Reducing Readmissions

1. Reducing Readmissions Cheryl Ruble, MS, RN, CNS Montana Regional Meetings Glendive Medical Center Glendive, MT

2. Your Improvement Opportunity • Do you know what your readmission rates are? Overall? For specific clinical conditions? • Compared to other hospitals in your area, state, national? Should you compare to others or just yourself? • What’s possible?

3. Aim Statement • Reduce overall readmissions by 20% from the 2010 baseline by December 31, 2012 • By end of 2013, reduce readmissions for heart failure by 30%.

4. Outcome Measure All cause readmissions within 30 days

5. Process Measure All cause readmission can include: • DC phone calls • Risk Assessment completed • Med-Rec completed on DC • Percent of patients with complete, customized after care plan • Percent patients with completed DC education

6. Outcome Measure Heart failure patients – readmission within 30 days, all cause

7. Readmission Reduction Drivers

8. AIM Secondary Driver Primary Driver

9. Driver: Identify high risk patients

10. Risk Stratify: Identify High Risk Patients and Communicate to all Providers Nielsen GA, Rutherford P, Taylor J. How-to Guide: Creating an Ideal Transition Home. Cambridge, MA: Institute for Healthcare Improvement; 2009. Available at http://www.ihi.org.

11. Risk Assessment • Use a validated readmission risk assessment tool • Select an easy to implement risk assessment

12. Assessing Patient Risk Project Red Risk Factors • Depressive symptoms • Limited health literacy • Frequent hospital admissions • Unstable housing • Substance abuse http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/TARGET.pdf

13. Risk Stratification • Low risk – normal process • Moderate risk – enhanced hospital process • High risk – enhanced hospital process + community intervention

14. Assessing Patient Risk Project BOOST 8P Screening Tool • Problem medications • Psychological • Principal diagnosis • Polypharmacy • Poor health literacy • Patient support • Prior hospitalization • Palliative care http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/TARGET_screen_v22.pdf

15. Driver: Self-Management Skills Patient self management as goal

16. Primary Driver: Self Management Skills • Assess patient / caregiver knowledge: of medications, symptoms, self-care strategies • Health literacy: Identify and address patient’s health literacy and activation level; use culturally appropriate training materials and clear written instructions using health literacy concepts • Teach-back: Use teach-back to validate understanding; use patient-centered, culturally sensitive educational tools

17. Medication Reconciliation • Medication reconciliation • Perform at a minimum on admission & discharge • List given to patient/care giver clearly identifies • For high risk patients, work with home health or other ambulatory providers

18. Medication Education Project RED – After Hospital Care Plan Example http://www.ahrq.gov/about/annualconf09/jack.htm

19. Assess Health Literacy Health literacy measurement tool, available in English and Spanish, from AHRQ

20. Red Flags for Low Literacy in Patients • Frequently missed appointments • Incomplete registration forms • Non-compliance with meds • Unable to name meds, explain purpose or dosing • Identifies pills by looking at them, not reading label • Unable to give coherent, sequential history • Ask few questions • Lack of follow through on tests or referrals

21. Strategies to Improve Patient Understanding • Focus on “need to know” & “need to do” • Use ‘Teach Back’ • Demonstrate/draw pictures • Use clearly written education materials • 5th grade level or below

22. 8 Tips for Clinicians • Use plain language • Limit info (2 – 4 points) • Be specific & concrete, not general • Demonstrate, draw pictures, use models • Repeat, summarize • Avoid Yes/No questions • Open ended questions • Teach Back • Be positive

23. Teach Back is…. • Asking patients to repeat in their own words what they need to know or do, in a non-shaming way. • Not a test of the patient, but of how well YOU explained a concept. • A chance to check for understanding and, if necessary, re-teach.

24. Teach Back Is… • Ensuring agreement & understanding • Critical to achieving adherence • Associated with improved patient engagement in their own care “I want to make sure I explained it correctly. Can you tell me in your own words how you understand the plan?”

25. Teach Back Examples • “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?” • “What will you tell your husband about the changes we made to your blood pressure medicine?” • “We’ve gone over a lot of information about getting more exercise in your day. In your own words tell me some of the ways you can get more exercise. How will you make it work at home?”

26. Teach Back Examples • “Can you tell me how you take each medicine?” • “When do you take these medicines?” • “Home much or how many do you take?”

27. “Show me how many pills you would take in 1 day.”

28. Teach-back • Teach-Back guide from Medicare Quality Improvement Organizations National Coordinating Center for the Integrating Care for Populations and Communities Aim (ICPCA) • Train clinical staff, use “I” statements

29. ASTHMA ZONESKnow your zone: Green, Yellow, or Red

30. COPD ZONESKnow your zone: Green, Yellow, or Red

31. DIABETES ZONESKnow Your Zones – Green, Yellow, or Red

32. PNEUMONIA ZONESKnow your zone: Green, Yellow, or Red

34. Resources • HRET’s Preventable Readmissions http://hret-hen.org/preventable-readmissions • State Action on Avoidable Rehospitalizations (STAAR) Initiative, http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidableRehospitalizationsSTAAR.htm • Project RED (Re-Engineered DC) http://www.bu.edu/fammed/projectred/index.htlm Brian Jack, MD • Project BOOST (Better Outcomes for Older adults through Safe Transitions) http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm Mark Williams, MD, FHM

35. Resources • Transitional Care Model http://www.transitionalcare.info Mary D. Naylor, PhD, RN, FAAN • Patient Activation Measure http://www.insigniahealth.com/solutions/patient-activation-measure • INTERACT II http://www.interact2.net/ • Hospital 2 Home sponsored by the American College of Cardiology and the Institute for Healthcare Improvement http://www.h2hquality.org/

36. Finding and Reducing ADEs Cheryl Ruble, MS, RN, CNS Montana Regional Meetings – Barrett Memorial Hospital Dillion, MT

38. What is an ADE?

39. What is an ADE? • Any injury resulting from medical careinvolving medication use. AHRQ

40. But be careful….. • The occurrence of an ADE does not necessarily indicate an error or poor quality of care AHRQ

41. What is a Medication Error?

42. What is a Medication Error? • Any error occurring in the medication use process ISMP

43. So how is an ADE and a Med Error Different?

44. Well what is An ADR? WHO: “Any response to a drug which is noxious and unintended, and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiological function.”

45. All ADRs are ADEs • All ADEs are not necessarily ADRs All ADEs ADRs

46. So how is an ADE and a Med Error Different? ADE BOTH Med Error Adverse Drug Event Medication Error

47. Why do we care? • Harm and Death >770,000 patients per year • Costs Up to $5.6M per hospital annually Up to $32,000 per patient AHRQ

48. So what is an ADE again? • Any injury resulting from medical care involving medication use. AHRQ

49. What do they look like?

50. What do they look like?