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