Transitions in Care aka Reducing Readmissions

1. Transitions in CareakaReducing Readmissions Shawnee Mission Medical Center Kim Fuller, MSW, MBA, CCE Janet Ahlstrom, MSN, ACNS-BC

2. Shawnee Mission Medical Center

3. Preventing Re-hospitalization within 30 days Selected populations: Congestive Heart Failure Pneumonia Acute Myocardial Infarction (AMI)

4. Our Journey • IHI Collaborative on Reducing Readmissions in 2009/2010. • Developed multidisciplinary internal team to participate in the Collaborative and to begin designing program. • Did chart reviews of readmissions to assess patterns, failure points, potential interventions and conducted tests of change. • Discovered many readmissions coming back from SNF’s, so invited key partners to join Collaborative.

5. Journey continued…. • Split internal team and external community partner group into separate meetings. • Justified initial addition of an FTE by quantifying potential cost to the bottom line following implementation of CMS penalties. • Hired .5 MSW and .5RN and Transition Coach role fully implemented in August, 2011.

6. SMMC Program4 main focus areas • Enhanced Admission Assessment for Post Hospital Needs • Effective Teaching and Enhanced Learning • Real – time Patient and Family Centered Handoff Communication • Post-Hospital Care Follow Up

7. Internal Team • Membership includes: • Nursing representation from cohort areas for CHF, AMI and Pneumonia. • Pharmacy • Social Work/Utilization Review • Ask a Nurse Call Center • SMMC Home Health • Cardio-Vascular Services • Nursing Education

8. External Team • Membership includes • Home health • Skilled nursing facilities • Assisted Living Facilities • Hospice • Private Duty • LTAC • Emergency Medical Response

9. External team focus • Case studies of readmissions from various facilities, identifying breakdowns and creating new processes. • Education re: disease specific protocols provided to SNF’s. i.e. importance of daily weights and use of the zone chart for CHF patients. • Development of common hand off tool that meets needs of hospital and external agencies. • Strategies to increase involvement of palliative care and hospice when appropriate.

10. External team focus • Education about national movement toward use of Transportable Physician orders for End of Life treatment wishes. • Development of special interest sub-committees to concentrate and problem solve issues that are unique to different settings. • Trend readmission data specific to various agencies/facilities to use in forming stronger community partners with those that have lower readmission rates.

11. Transitions In Care Shawnee Mission Medical Center Melanie Davis-Hale, LMSW Cathy Lauridsen, RN, BSN

12. Transition Coach • 0.5 Social Worker/ 0.5 RN • Identify high risk patients in hospital • Initiate individualized program • Follow for 30 – 45 days regardless of setting • Facilitate smooth TRANSITIONS • Early intervention with any readmissions • Meet weekly with physician champions at SMMC • Provide education for patients and healthcare team partners

13. Identifying High Risk Patients • Currently utilizing the Better Outcomes for Older adults through Safe Transitions (BOOST) Tool • Collaborative Care Team (CCT) process at SMMC • Chart review of Electronic Medical Record

14. Boost Tool 8P screening tool: • Problem Medications –(anticoag, insulin, aspirin, digoxin) • Punk (depression) - screen positive or diagnosis • Principle diagnosis – COPD, cancer, stroke, DM, heart failure • Polypharmacy - >5 or more routine meds • Poor health literacy - inability to do teachback • Patient Support – support for d/c and home care • Prior Hospitalization - non-elective in last 6 months • Palliative Care – pt has an advanced or progressive serious illness

15. Pre and Post Hospital Care and Follow Up • Initial contact with patients/family during the hospitalization. • Schedule follow-up PCP/Specialist appointment prior to hospital discharge. • Follow patient across all levels of care for up to 45 days post discharge. • Phone/in person home visits. • Continually assess patient needs post discharge.

16. Four patient centered elements for Teachback • Medication management • Follow up with PCP/Specialist • Patient centered record • Knowledge of Red flags and how to respond

17. Strategies for Success • Develop a relationship with patient and/or family prior to hospital discharge • Identifying patients’ healthcare goals • Matching patients to Social Worker or RN based on patient needs • Social Worker • Financial needs • Psycho-Social needs • Community resources • RN • Patient/Family/Caregiver Education • Facility/Service Provider Education • Symptom management

18. Strategies for success • Interventions to prevent readmission based on patients’ discharge plan • Patient Discharges to SNF/LTAC/Acute Rehab • Visit/phone call to patient, patient’s nurse, social worker, PT/OT, Medical Director. • Ensure patient has seen Medical Director within 72 hours • Identify medication issues/concerns/changes and other areas of symptom management. • Awareness of patient discharge plan from facility • Maintain communication with patient’s PCP/specialist • Prepare patient for transition to lower level of care/home

19. Strategies for Success • Patient Discharges to Home with Home Health • Collaborate with Home Health Agency/Case Manager to develop care plan to prevent readmission • Ensure patient attends follow-up PCP/specialist appointment • Patient Discharged to Home • Continue post-discharge education to patient/family/caregiver • Identify medications issues/concerns • Identify and referred to needed services • Encourage self-management when possible

20. Challenges • Identifying patients that will code out as CHF, Pneumonia, AMI • Continually educating service providers on role of transition coach • End of life issues

21. Program Results

22. Program Results

23. Program results

24. Program results

25. Program Results

26. Program Results

27. Contact Information • Kim Fuller • 913-676-2293 • Kim.fuller@shawneemission.org • Janet Ahlstrom • 913-676-2032 • Janet.ahlstrom@shawneemission.org • Cathy Lauridsen • 913-676-8611 • Catherine.lauridsen@shawneemission.org • Melanie Davis-Hale • 913-676-2168 • melanie.davis-hale@shawneemission.org