Breakout A : Ensuring Post-Hospital Care Follow-up

1. Breakout A: Ensuring Post-Hospital Care Follow-up Saint Anne’s Hospital

2. A Catholic Community Hospital – Saint Anne’s Hospital • 160 beds including 16-bed geriatric psychiatry unit with medical, surgical, oncology and pediatric units • No maternity unit • Multiple satellite outpatient services Founded in 1906 by the Dominican Sisters of the Presentation

3. Service Area Legend Primary Service Area Secondary Service Area Extended Service Area

4. Community Health StatusGreater Fall River Area • Highest incidence rate for cardiac disease in the state of Massachusetts • 24% higher incidence rate for coronary heart disease • Highest prevalence for diabetes in the state • 42.26 per 1000 persons • USA average is 34.1 per 1000 • Diabetes incidence has risen 49% since 1990.

5. Community Health StatusGreater Fall River Area As compared to state average: • Higher concentration of area residents with risk factors for developing heart disease, cancer, and diabetes including: • 30% higher rates for smoking • Higher obesity rates: 28.0% vs. 25.8 % state • Higher cholesterol: 36.8% vs. 28.3% state • High blood pressure: 29.2% vs. 21.6% state

6. Community Demographics • Median household income for Fall River • $33,124 vs. $64,081state (2009) • Nearly 1 in 5 families with children live below the official poverty level in Fall River. • Only 25% of Fall River residents have obtained a high school diploma. • Higher than state avg. of residents over age 65 • 13.2% Unemployment in Fall River (Sept. 2011) MASS state unemployment average 7.4%

7. Community DemographicsCity of Fall River • Fall River has been an economically disadvantaged city for many years after mass closings of the it’s textile mills. • It is a federally designated medically underserved area. • Violent crime has been on the rise accompanied by increasing drug use, notably heroin. • Largest Portuguese American population in the US between 43-49% depending on data source. • Hispanic American: 7.5% in 2010, up from 4.0% 2009 • African American: 4.0% in 2010, up from 2.5% 2009 • Asian American: 2.5%, in 2010, up from 2.2% 2009 World-class community health care where you live

8. Cross-Continuum Team Members • Ann Archibald RN CRNI, Director Clinical Operations & NE Infusion Resource Nurse, Genesis Healthcare • Carole Billington MSN, RN, NEA-BC Vice President Patient Care Services, Chief Nursing Officer, SAH • Debbie Costello RN, BSN, MSM, Vice President Quality & Safety, Steward Home Care • Mary N. Dana MSW, LICSW, Supervisor Case Management, SAH • Nicole Decoffe, Clinical Liaison, Kindred Healthcare • Lisa DeMello MSN, RN, ACNS-BC, Clinical Educator/Stroke Coordinator, SAH • Andrew Dousa RPh, Pharmacy Director, SAH • Erika Sundrud MA, System Director of Performance Improvement, Steward Health Care • Katherine Librera, Clinical Admission Director, Genesis Healthcare • Robin Lynch MS, RN, CAGS, CPHQ, Director of Quality and Patient Safety, SAH • Erin McGough RN, CCM, Director of Case Management, SAH • Theresa Moss MSN RN, Clinical Leader, Telemetry, SAH • John Arcuri,MD, Medical Director and Chief, Department of Emergency Medicine, SAH • Saira Nisar MD, Hospitalist, SAH • Robin Pelletier BSN, RN, CHPN, Director, Hospice and Palliative Care, Steward Home Care • Donna Rebello BSN, RN, OCN, Director St. Mary’s and St. Dominic's, SAH • Lisa Shea MSN, RN, Patient Care Director, SAH • Andrea Hodge, BSN, RN, ED Case Manager, SAH

9. Gina Gough, Supervisor, Rehab Department, SAH Jennifer Davis, Catholic Memorial Linda Perry RN, Nursing Informatics Manager, SAH Nancy Cooper RN, Nurse Liasion Steward HomeCare Susan Jamieson, VP of Integrated Services Susan Oldrid VP, Mission of Community Relations, SAH Terence McGovern, Pulmonologist Teresa Ferriera NP, Steward Christine G. Leeman MS, RN, CCM, Patient Care Coordinator, PrimaCARE Tina Whitney BSN, RN, CCM, Director of Case Management, Steward Network Services Lisa Souza, Wellness Director, Landmark Assisted Living Barbara Wales RN, Health Service Manager, Bristol Elder Care Maureen Bannan, VP of Clinical Service Steward Michael Spearin, Kindred Health Care Sheila Duval, Southpoint Skilled Nursing and Rehab Stephanie Weir RN, Steward Physician Group Tracy Faris, Kindred Health Care Cynthia A. Anderson BSN, RN, Director, ICU and Telemetry, SAH Lena Gomes RN, CMSRN, Clinical Leader, St. Mary’s, SAH Edwina Cummings, Patient representative Shannon Hebda, Director of Community Supports, People Incorporated, Patient and Family Advisory Committee Member Cross-Continuum Team Members (Continued)

10. Identified Opportunities from Our Starting Point • Accuracy of Home Medication List • Under utilization of Telehealth Resource • Lack of person to person hand off transition to Home Care • Availability/Capacity for follow-up appointments • Home Care Psychiatric Nurse • Family (care giver) education • End of life discussions with patients and families • Social Disparities (transportation, poverty, housing, education level, substance abuse etc.) • Knowledge Gap – related to Community Resources

11. Year of the Family • Identify Partner in Care at time of admission • Include Partner in care in discharge planning, instructions/education, pharmacist visit, follow up phone call • Color coded one page Zone Discharge Instruction sheets

12. Follow up Appointments • Attempts made to schedule follow up appointments prior to discharge on all 30-day readmits • Patients decline staff scheduling of appointments related to transportation issues and family members work schedules • Verification of follow up appointments made by patients independently done at time of discharge • Staff report greater success scheduling timely appointments when made prior to discharge • Barriers include late and weekend discharges. During initiation, attempts were made to make all appointments for all discharges. These efforts were unsuccessful related to volume and time required.

13. Discharge Phone Calls • All patients are called within 72 hours of discharge • If unable to reach on first attempt a second attempt is made the following day • Family present during the discharge call are encouraged to ask questions • Topics reviewed include: discharge medications, diet, follow up appointments, reportable signs and symptoms and any questions patient has • All calls are made by a Registered Nurse

14. Handover Communication • Implemented communication template to promote standardized approach (SBAR) • Nurse to nurse verbal report for all patients discharged to SNF • Nurse to nurse verbal report for all patients discharged to Steward Home Care

15. Financial Counseling • All self pay and underinsured are assessed by a financial counselor the day of admission or following business day • Patients are assessed for all public programs and eligibility for private insurance • Patients are assisted in navigating the process through to determination • Patient Advocate is available to all community members to screen for eligibility and assist with navigating the process

16. Inpatient Pharmacist Visit/ Medication Consult Goal • Provide medication education to patients considered high-risk for re-admission within 30 days of discharge, in an attempt to prevent re-admission due to lack of understanding of medication instructions once discharged. Process • Once a high-risk has been identified, the case manager assesses the patient and determines if patient needs, or is interested in, a medication consultation. • Eligible patient names are sent to pharmacy, who visits patient in their room and provides education to them and preferably a family member or caregiver as well. • The consultation is geared towards determining if the patient understands their medications, how to take them, and also compares meds upon last discharge to current admission. Discrepancies, if thought to be unintentional, are brought to the attention of the physician. • All consultations are documented in the progress notes, with recommendations for that particular patient’s discharge instructions to help them better understand them. • You’d be surprised what a patient tells a pharmacist, and not their physician!

17. Steward Healthy Transitions A 30-day program post-discharge for high risk Medicare patients with a diagnosis of Heart Failure, Myocardial Infarction and Pneumonia Service provides • A thorough medication review and optimization with a Clinical Pharmacist in the patients home within 2 days of discharge, and ongoing telephonic support for 30 days • Patient and caregiver disease state/medication education • Special attention to adherence issues and medication organization • Ensure patients are prepared for and attend their physician follow up visit • Patient and caregiver health coaching on self management of chronic illnesses. • Evaluation of falls risk and home safety risks for readmission.

18. Steward Home Care & Palliative Care • Palliative Care Team • COPD & HF team • Telehealth • Home Care Psychiatric Nurse • Teach Back

19. Post Acute Collaborative Team (PACT) • What is PACT? • Compliment to Cross Continuum Team • Objectives • Members • How PACT has improved communication, care transitions and reduction in re-admissions • Case reviews indentify causes for readmission

20. Resource Manual for ED • Clinical capabilities provided by area skilled nursing facilities. • Three resource books provided to ED listing clinical capabilities for each facility. Resource books are kept in physician and nurse areas for ease of access. • Overview of site capabilities and new medication turn around time provided

21. Saint Anne's Hospital30 Day Readmissions (All Cause)

22. Saint Anne's Hospital 30 Day Readmissions (All Cause)Heart Failure

23. Saint Anne's Hospital30 Day Readmissions (All Cause)Pneumonia

24. Saint Anne's Hospital30 Day Readmissions (All Cause)Acute Myocardial Infarction

25. Saint Anne's Hospital30 Day Readmissions (All Cause)Chronic Obstructive Pulmonary DisorderMS DRG 190,191,192

26. Next Steps Spiritual Care Parish Nurses High Risk identification algorithm Spread beyond Pilot Unit and population Address barriers to follow-up appointment Electronic integration of enhanced admission assessment Hospitalist ↔ PCP Communication Community Health Volunteers