1. Best Practices in Readmissions Titus E. Gambrell, MSN,RN-BC,ACM,CMAC Director - Case Management; Bed Control/Transfer Center; Clinical Education St. Mary’s Health Care System Athens, GA

2. St. Mary’s Health Care System Historical Good Performer 2013 High Turnover CM Department Staff Leadership Nursing Staff Leadership

3. St. Mary’s Health Care System 2013-14 Parent Company Merged with Larger Organization 20+% Increase in Inpatient Admissions 20+% Increase in ED & OP Volumes Patient with Greater Complexities Perfect Storm…or… Perfect Recipe

4. Performing an Honest Appraisal Use Performance Improvement Strategy…your choice Easy as APIE Assess Plan Implement Evaluate

5. Organizational Assessment Strengths People Processes Services Weaknesses Barriers Challenges Gaps Start, Continue, Stop Exercise

6. Internal Communication Strategic Plan Work Relationships Within Departments & Services – Internal & External to Hospital Communication – Generally Speaking & Otherwise Team Meetings LOS/Multi-Disciplinary…Interprofessional Huddles Readmission Reduction Team Processes Medication Reconciliation, Readmission Risk Assessment, Patient Education, Many, Many More!

7. Internal Communication Strategic Plan Maximize Use of Clinical Informatics Nursing Readmission Risk Assessment Score Charlson Comorbidity Index Score ACE Plus Score CM Prioritizing Patient Visits Standardized Discharge Plan Assessment Talking to the Patient

8. Disease Management Focus Redesign Forging Partnerships and Giving Credit Palliative Care Infection Control Respiratory Therapy Diabetes Education Stroke Cardiac Surgical Services/Ortho Dietary/Nutrition

9. External Communication Strategic Plan Build True Partnerships Case Management Sponsored Fair Breakfasts Onsite Visits Transparency Tough/Sensitive Conversations Physician Office Practices/Clinics QIO Community Meetings Other Means

10. Other Related Initiatives IHI Triple Aim CMS – Medicare FFS – Bundled Payments for Care Improvement Initiative April 2015 – COPD, MI, HF, Esophagitis/Gastroenteritis July 2015 – Patient Navigator October 2015 – Spinal Fusions, Joint Revisions, & Endocrine/Metabolic Comprehensive Care for Joint Replacement January 2016 Nothing Static About Health Care!