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Safe Transitions North Memorial

Safe Transitions North Memorial. Using Society of Hospital Medicine’s BOOST Toolkit To Improve Patient & Family Engagement. 2010 NMR Data. Readmits w/in 30 days = 3,452 Unique Patients Readmitted = 2,249 Readmits w/in 72 hours = 654 ED visits w/in 30 days = 2, 273 ALOS 1 st visit = 4.13

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Safe Transitions North Memorial

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  1. Safe Transitions North Memorial Using Society of Hospital Medicine’s BOOST Toolkit To Improve Patient & Family Engagement

  2. 2010 NMR Data • Readmits w/in 30 days = 3,452 • Unique Patients Readmitted = 2,249 • Readmits w/in 72 hours = 654 • ED visits w/in 30 days = 2, 273 • ALOS 1st visit = 4.13 • ALOS 2nd Visit = 4.23

  3. Digging A little Deeper - CHF • 474 CHF patients • 574 Hospitalizations • 22% Home Health Referrals • 7% Seen by Cardiologists Within 7 days • 12% Seen by NM Primary Care Clinics Within 7 days

  4. Who Are Our Patients At Risk For Readmission? A6 Daily Report

  5. Patient and Family Engagement • White Boards • Serve as a communication tool. • Used by all disciplines and patient/family. • Helps care team and patient/family focus on goals.

  6. Patient and Family Engagement • Patient/Family Centered Rounds • Identification of high risk patients • Rounding script used to develop plan for hospitalization and safe transition to home.

  7. Follow-Up Appointments Teach Back & Patient Education Materials Medication Reconciliation Home Health Phone Call 24-48 hours post discharge Palliative Care Optimization Family Care Conferences Patient and Family Engagement

  8. Teach Back & Patient Education • Patient Education At Bedside • RN conducting education rather than nurse educator • Teach Back added as methodology for patient educational assessment • Teach Back regarding medications & discharge instructions • CHF Binder used during Teach Back and to build redundancy between hospital and clinic

  9. Key Learnings • Follow up appointment compliance in 7 days tripled by assisting in coordinating appointments • Need the same tool for risk stratification across system • Need system staffing model to support care coordination across enterprise • Need community to help in preventing hospitalizations • Need to "un-teach" how to conduct Teach Back • Need learning environment to help support change effort

  10. Questions?? • John Degelau, MD • John.Degelau@northmemorial.com • Sonne Rivers, BSN, MA • Sonja.Rivers@northmemorial.com • Society of Hospital Medicine • http://www.hospitalmedicine.org

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