1. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 1 Preventing Avoidable Readmission Together Using Project Re-engineering Discharge PROJECT RED

2. Discharge Planning Pre Patient Admission H&P; Assessments; Rx Plan PATIENT EDUCATION/ Prepare for Home Discharge Order Written Discharge Process Discharge Event FINAL DISCHARGE INSTRUCTIONS Post-D/C FOLLOW-UP MEDICATION MANAGEMENT Discharge Folder Passport for Home White Board, Rounding & Bedside Report Community providers

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Modules Module 1 - Getting started. Module 2 - Patient admission care and treatment. Module 3 - Patient discharge and follow-up care. Module 4 - Preparing to launch. 3

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 Module 1: Getting Started Identify organizational strategic priorities that will align with local, regional, and national requirements Develop a systematic performance improvement process to facilitate knowledge transfer and sustainable change Review the roles of executive sponsor, project team leader, discharge advocate, physician champion, and pharmacist in the redesigned discharge process Develop an understanding of Project RED’s 12 elements 4

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 Where are we? All Cause, All Payor – Baseline 11.56% – 2012 11.50% – 3Quarter 2013 11.03% 30 day Medicare All Cause – Baseline 18.75% – 2Quarter 2013 17.36% 5 Goal = 9.2% GA HEN Goal = 15.24% CMS Average = 14.2%

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 Why? Keeping our Aim in sight! 14,300 individuals 6 What is your Aim?

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 HHS Project RED ALL 12 elements 8

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 1.Explicit delineation of roles and responsibilities 2.Discharge process initiation upon admission 3.Patient education throughout hospitalization 4.Timely accurate information flow: 5. From PCP ► Among hospital team ► Back to PCP 6.Complete patient discharge summary prior to discharge Principles of the Re-Engineered Hospital Discharge

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6.Comprehensive written discharge plan provided to patient prior to discharge 7.Discharge information in patient’s language and literacy level 8.Reinforcement of plan with patient after discharge 9.Availability of case management staff outside of limited daytime hours 10.Continuous quality improvement of discharge processes Principles of the Re-Engineered Hospital Discharge (continued)

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 12 Elements 1.Ascertain need for and obtain language Assistance 2.Medication reconciliation 3. Reconcile discharge plan with national guidelines 4. Follow-up appointments 5. Outstanding tests 6. Post-discharge services 7. Written discharge plan 8. What to do if problem arises 9. Patient education 10. Assess patient understanding 11.Discharge summary sent to PCP 12.Telephone reinforcement 11

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Performance Improvement Structure Deming, Shewhart, Lean Plan Do Check (Study) Act Lean Six Sigma Define Measure Analyze Improve Control

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Getting Started Leadership Support Determine Your Infrastructure – Oversight committee – Champion – Project Team Team formation Team Charter Process Flow – current state Swim Lane – Delineates roles and responsibilities Gap Analysis – measure current process with the 12 elements – What’s missing? Gallery Walk – SWOB – Prioritize

14. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 Questions to run on What really matters to the organization? Achieve bottom-line results Can we measure the impact of the project? How much has the project contributed this year and will contribute in future years? Is our project scope manageable? Do we have PI structure including oversight steering committee; project champion; DA; pharmacist; team members; team leader; scheduled dates, times, and resources needed for the meetings? Have we alerted ad hoc resources such as finance, medical records, IT, education dept, etc., as needed? What is missing and who will be responsible? 14

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 Define the Current State – finding the root cause(s) Initiate a high-level process map Multidisciplinary participation Patient admission is the starting point Start with the ending point - After hospital care provision is the ending point Ask each discipline what steps it takes to prepare the patient for discharge

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 Once the Process Map is Completed Analyze the work flow – get the patients input What defects exist? Where are communication breakdowns, failure to hand off information? Where do delays occur? What are your Project RED gaps? Do we have omission, selection, documentation, communication, administration failures? What steps in this process would the patient be willing to “pay for”? Value Added?

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Compare Discharge Information List current state What are we missing? RED Discharge Plan Components Individual hard copy care plan (language specific) Medication calendars in lay terms Daily morning, afternoon, and evening meds identified Patient questions list Scheduled follow-up appointments Pending tests and results Location of appointments

19. 19 Process Metrics

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22. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 22 Rounding, Communication Board, Huddles Do discharge planning rounds exist on your unit or for your designated patient population? Who attends discharge planning rounds? How often do they occur? Do your physicians participate in rounds? How accurate is the information that is discussed in rounds? How is the knowledge that is obtained during discharge rounds shared with the rest of the team? How are you using the communication board? 22

23. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 23 Tools What do I do when I go home? 23

24. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 24 Does your plan include: Medications in a clear format? 24

25. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 25 Does your plan include: Follow up appointments ? – How are they going to get there? – Who is going to take them to the appointment? – Location map? 25

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28. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Eliminate Documentation Time and Re-Writes Ideally, Information should flow from the medical record to the care provider who needs it Information should flow from one practice setting to another Information that is documented can be time stamped and assessed for accuracy The discharge care plan could be automated and flow to the hands of the care team and patient

29. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Primary Care Physician Referral Base Leaders will identify the PCP referral base PCP satisfaction will be assessed prior to project launch Physician champion will communicate with PCPs about project PCPs will advise how to handle their off- shift and weekend patient needs

30. Learn. Act. Improve. Spread. Keep the Drum Beat Going. Post-Discharge Phone Call Define who will call your patient after discharge Define when the follow-up call will be made Develop script for caller Develop a process for off shifts and weekends

31. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 31 Module 1: Summary Expected Outcomes Align your strategic priorities Develop an infrastructure that will promote communication, understanding of team progress, and documentation of the patient care plan Review roles of executive sponsor, project team leader, DA, physician champion and pharmacist in the redesigned discharge process Develop a systematic performance improvement process that will facilitate knowledge transfer and sustainable change Embed Project RED key principles, including application of the Discharge Care Plan, communication with PCPs and implementing post DC phone calls

32. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 32 Progression to Module 2 Checklist Before moving to Module 2: Create your current state process map Establish the primary physician referral base Determine the Patient Care Plan structure Initiate the project charter Set dates for training frontline staff

33. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 33 Everything you heard today is from: Internet Citation: Re-Engineering Discharge Project Charter: Project RED (Re-Engineered Discharge) Training Program. August 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/charter. html 33

34. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 34 Project RED mini-series: Dates to remember In-person – February 6, 2014 – Ramping up Readmissions: Getting to Target – 2 p.m. – 4 p.m. Cobb Galleria Waverly Teleconference/Webinars – February 19, 2014 10:00 – 11:30 – March 13, 2014 10:00 – 11:30 – March 27, 2014 10:00 – 11:30 34

35. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 35 Renew Your Sense of Purpose When we do what’s right for the patient the numbers will follow…..