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.
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.
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
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
Membership includes Home health Skilled nursing facilities Assisted Living Facilities Hospice Private Duty LTAC Emergency Medical Response
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.
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.
Shawnee Mission Medical Center Melanie Davis-Hale, LMSW Cathy Lauridsen, RN, BSN
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
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
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
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.
Medication management Follow up with PCP/Specialist Patient centered record Knowledge of Red flags and how to respond
Identifying patients that will code out as CHF, Pneumonia, AMI Continually educating service providers on role of transition coach End of life issues
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