reducing readmissions 1. objectives describe where we were prior to our interventions. describe...
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Reducing Readmissions
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Objectives
Describe where we were prior to our interventions.
Describe the multi-disciplinary involvement and support for reducing readmissions.
Describe 3 key interventions developed.
Describe our current state for readmissions.
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In 2009 HHS 30 Day All Cause
Readmission rate: 20%
The Opportunity
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Readmission Committee
Key Members and Departments:Medical Director ED and Quality 2 Skilled Nursing FacilitiesMedical Director HospitalistsSystem Director Pharmacy Mystic Valley Elder ServicesLeading PCP / Internist MWHInformation Services HHS VNALeading PCP/ Internist LMH 2 GerontologistsNursingVice President Quality ImprovementSystem Director Case Management
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Community Transitions in Care Committee Members
Genesis HealthCare: Courtyard Nursing Care Center (Medford)
Bear Hill Rehabilitation & Nursing Center (Stoneham)
Wingate HealthCare (Reading)
Epoch Senior HealthCare (Melrose)
Salter HealthCare: Aberjona Rehabilitation and Nursing Center-(Winchester) Woburn Rehabilitation and Nursing Center Winchester Rehabilitation and Nursing Center
Glenridge Nursing Care Center (Reading) Sunbridge HealthCare: Wakefield Care and Rehabilitation Center Everett Rehabilitation and Nursing Center Wilmington Health Care Center
Golden Living Centers: Elmhurst (Melrose)
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Internal Team Work
Regular team meetings
Data review / chart reviews
Patient Interviews
Transition reviews
Small tests of change
Continuous monitoring
Reaching out / Partnering with outpatient services:– MVES– HHS VNA– Skilled Nursing Facilities
Partnering with STARR / IHI 6
The Data
• Elderly (Psych separate)• >10 meds• Lives alone or with elderly spouse• Refuses support at discharge• Education efforts challenging• Behavior change challenging• Dispositions : 1/3,1/3,1/3
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Three Key Interventions:
2011
Nurse to Nurse Warm Calls to a SNF
Inpatient Pharmacy Consults
Treat & Return Assessment in the ED
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2012 Targets:
Communication of Patient Information
Improve Transitions in Care
Care Redesign
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Communication of Patient Information:
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Questions extrapolated from
our data
Auto tallied
Tallied within first 24 hours of
admission
Auto printed with nursing census q
morning on each unit
Communicated in daily rounding
Communicated to next care provider (report)
Risk for Readmission Score
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TitleTitleAGE 65 - 69 = 1 All Registrations calculate age
70 - 74 = 275 - 79 = 380 - 84 = 485+ = 5
LIVE ALONE Do you Live Alone? Y=1 Admission Query - Visit SpecificNURSING HOME Is this patient from a Nursing Home? Yes = 1 Admission Query - Visit SpecificSTANDING ORDER Does this patient have Standing Lab Orders? Y=1 All Lab Standing Order patients are "flagged" at the Medical Record LevelPREVIOUS ADMIT Did the patient have an INPT Admit 32-90 days ago? This information is pulled from Abstracting - the coding module
If YES = 2 Points2 ED VISITS Did the pt have 2 or more ED visits in the last 90 days This information is pulled from Abstracting - the coding module
If YES = 2 PointsPOOR HEALTH Generally, how do you consider your health to be? Admission Query - Visit Specific
If pt states POOR = 2 Points.WALK W/ASSIST Does pt use a cane, walker or wheelchair for assistance? Admission Query - Visit SpecificOR HX OF FALLS If YES = 2 PointsNO ASSIST AT D/C Can Pt obtain assistance, if needed, upon discharge? Admission Query - Visit Specific
If NO = 2 Points31 DAY READMIT INPT Admit in the Past 31 days - if yes = 5 This information is pulled from Abstracting - The coding moduleCORE MEASURE DXPrevious Admission with Diag Codes = 2 This information is pulled from Abstracting - the coding module
CHF Currenly looking back 90 days only - will look for historical DX CodesMYOCARDIAL INFARCTION (MI) ***NOTE - Currently any one of the diags listed will yield a "hit" and calculate a 2COPD the next round of changes will separate all of the psych diags in an OTHER categoryCHEST PAIN That change will allow for a patient with -PNEUMONIA CHF = 2ACUTE CORONARY SYNDROME Dementia = 2STROKE Calculating two diag values for 4 points in totalCEREBRAL BLEEDCEREBRAL VASCULAR ACIDENT (CVA) All listed diags are pulled by ICD9 codeTIAALL PSYCH DIAGS - INCLUDING DEMENTIA - ALCOHOL -DEPRESSION - DRUG - ECT.DIABETESASTHMAKIDNEY DISEASEMETS CA
NEW ADDITIONSDischarge Disposition Previous Discharge Disposition to a NH/VNA=2 This information is pulled from Abstracting - The coding module
Discharge Disposition - 03, 04, 05, 06 18
SAAD Score The SAAD Score Assessed at Triage = 2 ER Triage Query - Assessed by Triage RN - Visit SpecificNo determination of "what" SAAD score should calculate2 points - Please respond to the group with thoughts
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Improve Transitions in Care
Community Transitions in Care CommitteeED Treat & Return EffortsPhysician to Physician phone callsInteract Facilities Capabilities bookletNurse to Nurse Warm callsThe ‘new’ Page 2 referral formSNF improved care designNew Electronic Discharge Instructions
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The New “PAGE 2”Trial at 3 local SNF
Developed by staff nurses from:
Hallmark Health:
Medical 4
Medical 5
Surgical 5
Bear Hill Rehabilitation and Nursing Center
Epoch Senior Healthcare of Melrose
Golden Living Center, Elmhurst (Form)
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The HistoryACTION STEPS TO DATE
2010 2011 2012
VNA - earlier visits Continued Continued
VNA - front load med visit Continued Continued
Quality - Patient Interviews Continued Continued
CM; Lace/HHs tool Lace/HHS Tool discontinued 3/11 HHS Risk tool redesigned and trialed
HHS Risk for Readmission scoring - auto pulled at admission - communicated thru the admission
Pharmacy Consults - CHF only Pharmacy Consults expanded to elderly w >10 medsPharmacy Consults: expanded to include CHF,Pn, AMI -also targted elderly w > 10 meds.
Pharmacy Warm Line Continued Continued
Nursing: Patient education CHF Updated / now using Lexicomp online tools Continued
MVES at LMH campus MVES expanded to MWH MVES continues at both campuses
Nurse Call Center trialed on 2 medical unitsSystem wide nurse call access - phone number changed to specific unit number
Initial Nurse to nurse warm calls - LMH to Courtyard NCCNurse to Nurse Warm calls expanded to MWH trial w 3 SNF
Nutrition: Inpatient 2 Gm Sodium Teaching continues
HHS joins STAAR continues
HHS Initiates the Community Transitions in Care Committee Continues to grow
Post Discharge Nursing Calls trialed on 2 unitsSystem wide Post Discharge Nursing Calls - disease specific and multi calls if identified as high risk
Post Discharge Pharmacy medication calls trialed
Developed HHS Customized Pill boxes, given free with Pharmacy Consults 15
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Questions ?
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