1. Reducing Avoidable Readmissions A Cross-Continuum Approach

2. BIDMC’s Strategy for Readmission Reduction Risk Factors System Level Condition Specific Medication Mgmt Patient Activation Care Coordination Mitigation Strategies Disease Specific Pathways (Inpt & Outpt) Pharmacist Med Rec & Consolation Care Transition Coaching Effective Teaching & Learning Based on Health Literacy Level Family / Social Support & Community Services

3. Health Care Associates (HCA) Pilot Hospitalization30-Days Post Discharge Nurse Care Transition Specialist (CTS) Patient & Family Care Transitions Coach Primary Care TeamHospital Care TeamECF/VNAPharmacistsSpecialists ASAP Network Social /Community Support Services Target Population= HCA Medicare Patients with Discharge Diagnosis of Heart Failure, Pneumonia or Heart Attack (AMI)

4. HCA Pilot: Teaching & Learning Component Key Learning:Patients retain very little of the teaching that occurs at discharge Hospitalization30-Days Post Discharge CTS performs bedside assessment to identify patient’s health literacy level and knowledge of condition. When patient returns home CTS calls to review the discharge instructions and condition based teaching, using Teach Back techniques. CTS meets patient after post-discharge visit to answer questions and discuss the plan. Weekly calls from the CTS focused on condition management education, based on the patient’s learning needs.

5. Example of Alignment on Teaching & Learning Across the Continuum Heart Failure Patient A– Medication Knowledge & Adherence Bedside Visit Patient is able to name her medications and state why she takes them. She also checks her blood sugar 4x/day and is independent with administering her insulin. Progress Note from VNA Received update from pt's visiting nurse, after her home visit with the patient today. Reports that she visited pt around noon. Pt had not yet taken medications. Skilled nurse performed medication teaching with patient. Instructed her on how to take TID meds. Enforced that she needs to take am meds in the morning to be on schedule. Decompensation Management VNA called, patient cont with some dizziness with ambulation but did not feel like she was going to pass out. Pt denies any CP. I spoke with Dr who would like to decrease pt's dose of Torsemide to 40mg. I have explained this to pt who seems to understand current dosing of meds & new change. Follow-Up F/U call made to pt's home to check in & see how she was feeling. Pt states her dizziness has resolved & is feeling much better. She cont with 40mg Torsemide daily.

6. Progress to Date & Next Steps After two months, reliably implementing all elements of the intervention Next Step: At three months, evaluate outcome measures, including impact on readmission rates. Teaching and learning is most effective when reinforced consistently from multiple care providers Opportunity: Standard teaching tools across care settings (hospital, ECF, VNA, transition coaches, primary care) Opportunity: Identify way to track patient’s level of understanding and communicate teaching/learning needs across the continuum.