1. Wentworth-Douglass Hospital Story Kimberly Chapman, RN, MS, CNL, PCCN Discharge Advocate for Project RED Wentworth-Douglass Hospital Dover, NH Monique Drouin, RN RN Care Manager Strafford Medical Associates Wentworth Health Partners Dover, NH

2. About Us Wentworth-Douglass Hospital Dover, NH New Garrison Wing Not-for-profit charitable organization accredited by the Joint Commission on Accreditation of Healthcare Organizations. U.S. News Ranks WDH in the top 100 Best Hospitals Joint Commission Certified Primary Stroke Center 2

3. What Did We Test? Project RED Discharge Advocate 11 Components 1. Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Discharge summary sent to PCP 11. Telephone reinforcement 3

4. What Have We Learned So Far? After Hospital Care Plan is essential Communication is key! Patients like seeing a consistent person throughout the hospital stay Patient Engagement 4

5. What Barriers Did We Encounter? IT issues: – AHCP (time consuming manual data entry, no interface) – Notification of pilot patients After Hours Coverage: weekends, evenings, holidays and vacations Contacting patients after discharge Scheduling hospital follow-up appointment within 7 days 5

6. How Did We Overcome These Barriers? Demo of Engineered Care Software to create the After Hospital Care Plan Connecting with other hospitals who use our EMR system Planning proposal for budgeted position Creating more ‘hospital follow-up’ appointment slots. 6

7. How Are We Doing Now? Process metrics: -Average time to notify Discharge Advocate about new admission -Average time from admission to first patient visit -Percent of patients whose PCP office care manager was notified within 1 day of discharge -Percent of follow-up phone calls made within 2 days of discharge. Outcome metrics: -Average LOS -30 day unplanned readmission rate 7

8. What Can Others Learn From Our Journey? We are still learning too! Coordinated effort between inpatient and outpatient services Importance of follow-up call 8

9. 9 Do Not Try This At Home (Suggestions for What Not to Do…) Don’t start too big! Don’t minimize the work associated with creating the After Hospital Care Plan

10. 10 Teach Back Summary Next Tests of Change (TOC) Questions?