: Identify High Risk Population
Aligned with organization’s strategic plan D S P A
Cycle 4: Medication Education & Reconciliation Pilot
Clarification of Rx – Nursing or Pharmacy?
Roles and Responsibilities clarification
Cycle 3: Create Readmission Notification & Survey
Created HAC Readmission account
Pilot PHM Survey
Modified survey
Expand to other Services A P S D A P S D
Cycle 2: Survey Services for Existing Phone Calls Made Post Discharge
Pilot making post discharge calls at one campus
Determine capability of existing resources, including StarKids
Expand to other campuses and focus on another high risk group
Cycle 3
Cycle 1: Create Post-Discharge Appointment Order in Epic
Discharging provider enters F/U order with Service needed and timeframe for appt
Central Scheduling can make appt prior to discharge
Report created to track use of Discharge Order, appts made, and if patient completed appt

6. Readmission Rate (7-Day)
Aug 14
Sep 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Mar 15
Apr 15
May 15
Jun 15
Jul 15
Aug 15
Sep 15
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
Apr 16
May 16
Jun 16
Jul 16
Aug 16
Sept 16
Oct 16
# of Readmission Events 75 86 65 70 60 61 76 74 58 68 41 79 42 39 51 83 82 72 66 87 64
Discharges
1717
2316
2293
2194
2410
2273
2189
2413
2165
2203
2153
2213
1598
2061
2282
1949
1854
1842
1802
2040
2386
2358
2333
2294
2338
2379
2350
Monthly Hospital Rate
4.37
3.24
3.75
2.96
2.90
3.08
2.74
2.53
2.82
3.45
3.44
2.62
4.26
1.99
2.63
4.05
2.21
2.28
2.16
2.50
3.48
3.00
3.14
3.66
2.72

7. Readmission Best Practice Recommendations
In collaboration with SPS Executive Leadership at TCH, aligned with TCH’s strategic goal to manage STAR Kids
High Risk Population identified
Data Transparency
Provide readmission reports by Service
Provide feedback to Units on bundle compliance

8. Readmission Requests for Assistance
Information Sharing
Challenges
Bundle trigger in Epic
Post discharge follow-up phone calls
High Volume, limited resources
Other organizations’ successes and failures?

9. Questions?