1. DECREASING HOSPITALIZATIONS Palmarius Consulting 214-620-6569 info@palmariususa.com Palmariususa.com palmariususa.com, Quality Management Consulting 1

2. GOOD NEWS: HOSPITALIZATION RATE IS DECREASING NATIONALLY! palmariususa.com, Quality Management Consulting 2 Source: USRDS

3. BUT, NOT MUCH IMPROVEMENT IN CARDIAC AND INFECTION RELATED ADMISSIONS palmariususa.com, Quality Management Consulting 3 Source: USRDS

4. READMISSIONS HIGHEST IN ESRD PATIENTS palmariususa.com, Quality Management Consulting 4 Source: USRDS

5. What are some reasons for our patients’ hospitalizations in this clinic? palmariususa.com, Quality Management Consulting 5

6. REASONS FOR HOSPITALIZATIONS Patient new to dialysis and unsure of self care Poor self care skills Patient lacked support to comply with self care Comorbid conditions – diabetes, heart conditions, etc Missed treatments Noncompliance Poor coordination of care between care providers including dialysis units palmariususa.com, Quality Management Consulting 6

7. REASONS FOR READMISSIONS Patient did not follow discharge instructions Patient lacked support to comply with discharge plans Patient had no PCP Prescriptions not filled (or picked up) Poor transition of care: No coordination between care providers including dialysis units palmariususa.com, Quality Management Consulting 7

8. HOW CAN WE DECREASE HOSPITALIZATIONS? Prevent Re-admissions Divert Emergency Room visits Minimize Missed Treatments Manage care related causes of hospitalizations: Infection Cardiac Improve access management – catheter prevention and AVF maintenance Comorbid conditions management (Care coordination) Education: patients and staff palmariususa.com, Quality Management Consulting 8

9. PREVENT READMISSIONS: WITHIN 2 WEEKS POST-HOSPITALIZATION… RN - Medication Reconciliation - Educate patient on d/c instructions - Post d/c assessment of functional status - Coordinate Nephrologist/NP post discharge assessment RD - Assess fluid status - Educate patient on post- discharge optimal nutrition - Discuss patient and family concerns SW - Coordinate discharge planning needs (DME, specialists appointments, etc) - Assess psychosocial status - Discuss patient and family concerns PCT - Discuss Patient and family concerns and refer to appropriate discipline - Reinforce IDT education palmariususa.com, Quality Management Consulting 9

10. EMERGENCY ROOM DIVERSION Frequent and timely volume control assessment for high risk patients Culture of “treatment the patient in unit rather than send to ER” Monitor patient with hypotension closely palmariususa.com, Quality Management Consulting 10 How can we prevent ER visit in this unit? Think of a patient who visited ER recently. Could that have been prevented?

11. MINIMIZE MISSED TREATMENTS palmariususa.com, Quality Management Consulting 11 DisciplineTasks related to Care RN-Coordinate reschedule ASAP -Work with patient to identify root causes -Educate patient on consequences of missed treatments RD-Work with patient to identify root causes -Discuss diet and lifestyle management to prevent fluid overload SW-Work with patient to identify root causes -Depression intervention -Coordinate support at home for self-care -Coordinate transportation assistance, if needed PCT-Discuss patient’s concerns and refer to appropriate discipline -Educate patient on importance of treatment compliance Please compare notes and share information with your team

12. INFECTION MANAGEMENT Wound care referral and coordinate appointment, when appropriate Staff education on infection control Patient education on infection control Ensure good nutrition at home Regular staff audits of infection control practices Watch the trend in infections and tackle root causes palmariususa.com, Quality Management Consulting 12

13. ACCESS MANAGEMENT Anticipate access issues and proactively resolve Scheduled de-clotting rather than ER visit ABX Block – to prevent catheter infections Catheter change in a vascular center rather than hospital Educate patient on access care when at home Assess patient’s skill in caring for the access on a weekly basis until the access is fully functional and matured. palmariususa.com, Quality Management Consulting 13

14. CARE COORDINATION FOR COMORBID MANAGEMENT palmariususa.com, Quality Management Consulting 14 RN -- coordinate specialists referral - Assess patients’ self care status and educate - Discuss patient’s concerns RD - Ensure patient’s good nutritional status - Educate patient on self care related to diabetes or other condition SW - Coordinate specialists’ appointment - Assess self care skills and coordinate appropriate referral (HH or PT) PCT - Encourage patient to keep specialists appointments - Discuss patients’ concerns and refer to IDT Clinic Manager - Coordinate staff education on care coordination - Identify community resources with the help of the team

15. IN SUMMARY… Decreasing hospitalizations is a complex process that requires Collaboration between hospitals, dialysis, and physicians Commitment from staff to do the right thing Care coordination to reduce readmissions Decreasing hospitalizations will create: Huge opportunities for the patients and clinic Increased quality of life for the patient Better quality of care for the clinic resulting in reduced costs and good reputation palmariususa.com, Quality Management Consulting 15

16. FOR MORE INFORMATION OR ASSISTANCE WITH DECREASING HOSPITALIZATIONS, PLEASE CONTACT: Palmarius Consulting Phone: (214) 620-6569 info@palmariususa.com