1. Shawnee Mission Medical Center Kim Fuller, MSW, MBA, CCE Janet Ahlstrom, MSN, ACNS-BC

3. Selected populations: Congestive Heart Failure Pneumonia Acute Myocardial Infarction (AMI)

4.  IHI Collaborative on Reducing Readmissions in 2009/2010.  Developed multidisciplinary internal team to participate in the Collaborative and to begin designing program.  Did chart reviews of readmissions to assess patterns, failure points, potential interventions and conducted tests of change.  Discovered many readmissions coming back from SNF’s, so invited key partners to join Collaborative.

5.  Split internal team and external community partner group into separate meetings.  Justified initial addition of an FTE by quantifying potential cost to the bottom line following implementation of CMS penalties.  Hired.5 MSW and.5RN and Transition Coach role fully implemented in August, 2011.

6.  Enhanced Admission Assessment for Post Hospital Needs  Effective Teaching and Enhanced Learning  Real – time Patient and Family Centered Handoff Communication  Post-Hospital Care Follow Up

7.  Membership includes:  Nursing representation from cohort areas for CHF, AMI and Pneumonia.  Pharmacy  Social Work/Utilization Review  Ask a Nurse Call Center  SMMC Home Health  Cardio-Vascular Services  Nursing Education

8.  Membership includes  Home health  Skilled nursing facilities  Assisted Living Facilities  Hospice  Private Duty  LTAC  Emergency Medical Response

9.  Case studies of readmissions from various facilities, identifying breakdowns and creating new processes.  Education re: disease specific protocols provided to SNF’s. i.e. importance of daily weights and use of the zone chart for CHF patients.  Development of common hand off tool that meets needs of hospital and external agencies.  Strategies to increase involvement of palliative care and hospice when appropriate.

10.  Education about national movement toward use of Transportable Physician orders for End of Life treatment wishes.  Development of special interest sub-committees to concentrate and problem solve issues that are unique to different settings.  Trend readmission data specific to various agencies/facilities to use in forming stronger community partners with those that have lower readmission rates.

11. Shawnee Mission Medical Center Melanie Davis-Hale, LMSW Cathy Lauridsen, RN, BSN

12.  0.5 Social Worker/ 0.5 RN  Identify high risk patients in hospital  Initiate individualized program  Follow for 30 – 45 days regardless of setting  Facilitate smooth TRANSITIONS  Early intervention with any readmissions  Meet weekly with physician champions at SMMC  Provide education for patients and healthcare team partners

13.  Currently utilizing the Better Outcomes for Older adults through Safe Transitions (BOOST ) Tool  Collaborative Care Team (CCT) process at SMMC  Chart review of Electronic Medical Record

14. 8P screening tool:  Problem Medications –(anticoag, insulin, aspirin, digoxin)  Punk (depression) - screen positive or diagnosis  Principle diagnosis – COPD, cancer, stroke, DM, heart failure  Polypharmacy - >5 or more routine meds  Poor health literacy - inability to do teachback  Patient Support – support for d/c and home care  Prior Hospitalization - non-elective in last 6 months  Palliative Care – pt has an advanced or progressive serious illness

15.  Initial contact with patients/family during the hospitalization.  Schedule follow-up PCP/Specialist appointment prior to hospital discharge.  Follow patient across all levels of care for up to 45 days post discharge.  Phone/in person home visits.  Continually assess patient needs post discharge.

16.  Medication management  Follow up with PCP/Specialist  Patient centered record  Knowledge of Red flags and how to respond

20.  Identifying patients that will code out as CHF, Pneumonia, AMI  Continually educating service providers on role of transition coach  End of life issues

26. Pt originally admitted to hospital for: Pt admitted from:Pt discharged to:Readmission reason: PNAHomeSNFDehydration CHFHome w/ Home HealthSNFCHF SNF CHF HomeHome w/ Home HealthCHF HomeHome w/ Home Health Hemorrhage of Gastrointestinal CHFHome w/ HHHome w/ Home Health Transient Cerebral Ischemia CHFHomeHome w/ Home HealthA-Fib PNAHome Mitral Valve Disorder CHFHome CHF PNAHome Pulmonary Embolism

27.  Kim Fuller  913-676-2293  Kim.fuller@shawneemission.org Kim.fuller@shawneemission.org  Janet Ahlstrom  913-676-2032  Janet.ahlstrom@shawneemission.org Janet.ahlstrom@shawneemission.org  Cathy Lauridsen  913-676-8611  Catherine.lauridsen@shawneemission.org Catherine.lauridsen@shawneemission.org  Melanie Davis-Hale  913-676-2168  melanie.davis-hale@shawneemission.org melanie.davis-hale@shawneemission.org