A Model to Reduce Acute Care Readmissions

Susan Weber, RN Chief Nursing Officer Angela Venditte, LPN, CMCO Assurance HealthCare

“In God we trust, all others bring data”

Found in The Elements of Statistical Learning by Trevor Hastie, Robert Tibshirani and Jerome Friedman

» Identify sources of data ˃ HSAG o No Place Like Home ˃ ˃ ˃ CASPER Reports Home Health Compare Agency Database/EHR

» » The Centers for Medicare and Medicaid Services (CMS) defines a readmission as “an admission to a subsection(d) hospital within 30 days of a discharge from the same or another subsection(d) hospital” Subsection (d) hospitals are hospitals that are paid under the hospital inpatient prospective payment system (IPPS) and are located in one of the 50 states or the District of Columbia

» Roughly 1 of every 6 Medicare beneficiaries hospitalized are readmitted within 30 days of the discharge. » Effective care coordination and transitions can help to integrate care and prevent the situations that give rise to avoidable hospital admissions and readmissions.

» » Know your re-admission rates Monitor and update the numbers regularly » Is the data flawed?

˃ Unreliable ˃ Out of Date ˃ Moving Target » » All Data is not Equal ˃ Sample Size ˃ Payor Mix How do we measure ourselves?

» The goal is to develop an educational program that provides accurate and clear information, and user-friendly tools to promote employee compliance » Staff Education ˃ Publicly Reported and Internally Measured Re-Admissions Data ˃ ˃ ˃ Develop Understanding of Continuing Care Concepts Convey the Vision Specific Topics: o Post Discharge Care Planning o Assessment and Management of Risk for Re-Hospitalization o Improvement of Communication and Collaboration between disciplines > Continuing Care Processes

» » » » Initial training focuses on core principles and rationale related to the overall program.

Individual learning styles assessed and training altered for small group and individual sessions.

Effective team functioning addressed at each training session.

Monthly education meetings.

» » Pre-Discharge Activities ˃ Consider a hospital visit with patient and/or family ˃ Educate the patient on self-care ˃ Planning for post-discharge needs Communication with the discharge planner

» » » » » » Review: ˃ Discharge summary ˃ Discharge instructions ˃ In-patient records Assessment of patient problems and needs Medication Reconciliation ˃ Identify and address discrepancies ˃ Cannot be over-emphasized!

Communication with the physician Develop the plan of care incorporating Best Practice interventions Checking on or scheduling follow-up appointments

» » The environment of case conference shifts from one of exchange of information to a focus on managing the patient’s re-hospitalization risk.

˃ patient status ˃ rehab potential ˃ ˃ re-hospitalization risk possible adjustments to the plan of care Review of Best Practice Guidelines, Zone Tool (Green, Yellow, Red) and teaching tools

» Patient invited to participate in Continuing Care Program with the following goals: ˃ Designed to help patients manage their transition from the hospital to home ˃ Providing patients with tools to better manage their health care ˃ Increasing overall satisfaction with the transition from hospital to home ˃ Reducing emergency department visits and hospital readmissions

» » Each patient works with a Health Care Coach with the following benefits: ˃ Creation of a personal health care record to improve communication between patient, doctor and other providers ˃ Identify Red Flags and advise actions to take ˃ Medication reconciliation and assistance with questions/concerns A Health Care Coach is available at all times, including after hours, and makes scheduled, scripted calls to the patient during the 30 days following hospital discharge.

» » » » Hospital Readmission Risk Assessment Tool Zone Tool ˃ Green Zone: All Clear ˃ Yellow Zone: Caution ˃ Red Zone: Medical Alert Disease specific Best Practice measures and interventions Disease specific risk assessment tools

» » » » » » » Discharge Preparation Checklist My Personal Health Record Personalized Emergency Plan including Care Team contact information “Call Me First” Guidance Tool Personal Goal Setting Medication Schedule Disease specific teaching sheets

» Patient » Family / Caregiver(s) » Physician » Non-Physician Provider(s) » Home Health Agency Staff

Put everyone in the company to work to accomplish the task at hand. Reducing readmissions is everybody's job.

“It is not enough to do your best; you must know what to do, and then do your best” -- William Edwards Deming