1. Hospital Story Donna Collins, RN,MS/ CPHQ, Quality Manager, Weeks Medical Center, NH

2. About Us Weeks Medical Center, 25 bed CAH Single entity w/ full service hospital, OP oncology, 4 office practices, home health, hospice Catchment area – primarily older population w/ multiple co-morbid conditions Lowest per capital income in State of NH Long standing history - high re-admission rate

3. What Did We Test? Follow-up appointments scheduled within 4 days of discharge; appointment phone line established for weekend discharges Earlier referral to Home Care/Hospice/Palliative Care services Post discharge patient phone calls by outpatient case manager/nurses Transition of care summaries ( H&P, discharge summary, discharge medications, instructions) sent to PCP; EMR preparation prior to follow-up visit 3

4. What Have We Learned So Far? Aligning the readmission reduction goal throughout the organization elevates the goal to a priority status- CEO driven Hospital, office and home health team leaders and representatives are essential ( CMO, CNO, Office Practice Director) A new communication/coordination infrastructure is required- change in employee roles/functions in all care settings Patient and family involvement with follow-up care gets you far but not 100% 4

5. What Barriers Did We Encounter? Hospital, office and home care information systems are not integrated Medication Reconciliation is still a burden; most patients are discharged on >9 medications Patients and families are optimistic for cure; often prefer acute hospital care late in disease process – delayed referrals to Hospice 5

6. How Did We Overcome These Barriers? Expanded roles and responsibilities of admitting/communication, case management and clinic nurses to build transition bridge Continuing development of Medical Home model Continuing development of Palliative care program Involvement of Home care and hospice staff in design Patient education regarding palliative care options 6

7. How Are We Doing Now? YearQuarterNum.Den.% Goal = 6.7% 2010 2011 1234112341 19 6 11 15 9 207 164 157 176 166 9.1% 4.9% 7.0% 8.5% 5.4% 201121615810.1% 2011361254.8% 2011491296.9% 20121111397.9% 7 Readmissions within 30 days

8. Weeks Medical Center Acute Care Readmission

9. What Can Others Learn From Our Journey? Share team activities/ updates with medical staff- they are concerned about re-admissions and will offer valuable improvement suggestions Conduct case reviews using a standardized tool; helpful in identifying subtle quality issues and barriers Refer cases into QA peer review process if indicated Re-visit basic processes to check all are functioning well- consistency in patient activity orders; PT/OT evaluations 9

10. 10 Do Not Try This At Home (Suggestions for What Not to Do…) Attempt to implement major changes without MD input and involvement Assume that one or two strategies will fix the problem ( we know it can’t) Implement new work processes without adequate staff education and training