1. Best Practices in Readmissions Susie Payne, RN MSHA Director Resource Management Clearview Regional Medical Center

2. Clearview’s Data Readmission Rates dropped from ◦ 35% in 12/11 to ◦ 16% in 12/12 to ◦ 9% 12/14 Patients presenting to ED after inpatient admission ◦ Admitted In-patient  12 - 18% ◦ Admitted to Observation  4 - 6% ◦ Seen Only in ED  50 - 76%

3. Also, “there’s an app for that!”

4. Download from app store

5. Hit SUBMIT Drop down boxes to fill in

6. Patient’s Readmission Risk Score

7. We have a score…. Now what ? Looked at top three reasons patients were being readmitted. ◦ Nonadherent ◦ Can’t get in to a doctor ◦ Can’t get medications Then developed interventions to coincide with these reasons

8. Medications Was still problemsome Working with Carmichael’s for bedside delivery BEFORE discharge Pharmacist available for teaching and follow up

9. House Calls Program Transitional Care Program Nurse Practitioner and Paramedic Home Visit on High Risk Readmit Supplement PCP’s unable to schedule an appointment for patients within 7 days.

10. Last but not least.... The NonAdherent patient Create Patient Agreements ◦ Define Patient’s Responsibilities ◦ Define Hospital’s Responsibilities

11. The Patient Agreement The patient will be expected to: ◦ Go to appointments (Dr., Dialysis, etc.) ◦ Obtain medications ◦ Take medications as directed ◦ Call Home Health, Hospice, Physician for follow up

12. The Beginning... READMISSION HIGH RISK ALERT: PATIENT HAS A SCORE OF _________________ (ABOVE 11= HIGH RISK) AUTOMATIC HOME HEALTH CONSULT. ◦ AGENCY __________________________ FOLLOW UP APPOINTMENT MADE BEFORE DISCHARGE. ◦ DOCTOR _______________________________ ◦ DATE / TIME _____________________________ NOTIFY JULIE RICHARDSON UPON DISCHARGE FOR DISCHARGE PHONE CALL AT EXTENSION 3196. ONE PHONE NUMBER TO CALL 770-267-1814 RETURN THIS FORM TO RESOURCE MANAGEMENT.

13. Now.....

14. PATIENT SCORE: High Readmission Risk Discharge Checklist (LACE score > 11 points) On ADMISSION: Dietitian consult Provide Supplement coupons SECOND DAY OF ADMISSION: Provide customized Discharge Plan and education Consult Carmichaels to evaluate at home for home O2 Opt in/out for Carmichaels Prescription Delivery to bedside Please place “Bedside Medication Delivery Checklist” in the chart Please notify case management (if not already aware) Have patient complete and sign “Bedside Medication Delivery Agreement” and place with the checklist in the chart Schedule PCP follow-up appointment Doctor:_____________________________ Apt. date and time:___________________ Discharge location: □ Home □ NH □ Hospice □ Other facility If DC Home: Schedule HOUSE CALL follow up appointment @ 770-554-9773 Will patient need an ambulance at discharge ? Fax copy of Face Sheet and Discharge Summary to 678-730-4379 Home Healthcare Consulted Company________________ Care Transitions Program Consulted if on Medicare After discharge (if discharged home): *Apogee or Julie Richardson MS, RD, LD to call and return Checklist to Julie Richardson Receive Discharge Phone Call within 72 hours of discharge Verify using teach back (medications, symptoms, and follow-up):disease specific questions Call not completed. Reason:________________________ This is NOT part of the medical record Patient Sticker

15. Readmit Questionnaire DIAGNOSIS DISPOSITION REFFERED TO OUTSIDE SOURCE WHO MEDICATIONS BUY THEM TAKE THEM PHYSICIAN –DID YOU SEE THEM DISCHARGE INSTRUCTIONS UNDERSTAND THEM SUSPECT NON-COMPLIANCE PREMATURE DISCHARGE INADEQUATE D/C PLANNING INADEQUATE PATIENT EDUCATION RELATED TO PREVIOUS DISCHARGE ? NUMBER OF DAYS FROM LAST ADMISSION

16. Key Points Readmission Risk assessment Score ◦ Know who to focus on ED Case Manager ◦ Has to be present to redirect potential readmission Communication ◦ Backwards, forward and sideways Team Effort