Transcript Introduction

Introduction
The Readmission and Transition of Care teams at Scott & White Hospital –
Brenham combined in an effort to develop, in the absence of a Case
Management Model, a process aimed at optimizing care coordination through
collaboration with outside facilities, community resources, and physicians.
Three high-risk patient populations were identified through data analysis:
- Elderly long-term care facility patients
- Clients of the State Supported Living Center
- Patients without a Primary Care Provider
Opportunities for avoiding readmission:
- Improving patient history and medication reconciliation upon admission
- Improving coordination of care during admission and upon discharge
- Improving timely follow-up appointments
Methods
1) Participated in Scott & White Healthcare system meetings and
used evidenced based practice and current research to provide
a basis for understanding the timeframe of admissions,
validating data analysis findings and determining future state.
Research tells us that the likelihood of readmission
occurs if the patient:
1) Is readmitted within
7 days or < - Incomplete Medical Management; Wrong Site of post-acute care
<14 days – 20 days – Medication Problems; Socioeconomic Factors, Physician follow-up
<20 days – 30 days – Patient non-compliance; Disease trajectory;
2) Has multiple visits to the ED, and
3) Physician f/u occurs > 5 days following discharge
Methods
Data Analysis
Identification of Primary Care Physician
(Numerator = number of admit/readmit core measure
patients (Pneumonia, CHF, MI) seen in the ED at least
once during previous 6 months prior to
admission/Denominator = number of patients admitted
with core measure diagnosis)
(Numerator = number of admits with no PCP (stated by
patient and/or not listed)/Denominator = number of
patient admits during two week audit)
No prior ED
visit
ED visit at least
once
Based on 2 week audit during the months of February, April, May,
and August, 2012
8%
16%
38%
ED visit >3
30%
54%
84%
70%
March – October 13, 2012
Patients with PCP
Patients with > 5 day f/u discharge orders
Patients with < 5 day f/u discharge orders
Patients w/o PCP
Results
2) Revised Medication Reconciliation process – Home
Medication list for Outpatient departments – full medication
reconciliation of Inpatient admits – based on revised
regulatory requirements.
3) Developed Patient Assessment for Subsequent (Re)admission
form (adapted from htttp://www.ohri.ca., March 1, 2010) – used to
identify readmissions and/or those patients at high risk for
readmission – focusing on CHF, Pneumonia and MI diagnosis;
Social Worker and Utilization Review nurse, as part of the
internal collaboration process provide information related to
current length of stay and identify those patients who may be
high risk for readmission and if the patient is a readmit, what
occurred to bring them back to the hospital.
Results
4) Implemented daily admission audits identifying “real-time”
readmissions; readmit cases discussed at Physician Case
review, often while patient is still hospitalized.
Results
5) Identified ways to increase utilization of community resources
including the Washington County Community Clinic and Scott &
White Primary Care physician group.
Washington County Community Clinic
Inpatient f/u
8
Inpatients with no PCP – referred to S&W
Primary Care
30
25
20
15
10
5
0
6
4
2
0
Number of
Patients referred
Number of
Patients seen
No shows
Number of Number of
patients appointments
screened
made
Patient
refused
Dec, 2012 - March, 2013
Sept – Oct, 2012/Jan – Feb, 2013
Patient
decided to
see another
physician
Other
(Hospice,
Long-term
care)
20
In 2012, the Community Clinic provided f/u care for 65
patients referred from the Emergency Department; In January
– February, 2013, 10 patients have been seen – March 2012,
implemented process for formal, written referral to
Community Clinic provider via ExitCare (ED discharge
instructions).
(Data provided by Washington County Community Clinic)
15
10
5
0
Number of
appontments
made
Number of
patients seen
No shows
Results
6) Collaborative monthly “open dialogue” meetings with the State
Supported Living Center and Long-term care facilities resulting in
development of trust and determination of mutual goals;
coordinated through Quality Department and community facility
Administration.
- Meetings cancelled if key decision makers are not able to attend
- Hospital membership ad hoc based on agenda topics
- Smaller groups vs. larger groups
- Hospital flexes internal schedules to accommodate facility time constraints – rotating
meeting facility – breakfast meetings
- Developed understanding of regulatory requirements of each facility – different for all
•
•
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Decreased surgery cancellations due to inadequate prep
Decreased cancellation of EEG tests – implementation of testing coordinator
Identification of need to provide clients with “personal likes” when coming to
hospital – reducing agitation during wait time
Conclusions
As a result of this initiative, physicians and staff have an increased awareness of readmissions
at Scott & White Hospital - Brenham. High-risk patients are being identified in a more timely
manner and appropriate discharge plans initiated. Open communication and collaboration
between community facilities is positively impacting patient safety through a willingness to
understand what is required of each facility to meet the needs of their patients/clients and
openly discuss opportunities in an effort to improve the care and safety of the patients/clients
served in this community.
SCOTT & WHITE HOSPITAL BRENHAM
PEPPERresources.org
Future Plans
•
Development of Transition of Care Coordination within next 6 months –
Hospitalist’s piloting program on patients under their care
•
Implementation of bedside care coordination upon admission and
discharge – possible liaison for long-term care facilities
•
Determine options for including trained Care Coordinators into Transition
of Care model
•
Evaluate Transition of Care Coordination of Hospitalist pilot program
determining expansion timeline and next steps
•
Continue collaborative meetings with community facilities
•
Evaluate for potential increase in Community Clinic resources
2010 – Scott & White Healthcare System assumed
ownership of Trinity Medical Center. The name was
changed to Scott & White Hospital – Brenham;
Serve Seven County Area:
Washington, Grimes, Austin, Brazos, Burleson, Lee, Waller
•
Level III Trauma Center and designated as Advance (Level III) Stroke Center – May 2012
•
Received the Texas Healthcare Quality Improvement Silver Award for improving
performance on national quality measures and achieving improvement on Core Measures
and HCAHPS – May 2012
•
Recognized September 19, 2012, as a Top Performer on Key Quality Measures as one of top
18% of Joint Commission accredited hospital that report core measures for the calendar year
2011.
•
218 respondents participated in the 2012 CULTURE OF SAFETY SURVEY– Texas Center for
Quality & Patient Safety “Partnership for Patients Program” identifying Management Support
for Patient Safety, Teamwork within Units, Supervisor/Manager Expectations & Actions
Promote Patient Safety and Patient Safety Grade with a score of 80% or higher
•
2012 Triennial Survey - the Administrative Surveyor recognized significant growth in creating
of a “Culture of Safety”.