1. Reducing Readmissions 1

2. Objectives  Describe where we were prior to our interventions.  Describe the multi-disciplinary involvement and support for reducing readmissions.  Describe 3 key interventions developed.  Describe our current state for readmissions. 2

3. In 2009 HHS 30 Day All Cause Readmission rate: 20% The Opportunity 3

4. Readmission Committee Key Members and Departments: Medical Director ED and Quality 2 Skilled Nursing Facilities Medical Director Hospitalists System Director Pharmacy Mystic Valley Elder Services Leading PCP / Internist MWH Information ServicesHHS VNA Leading PCP/ Internist LMH 2 Gerontologists Nursing Vice President Quality Improvement System Director Case Management 4

5. Community Transitions in Care Committee Members Genesis HealthCare: Courtyard Nursing Care Center (Medford) Bear Hill Rehabilitation & Nursing Center (Stoneham) Wingate HealthCare (Reading) Epoch Senior HealthCare (Melrose) Salter HealthCare: Aberjona Rehabilitation and Nursing Center-(Winchester) Woburn Rehabilitation and Nursing Center Winchester Rehabilitation and Nursing Center Glenridge Nursing Care Center (Reading) Sunbridge HealthCare: Wakefield Care and Rehabilitation Center Everett Rehabilitation and Nursing Center Wilmington Health Care Center Golden Living Centers: Elmhurst (Melrose) 5

6. Internal Team Work Regular team meetings Data review / chart reviews Patient Interviews Transition reviews Small tests of change Continuous monitoring Reaching out / Partnering with outpatient services: –MVES –HHS VNA –Skilled Nursing Facilities Partnering with STARR / IHI 6

7. The Data Elderly (Psych separate) >10 meds Lives alone or with elderly spouse Refuses support at discharge Education efforts challenging Behavior change challenging Dispositions : 1/3,1/3,1/3 7

8. Three Key Interventions: 2011 Nurse to Nurse Warm Calls to a SNF Inpatient Pharmacy Consults Treat & Return Assessment in the ED 8

9. 2012 Targets:  Communication of Patient Information  Improve Transitions in Care Care Redesign 9

10. Communication of Patient Information: 2 2012  Nurse to Nurse Warm Calls expanded  Expanded Pharmacy Consults  Trial Post Discharge Pharmacy Medication calls  Risk for Readmission Score trialed  Improve clinical response  Improved Patient CHF Education  Nursing Post Discharge Calls 10

11. Questions extrapolated from our data Auto tallied Tallied within first 24 hours of admission Auto printed with nursing census q morning on each unit Communicated in daily rounding Communicated to next care provider (report)(report) Risk for Readmission Score 11

12. Title 12

13. Improve Transitions in Care Community Transitions in Care Committee ED Treat & Return Efforts Physician to Physician phone calls Interact Facilities Capabilities booklet Nurse to Nurse Warm calls The ‘new’ Page 2 referral form SNF improved care design New Electronic Discharge Instructions 13

14. The New “PAGE 2” Trial at 3 local SNF Developed by staff nurses from: Hallmark Health: Medical 4 Medical 5 Surgical 5 Bear Hill Rehabilitation and Nursing Center Epoch Senior Healthcare of Melrose Golden Living Center, Elmhurst (Form)(Form) 14

15. The History ACTION STEPS TO DATE 201020112012 VNA - earlier visitsContinued VNA - front load med visitContinued Quality - Patient InterviewsContinued CM; Lace/HHs tool Lace/HHS Tool discontinued 3/11 HHS Risk tool redesigned and trialed HHS Risk for Readmission scoring - auto pulled at admission - communicated thru the admission Pharmacy Consults - CHF onlyPharmacy Consults expanded to elderly w >10 meds Pharmacy Consults: expanded to include CHF,Pn, AMI -also targted elderly w > 10 meds. Pharmacy Warm LineContinued Nursing: Patient education CHFUpdated / now using Lexicomp online toolsContinued MVES at LMH campusMVES expanded to MWHMVES continues at both campuses Nurse Call Center trialed on 2 medical units System wide nurse call access - phone number changed to specific unit number Initial Nurse to nurse warm calls - LMH to Courtyard NCC Nurse to Nurse Warm calls expanded to MWH trial w 3 SNF Nutrition: Inpatient 2 Gm Sodium Teachingcontinues HHS joins STAARcontinues HHS Initiates the Community Transitions in Care CommitteeContinues to grow Post Discharge Nursing Calls trialed on 2 units System wide Post Discharge Nursing Calls - disease specific and multi calls if identified as high risk Post Discharge Pharmacy medication calls trialed Developed HHS Customized Pill boxes, given free with Pharmacy Consults 15

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17. Questions ? 17