1. COALITIONS

3. Arkansas Medicare Readmissions

4. Overall Goals by 2019:
Reduce Medicare Hospital Readmission Rates by 20%
Reduce Medicare Hospital Admission Rates by 20%
Increase community tenure by increasing the days Medicare FFS Beneficiaries spend at home by 10%
Reduce Adverse Drug Events, Emergency Department Visits, Observation Stays occurring as a result of the care transitions process.

5. A Community-Based Approach:

6. Case Management
Quality Program Manager
Med. Mgmt / Referral Nurse
Director of Community Relations
RN/ Patient Intake Coordinator
Sales/Marketing
Director of Pharmacy
In Home Services Specialist
Grant Coordinator
Director of Quality
VP of Quality & Patient Safety
Quality Specialist
Director Quality
Home Health Director
Director of Nursing
Nursing
AASN Coordinator
General Manager
Director of Clinical Services
MBA, RN, RNP
Volunteer Caregiver Advocate
RN Director
Care Manager
RN Care Coordinator
Director
Community Liaison RN
Care Management Supervisor
Director of Client Services
Manager
Marketing Director
Administrator
Director of Marketing
Physician
Sales Representative
Pharmacist
Director Quality and Case Management
Director of Behavioral Health/Senior Care
Director Case Management
Supervisor
MRC, CRC
Marketing
Caregiver
Marketing Manager
Senior Area Business Specialist
Marketing Director/Admission Director
Patient Services Director
RN Discharge
CNO/Quality Director
ADON
DON
SW/CM
Quality
LCSW
COMMUNITY EDUCATOR & MEDICAL CONSULTANT
Community Education Coordinator
LPN
Administrator
Intake Coordinator
Clinical Specialist
Office Manager
Business Developer
Consultant Pharmacist
Community Relations Consultant
RN, MSN
Behavioral Health Director Director Home Health Business Development Manager Patient Safety Officer Manager, bundled payments Director of Pharmacy Quality Health Coach Director Manager Care Transitions Vice President Marketing Assistant Administrator Sales/Marketing Community Outreach Administrator Nurse Manager QI Coordinator Administrative Coordinator Director of Corporate Marketing Arkansas sales Manager Admissions/Marketing Director Account Executive Director, Office of Rural Health and Primary Care Community Relations Specialist Director of Quality & Patient Safety Quality Specialist VP of Quality & Patient Safety Regional Account Director Patient Care Coordinator Billing RN, Manager of Clinical Services Customer Relations Executive, Care Transition Nurse
Director of clinical services
Director of Nursing
Social Services Director
Administrator
Clinical Transition Nurse
Case Manager
Director Quality
Team Lead - Transitions of Care
Community Resource Specialist
RN-Hospice Specialist
Patient Care Manager
RN, Care Transition Liaison
Director of Clinical Services
Area E.D.
Social Director
Director Mktg & Business Development
Clinical Consultant for Remote Pt Monitoring
Community Education Specialist
Clinical Manager
Population Health State Coordinator
Admissions RN
Clinical Assessment Coordinator
Director of Community Education
Manager of Clinical Practice
Medical Director
Director
RN Program Director

7. Cohort A: ACT Delta/ACT East
Cohort B: ACT North Central/ACT Northwest
Cohort C: ACT Ozarks, ACT Southwest, ACT Central, ACT South Central, ACT River Valley

8. What do we do first? DATA Root Cause Case Studies
Readmission Interviews

9. What causes a PREVENTABLE Readmission/Admission?
The four factors “most strongly associated with potentially preventable readmissions”:
Premature discharge from the index hospitalization
Failure to relay important information to outpatient health care professionals
Lack of discussions about care goals among patients with serious illnesses
Emergency department decision-making to admit a patient who may not have required an inpatient stay
The four most common factors affecting potentially preventable admissions:
Emergency department decision-making
Inability to keep appointments after discharge
Premature discharge from the hospital
Patient lack of awareness of whom to contact after discharge
“Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients” JAMA Internal Medicine doi: /jamaintermed (published online, March 7, 2016),

10. Arkansas 30-day Hospital Readmissions by Care Setting

11. Arkansas 30-day Readmissions by Diagnosis
CHF (24.2%) COPD (19.1%)
Average 138/month (4-5/day) Average 76/month (2-3/day)
Diabetes (24.4%)
Average 42/month (1-2/day)

12. When do most readmissions occur?
0-7 Days
8-14 Days
15-21 Days
22-30 Days
Number %
7,149
38%
4,909
26%
3,533
19%
3,203
17%

13. Expectations for Coalition Work:
Workgroup
Name Badges at the Door
Buy-in/Participation
FOCUS
Measurable Goals
Patient-Driven Change

14. What do our patients say?
Better communication = face to face.
Adjust your message to fit your audience.
Connect the thread for all services involved in a patient’s care.
Don’t overwhelm the people that are sick.
See the patient as an individual. Explain things at a lower level that they might normally meet. Ask them to repeat back to you what they understood.
St. Bernards Medical Center Patient Family Advisory Council

15. 1 Year = 365 Opportunities 9 Coalitions 68 Counties
96% Medicare Population
96% State Population
255 Unique Providers
17 Critical Access Hospitals
43 Acute Care Hospitals
70 Nursing Homes
15 Home Health Agencies
8 Hospice Agencies
30 Coalition Meetings
2 Care Transitions Conferences
1 Coalition Leader Conference
100+ Subcommittee Meetings
18,422 Miles
68 Ongoing Projects
9 Statewide Projects
8/9 Coalitions with significant RIR in last quarter (Range from 2.4% to 17.1%)
7.87% combined decrease in readmissions across coalitions

16. And…1 Aunt Bertha

17. Numbers – Names – Processes - Validation

18. AFMC Care Transitions Outreach Specialists:
Melodie Zipfel MSN, RN Jo Whitmore MPH, RN