Hospital StoryKristen van Bergen-Buteau, CPHQAssistant Director, Quality Services

Littleton Regional HospitalNew Hampshire

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About Us• Located in Littleton NH since 1907• 25-bed Critical Access Hospital

– General Med/Surg & Intensive Care Units– Agnes Norris Family Birth Center– 24 hour Emergency Department with Level III Trauma Center– Surgical services, including orthopedics joint replacement excellence program,

endoscopy and – Outpatient ancillary services include new fixed MRI, 64-slice CT, nuclear

medicine & clinical/pathology lab services for both patients and as a reference lab for facilities throughout NH & VT

• Outpatient Sleep & Oncology/Infusion Centers• 11 provider-based primary and specialty care practices on campus (26

employed practitioners)• 111 members of the Medical Staff

What Did We Test?

• Post discharge follow-up calls• Follow-up appointments made prior to discharge• Inpatient interviews of patients during readmission• Electronic access to provider records for

admission/discharge notification• Immediate dictation & distribution of Discharge

Summaries at time of discharge• Medication Reconciliation list sent with Discharge

Summary

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What Have We Learned So Far?

• Improvements in process don’t necessarily mean immediate improvements in readmission rates!

• “Hot Spotters” exist, but we can’t reduce their utilization until we establish cross-continuum plans

• No significant trends in readmissions by diagnosis, but opportunities are similar regardless of primary reason for utilization

What Barriers Did We Encounter?

• Patient “non-compliance”• “Non-compatible” medical records systems• 30-day rule• Medications• “Different” needs for receiving providers• Lack of a social safety net

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How Did We Overcome These Barriers?

• Patient “non-compliance”– It’s a misnomer! We just need to ask the right questions to identify their barriers

• “Non-compatible” medical records systems– Look closer, and think outside the box (but within the rules)

• 30-day rule– It’s okay to dictate and sign SOONER!

• Medications– Electronic Reconciliation forms in paper format– Polypharmacy & cross-reactions

• “Different” needs for receiving providers– Not really – it’s all about communication & shared vocabulary

• Lack of a social safety net– “Hot Spotters” have many socioeconomic barriers in a rural area with few

resources

How Are We Doing Now?

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How Are We Doing Now?

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How Are We Doing Now?

How Are We Doing Now?

What Can Others Learn From Our Journey?

• Start collaborating across the continuum – NOW!– Multiagency meetings to identify collective

opportunities (LTC, ALF, HH, PCT, etc)– Task forces focused on specific transitions in care and on

specific “Hot Spotters”• Be willing to use LOTS of Rapid Cycle Improvement

– every form & script is a draft and that’s okay• Think outside the silos – there ARE resources we’re

not tapping in rural areas, but most are NOT health-care related

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Do Not Try This At Home (Suggestions for What Not to Do…)

• Insist on cleaning up internal processes before any other cross-continuum work can begin – “Neat” and “Sterile” are two very different standards!!

• Get bogged down in data• Fix the whole system at one time

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Next Tests of Change

• Multi-agency Interdisciplinary Care Plans for “Hot Spotters”• Task Forces for specific transitions in care• Follow-up calls and appointments for Emergency

Department patients• New Patient Education/Discharge Instruction product• Sooner post-discharge appointments (within 7 days) and

more same-day appointments for high risk patients• Clearer communication about who can implement a

treatment plan (Admission vs. return to NH or HH)• Earlier PCT/Hospice intervention• Paramedic home visits

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Teach Back

• Summary:• We’re only just getting started• Collaboration is key to success• Patients and ALL of their

providers need to be engaged

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Teach Back

• Questions?