jenny riddle rn, mha, cpn, ccm,...

Cook Children’s Medical Center

Readmissions Update

Jenny Riddle RN, MHA, CPN, CCM, CSSGB

Source: Claritas Demographics (2007)

Cook Children’s Health Care System:

▲ Cook Children’s Medical Center ▲ Cook Children’s Northeast Hospital ▲ Cook Children’s Physician Network ▲ Cook Children’s Home Health ▲ Cook Children’s Health Plan ▲ Cook Children’s Health Foundation ▲ Cook Children’s Pediatric Surgery Center

Primary service area: six counties

Serves children from: 120 counties

Population of Tarrant Co.: 1.9 million

Children 0-18: 531,083

Who is Cook Children’s?

Readmissions Bundle Elements

Identify high risk populations of patients & develop

specialized care plan.

Schedule primary provider follow-up appointment prior

to discharge.

Post discharge phone call to reinforce discharge

instructions.

Discharge instructions contain a plan for potential

problems.

Provide Feedback to clinicians on any unplanned

readmission.

Identify high risk populations of patients and

develop specialized care plan.

High-Risk Population Identified – Asthma

Admissions.

Ensure patients receive Asthma Action Plan

when discharged

CM places follow-up call

Readmission Rapid Improvement Teams

• Meet bi-weekly

• Multi-disciplinary

• Ongoing PDSA work

• Discuss opportunities and barriers

• Audits on discharges

Schedule primary provider follow-up visit.

Discharge instructions contain a plan for

potential problems

Updated Nursing Discharge Instructions

Monthly audits with feedback to units

Post discharge phone call to reinforce

discharge instructions.

CM Staff follow up on all high risk patients

DME orders

Ostomy/g-button supplies/ wound care supplies and

formula

Therapy orders

SNV or PDN orders

Readmission with 7 days

Patients with prior services

Five or more medications.

Post discharge phone call to reinforce

discharge instructions.

Call Center staff place follow up calls on discharged

hospitalists patients. • Did the patient receive any new Rx and were they

filled?

• Any questions about giving the medications?

• Has a follow-up been scheduled?

• Any questions about discharge instructions?

Provide Feedback to clinicians on any

unplanned readmission.

E-mail Notification from Chief Quality Officer

Send to discharging physician & Medical Director

Your patient, Mary Smith was readmitted on April 3, 2016.

Cook Children’s Medical Center is actively involved in reducing

preventable readmissions. Any suggestions you might have to

reduce preventable readmissions would be appreciated.

Please feel free to e-mail me if you have feedback or questions about

this patient or our work on readmissions.

Data Collection

Readmission Report reviewed monthly by

Multidisciplinary Readmissions Committee

• Readmissions within 48 hours, 7 days & 30

days

Readmission Dashboard

Monthly audit of 40 charts-30 discharges & 10

readmissions for compliance to bundle

elements.

Readmission Dashboard

Readmission Rate

Readmission Bundle Compliance

Readmission Interventions

CM runs daily readmission report.

Family Interview completed by Social Work and

Case Manager

Opportunities identified to improve discharge

care reported to units/readmissions team.

Monthly meeting with Case Management/Social

Work Team and Quality to review opportunities.

Social Work/ Case Management Readmission

Interview

Readmission Interventions

Readmission Best Practice Recommendations

Readmission Requests for Assistance

Readmission Review Committee

Structure.

Follow-Up Call Structure

• Who?

• When?

• Outcomes?

Provider notification process

High-Risk Population processes

Questions?