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Hunterdon Medical Center's experience in reducing readmissions, including patient education, partnering with post-acute providers, and care coordination across the continuum.
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Readmissions Experience Hunterdon Medical Center CMO Roundtable October 2014
Background • Hunterdon Medical Center is a 176 bed hospital in west-central New Jersey • It is part of Hunterdon Healthcare, which also includes Hunterdon Regional Community Health (home care, visiting nurse, and hospice) and Mid-Jersey (for profit arm) • Hunterdon Healthcare partnered with the Hunterdon Physician Practice Association, an IPA, to form Hunterdon HealthCare Partners
Background • Readmissions Committee work began in 2011 in anticipation of CMS penalties to begin in fiscal 2012 • Focused on CHF first as we had the highest rate out of the three • First looked at patient education
Patient Education • Created forms for nursing to document education during the inpatient stay • Used a “stop light” system for patient self-assessment after discharge • Tried to institute a discharge “test” for teach-back
Why Are Patients Readmitted • We had our patient care managers complete a short questionnaire with readmitted patients • Did the questionnaire with 50 patients • Did not see any real trends
CHF Study • Conclusions • 37% of these patients left HMC without an appointment to see their doctor on the first admission • 16% of these patients left HMC without an appointment to see their doctor on the second admission • 60% of these patients were 81 years of age or older • 64% of these patients were discharged to home
Partnering with Post-Acute Providers • Post Acute Providers were added to the Committee • INTERACT II (Interventions to Reduce Acute Care Transfers) Program introduced at one nursing home • Program to identify early changes in resident status that could lead to hospitalization • Tools available through http://interact2.net/
Expansion of the Committee Role • In September 2012, the Committee decided to look globally at readmissions and to look at processes around readmissions including: • Discharge checklists • Transfer of Information • Medication Reconciliation
Risk Stratification • We beta tested a program called Crimson RealTime from the Advisory Board Company • Using historical billing data, the software was designed to: • Identify patients at high risk via a proprietary algorithm • Identify CHF, Pneumonia, MI patients
Care Co-ordination Across the Continuum • Set up a meeting with our inpatient Patient Care Managers and our Care Coordinators in the primary care offices • Had them exchange phone numbers • The Care Coordinators are informed when a high risk patient is admitted and when they are discharged
Exchange of Information • At discharge, the unit coordinator will fax (don’t judge me) the discharge medication reconciliation and the discharge instructions to the PCP office (we are looking into a scan/e-mail system) • It is an expectation that discharge summaries are dictated at the time of discharge—our hospitalists have this built into their bonus calculation
Follow-up • Through our IDS, we created an expectation that high risk patients have a follow up appointment within 3 business days and moderate risk patients within one week • We have not been universally successful in getting f/u appointments made prior to the patient leaving the building
Follow-up • Our Clinical Nurse Leaders make phone calls 1-2 days after discharge and ask whether patients have their post-acute appointments made and whether they have filled their discharge prescriptions • Care Coordinators will also reach out in a similar manner
Other Factors • Our Home Health Company has invested in 20 telehealth monitors for CHF patients • We have had our word processing department “push” discharge summaries out to the PCP of record
Next Steps • Getting our inpatient EHR (Quadramed QCPR) to talk to our outpatient system (NextGen), especially regarding medications, and medical documentation • Continue to improve our patient education functions • Continue to improve communication between Hospitalist and PCP • Filling discharge prescriptions in outpatient pharmacy • Greater acceptance of Palliative Care and Hospice services by both physicians and families
