1. Readmissions Breaking the Cycle The Nevada Partnership for Value-Driven Healthcare And HealthInsight March 30, 2011

2. What we know The patient is at the center The answers are local Coordination and change are challenging for everyone Building a supportive environment is about building community Homeward Bound: California Healthcare Foundation

3. What you now know Nevada’s Readmission status Readmission Root Causes Transitions of Care basics Current data and the project goal

4. What NPV brings Evidence-based best practice research Collaborative coordination on an outcomes based project to improve the quality and safety of patient care delivered in Nevada Data sharing mechanism

5. Intervention examples What is working Care Transitions – communication across the continuum of care (hand-offs) Teach back – strategic transfer of information from caregiver to patient EOL – focus on end of life issues (advance directives, patient and provider education)

6. Transitions of Care Enhanced assessment of post-hospital needs Effective teaching and Enhanced learning Real-time handover communications Mechanism to ensure timely post-hospital care and follow-up IHI’s Four Cornerstones

7. Teach Back - fundamentals Listen to the patient Determine patient/family needs up front Make sure the patient/family understands Do not allow “passive patients”

8. Teach Back During hospitalization – to educate patient/family about diagnosis and care At Discharge – to educate patient and caregivers on continued needs Post-discharge – reinforce compliance of discharge instructions and teaching

9. End-of-life Patient education surrounding options Ensure that patient’s wishes are understood and honored Training in palliative care

10. Readmission Reduction “Success in reducing readmissions lies in effectively partnering to not only achieve better outcomes but also to reduce the fragmentation and lack of support that so often comes with transitions between providers and care settings.” Amy Berman, Program Officer, The John A. Hartford Foundation

11. Collaboration is Key It takes a community