Roadmap to Readmission Reduction: Sharing Resources

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Presentation transcript:

Roadmap to Readmission Reduction: Sharing Resources Julia Slininger, RN, BS, CPHQ Vice President, Regional Quality Network Hospital Quality Institute (HQI) July 14, 2017

Disclosure I do not have relevant financial relationships with commercial interests.

Objectives for Today Assess the strengths and weaknesses in your current readmission reduction strategies. Implement targeted solutions to improve outcomes. Tap into HIIN Resources

Commending Hospitals’ Progress Carrots and sticks in healthcare reform Readmission rate penalties Hospital Engagement Network (HEN) resources with peer-to-peer learning Special grants (i.e., Community-based Care Transitions Program [CCTP]) Results of efforts to date CalHEN hospitals reduced all-cause readmission by 9 percent in the aggregate But the range of rates indicates more is possible

Primary and Secondary Drivers Primary Driver Secondary Driver Change Idea Reliable discharge process Educate patients about red flags Use take-home checklist Schedule follow up MD appointment Case manager (CM) to schedule and give patient appointment card Use teach-back to validate patient understanding Train nursing staff on teach-back method Enhance post-acute services based on need Conduct risk assessment, safety check, and person-centered goals Create an in-home safety and social needs check

Readmissions Reduction Algorithm A picture is worth a thousand words! https://www.hsag.com/en/hiin/tools-and-resources/

“Best Practices” Requirements Periodic reassessment and analysis Targeted strategies Innovative thinking Small tests of change (STOC)!

Best Practices from the Southern California Readmissions Reduction Collaborative

Key Change Strategies Use “teach-back” in discharge planning Video training (Better Outcomes to Optimize Safe Transitions [BOOST] or YouTube) helpful Post-discharge contact mechanism Call or visit to review medications, safety, medical doctor (MD) appointment, social, and safety factors Partner with the emergency department (ED) and outpatient clinics Creative (safe) options to inpatient (re)admission Partner with skilled nursing facilities (SNFs) and home health agencies (HHAs) Improve the handoff Recognize and address changes in condition

Next Steps (Re)assemble your team (Case Management/Quality Improvement/Nursing/Pharmacy/ Patient Advisor) Share the algorithm and conduct a current review of cases PLUS flowcharting or fishbone session Map out your approach to keep the improvement momentum going Use a Gantt-style chart like the Plan Ahead Tool Remember to design small tests of change to include purposeful Plan, Do, Study, Act (PDSA) (Some things never get old!)

Thank you! Julia Slininger Vice President, Regional Quality Network Hospital Quality Institute (HQI) jslininger@hqinstitute.org