Transcript Northern California Readmission Summit

PREVENTING
READMISSIONS
January 16th, 2015
Presented by Debbie Rivet, MSW, CCM
PRESENTATION OBJECTIVES
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Assist each health care organization in developing a collaborative
across the continuum of care.
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Demonstrate the impact to the community in reducing readmissions
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Share the data regarding readmissions over the past year.
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Review the process in developing a collaborative
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Share the tools used for the collaborative to reduce readmissions
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Empower all organizations to assist in the process to reduce
readmissions.
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NRPC So Cal Readmissions Update
October 16, 2014
Southern California Readmissions Summit – 10/16/2014
Preventing Readmissions
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Establishing the Preventing Readmissions group goal was to improve patient care and reduce readmissions.
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It is a non-judgmental environment to share information and work cohesively to reduce readmissions. It was
initiated in response to the CMS mandate to reduce readmission or face a financial penalty. The group began in
the fall of 2011. The initial group was comprised of approximately 15 (fifteen) members and has grown to 45 as of
July 2014. This is a working group not a marketing based meeting. This is to change our community working
relationships, reduce readmissions and increase patient satisfaction outcomes.
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An initial meeting was held consisting of
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Two local community skilled nursing facilities administrators
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Local home health agency administrator
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Director Case Management
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Chief Nursing Officer
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Coronary Artery Disease Coordinator
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Director of Quality Support services
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Nursing Directors from ICU,ER and Medical Surgical Units
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Social Work Services
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Dietary Clinicians
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Director of Pharmacy
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Director of Respiratory Care
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Director of Rehabilitation Services
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NRPC So Cal Readmissions Update
October 16, 2014
Goals
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Each member of the group discussed the impact of readmissions to their
particular agency and the overall impact to the hospital.
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The goal of the first meeting was to set up oncoming monthly meetings to
formulate strategies, evaluate and analyze the readmission scores.
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The goal would be to establish a community network meeting to reduce
readmissions.
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Create and implement a community based supportive system that is united in
using an evidenced based approach to reducing readmissions to hospitals.
The initial focus is to decrease the rate of readmission of AMI, CHF and
Pneumonia.
Introduction
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The hospital created a community based coalition that meets monthly at the
hospital to improve transitions of care, reduce readmissions rates, share
readmission rates, level of care concerns and processes,
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LTACs, Home Health, Hospice, DME and other stakeholders in this transition of
care community approach.
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HISTORY OF READMISSIONS
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The hospital looked at readmissions each month and found 4(four) trends:
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Patients came back within 15 (fifteen) days.
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Patients did not have physician appointments, method to get to the appointment, or finances to get
their medications.
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Patients had left the SNF and were at home, felt poorly, called 911 and were brought to the Emergency
Department.
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This group quickly realized that patients and health care providers did not know the details of care,
indications, insurance coverage, restrictions, etc. of the other healthcare providers. The group was
comprised of entities working in silos without seeing the wholeness of the continuum of care with the
patient and family at the center. The group has developed, built trust and increased attendance and
members. They have created a patient clinical pamphlet that explains entities from SNF to DME and
hospice.
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After a readmission, we began to examine what happened in the patients’ life that we may have missed.
Education in the community for both patients and health care providers is paramount to becoming astute
in detecting and interceding in patient care to decrease readmissions.
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We began interviewing patients who were readmitted to determine what had caused their return to the
hospital:
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Change in Medical condition exacerbation of symptoms
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Medication management
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Lack of caregiver support /appropriate level of care
Components of Group
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The ongoing theme was to further analyze the readmission process and seek to
develop key focuses that would reduce the readmission rate.
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The CAD coordinator presented her role of specifically following any patient in
the hospital that had a diagnosis related to CHF, and cardiac disease.
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The hospital offered classes on site and in the community to patients and staff
from the local SNF’s, opened to the community through providing ongoing
classes to the community. These classes would provide education to the
community.
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The group set up agendas that are geared toward looking at the risk factors
that would pre-exempt an admission to the acute care facility.
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Evidence suggested that the patient was not aware of resources and levels of
care available nor did the acute care hospital know what each facility or
service post discharge could provide.
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Classes Offered
Sample of Classes (Available by e-mail)
Congestive Heart Failure
Congestive Heart Failure
Tests
Medications
Nutrition
Core Measures
Exercise Activity
Coping
Coronary Artery Disease
Coronary Artery Disease
Tests
Medications
Nutrition
Exercise and Activity
Coping after a Heart Attack
Core Measures and CAD
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Community Follow-Up
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Each service was to provide education at the community meeting to
educate the group on what services were provided.
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Members of the group were invited to ongoing educational sessions
via the web thru IHI (Institute for Healthcare Improvement).
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The group reviewed the high risk form which allowed provider to
anticipate the risk of readmission.
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Each organization was asked to prepare an outline of services
provided to their specific population.
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Agencies
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The Skilled Nursing Facility presented on what services were provided in the
facility.
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Home Health did a presentation on telemonitoring in the home.
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The outcome of these two presentations educated the group that there was a
lack of communication when transferring a patient to one level of care to
another.
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The next step was to set up a written and verbal report to key personal at the
next level of care to provide continuity for improved patient care (hand off
communication). To the SNF, exam the impact.
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The group examined the timeliness of arrival to the SNF and the impact and
risk of late admissions.
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Agencies
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Hospice presented on available services, criteria for admission and
the ability to evaluate the patient at all levels of care.
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The outcome of their presentation led to engaging a physician to
speak at the next monthly meeting on Palliative Care.
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Each month the group presented statistics on their readmission rates
in order to continue to evaluate what went wrong that required the
patient readmission.
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Developing a Brochure
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Evidence suggested that there were resources available to prevent the
readmission.
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A plan was made to develop a brochure that could be utilized to
educate all health care providers and patients and their families.
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Once completed this brochure was introduced to the community,
doctors offices and presented to HSAG as tool for best practice.
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Health Services Advisory Group
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A member of HSAG (Health Services Advisory Group) coalition was
asked to present information on the Long Beach coalition as we
served the outlying communities.
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The two groups began to interact to formulate continued efforts.
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One of the areas was to examine the patient arrival time to the SNF
suggesting that the later the patient arrived the more likely the patient
was at risk for readmission due to securing medications and starting
therapeutic measures such as rehabilitation therapy.
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Pharmacy Consultant
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A speaker from the SNF included a Pharmacy consultant who presented
on the effects of late arrivals and securing medications.
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LAMC also presented a brochure containing information for the patient
and family educating on all pharmaceutical issues.
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Involving The Community
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Two physicians participate in the group as well as the regional CMO.
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The CMO has presented information on readmissions and the impact
to the acute care facilities.
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The group also engaged a Home Health Care (HHC) medical director
to speak regarding his efforts to prevent readmissions . The physician
provided information on his interventions with the HHC agency. His
ability to go and see the patient at home rather than the patient being
sent to the ER.
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The main factor is lack of concrete support adds to the risk of
readmission. Noted is the patient and family need immediate attention
to resolve what appears to be their crisis and lack of a service to fix
the problem expressed.
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Readmission Case Management
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Hospital attended the Preventing Readmissions meeting at Torrance
Memorial Hospital.
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Their group has added a Preventing Readmission Case Manager who
is assigned to the ER.
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A speaker presented to incorporate the process at the hospital.
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Code 30 was initiated where the Case Manager would evaluate any
patient admitted to the ER within 30 days.
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Post Discharge Calls (for CHF)
Patient Name: ________________________
Date of call: __________________________
Name: _______________________
Good (morning, afternoon, evening), I am _________________________, a staff member from Los Alamitos Medical
Center and I’m calling to follow up on your stay with us and make sure all of your questions have been answered.
1. How have you been feeling?
2. Are you taking your medications as prescribed by your doctor?
3. Do you have any questions about your medications or side effects?
4. When is your follow-up doctor appointment?
5. Has Home Health come to see you?
Follow up Item Re #1:
6. Are you on home oxygen? ____________________________________________________
7. Do you have a breathing machine? ______________________________________________
8. Are you doing the treatments? _________________________________________________
9. Any problems with the equipment or doing the medications? _________________________
10. Do you use an inhaler? ________________________________________________________
11. When do you see the specialist? ________________________________________________
12. Are there any other questions you have or do you need any other assistance or information?”
___________________________________________________________________________
13. How are you sleeping at night? _________________________________________________
Comments: _______________________________________________________________________________________
Pt. Account #: ____________________________
D/C Date: ____________________________________________
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Successes
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Recent admission from the ER to the SNF.
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Patient placed in SNF from HHC.
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Overall readmissions scores reduced.
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A weekly meeting has been established at LAMC to monitor readmissions from
week to week and will be presented to the monthly group focusing on the root
cause analysis of the patient readmission.
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Next Step: Focus on the Pneumonia Readmissions – Follow Up Calls
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Evaluate the SNF ability to provide higher levels of care related to IV Lasix , IV
solumedrol.
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Providing an education program to the SNF by the Respiratory Department.
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Components of Mini-RCA
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Chief Complaint
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Reason for initial admission and reason for readmission.
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Time of day for readmission, day of week
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What services were in place prior to readmission – LTAC, SNF,
HH, Transition Coach, Telephonic Care, Area Agency on Aging,
community services
• Include reports from these providers as appropriate
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Who was contacted/involved prior to the call to the MD?
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Did you follow a protocol, if so which one?
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What interventions were provided prior to sending to the ED?
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Components of Mini-RCA (Cont)
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Did you use an SBAR with the MD?
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What specifically happened prior to patient coming to the hospital?
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Was it a 911 call?
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Was PCP follow-up visit completed prior to the readmission? If
yes, # days post initial hospital DC.
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Med reconciliation, discrepancies, Rx filled.
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What support person does the patient have. Does the family
understand the needs of the patient?
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Did you ascertain the wishes of the patient at the time, palliative
care discussion/consult?
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Components of Min-RCA (Cont.)
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Code status
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Is patient appropriate to return to the prior level of care? Is a
higher level of care indicated?
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Was readmission avoidable. If yes, what are recommended actions
to prevent this in the future?
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READMISSION DATA
Diagnosis
Target
Jan
Feb
Apr
May
June
July
Aug
YTD
AMI
11.00%
14.286%
0.00%
14.286%
10.00%
6.667%
12.50%
20.00%
9.09%
HF
16.00%
6.67%
20.00%
17.391%
27.273%
25.0%
21.053%
16.667%
15.1%
PN
11.00%
18.00%
11.111%
7.692%
0.00%
6.061%
7.407%
9.091%
13.4%
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What Have We Accomplished
Major result has been the interface with multiple community organizations
which has resulted in the primary focus of reduced readmissions goals
•CHF Teaching – Community Outreach: SNFS – Interdisciplinary approach
•Pharmacy Interventions – In-house – Outpatient
•Rehabilitation – Choosing the correct level of care.
•Respiratory programs” Community Outreach – SNFS – interdisciplinary
approach
•Education – Levels of Care
•LTAC
•Acute Rehabilitation
•SNFs
•Home Health Care
•Physicians
•Durable Medical Equipment
•Financial – Medi-Cal
•Hospice
•Palliative Care
•What we have learned and the results
•Participate in TRAC Team
•Code 30 (Forms on Educational Table) – Developed by Fountain Valley
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CONCLUSIONS
Improvements
Next Steps
Address the new two added diagnosis
COPD
Orthopedic
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Josh Luke, Ph.D., FACHE
Founder, The National Readmission
Prevention Collaborative
Contact: [email protected]
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NRPC So Cal Readmissions Update
October 16, 2014