Transitioning Care

1. Transitioning Care Matthew Schreiber MD Chief Medical Officer Piedmont Hospital

2. What Ails Medicine Today • Uncontrolled and Unsustainable Costs • Unplanned Re-hospitalizations cost Medicare $17 – 20 Billion per Year • Inadequate Outcomes • Approx 1 in 5 General Medicine patients are readmitted within 2 weeks of discharge • Work-Force Shortage and Intense Dissatisfaction

3. The Solution Make People Happier to Do More Work Better

4. Making People Happy—The Current State • Today Is Going to be a Crappy Day—we’re understaffed and overworked and no one cares • I can’t find the doctor, he doesn’t know the patient and they seem to change every day • No one takes ownership of the problem. . . • I can’t get the testing that I need when I need it • Communication and handoffs are abysmal • All anyone Cares about is money • It seems like it takes management forever to fix the problems

5. Hospitalist Ward Organization Have you ever thought the world would be a better place if only everyone would let you call the shots? Have you ever thought why am I doing job x when person y is really expert in that? Or why is person y doing what I could really do best? Have you ever had the experience that no one completed the task that was everyone’s job? Have you ever found out the hard way that no one was responsible for something important? Have you ever felt that the patient was getting in the way of our care process? Have you ever felt the rhetorical questions would never end?

6. Hospitalist Ward Solutions If you ever have a problem, ask the people that do the work—they have all the answers You cannot buy, contract, or write a job description that will get you beyond good Amazing things happen when you tap into “mission motivation”, and collaborate with exceptional individuals to reach a common goal People in health care are superior people—every single person in healthcare could probably earn more for doing less in another field—yet here they are Taking exceptional care of people is the best business plan We are our greatest asset—the best recruitment plan is a retention plan Always ask what can I contribute to the solution, no matter how small that may be Outcome orientation—we WILL produce the best results because there will be no “effort dependent failures” Focus on post discharge services and phone follow-up—responsibility for the outcome does not disappear when the patient disappears

7. “Unique Mechanics” Geographically designated personnel including IMS MD—LEAN Advantage Ward organized around attending MD instead of disease state Name in the Box* Right person, right job***(eg pharmacy) Centralized Communication—d/c criteria, what’s next, patient out of room on “public” whiteboard Automation/Standardization—data retrieval results in predictable responses Detailed Risk Assessments translate into proactive care—medications, functional assessments “Specialized testing triage” Create “the Pull” Charge RN in Charge of being in charge BOOST toolkit

8. Identify and Risk Stratify For Discharge Failure • Intervene with focused care • Educate/Inform the Patient AND Key Contact • Written Discharge Action Plan that Patient/Caregiver can “Teach Back” • Follow up with 72 hr call, home health, provider visit

9. $50 White Board with the $1 Million Impact • Main Whiteboard in RN Station • Pt Room Whiteboard

10. The Outcomes—Making People Happy • I’d rather see 20 patients like this than 15 patients the old way • I can discharge so many patients because I know there are no loose ends • When did all the IMS MDs get their lobotamies? They are so nice and so responsive now. It’s great having them always around • When did the nurses get their lobotomies? They are excellent—so well informed and so helpful—they make sure everything goes right and they will take great care of our patients • Significant Increase in Patient Satisfaction • Why don’t I have a board like this in my room? It’s awesome • The IMS Unit was the only place where the charge nurse could tell you about the status and discharge readiness/plan for every patient [Happy Administrators]

11. Doing More Work With the Same People • The number of Bed Turns Doubled compared to the same period on the same unit the year prior • The number of bed turns is 2x higher than the next most efficient unit in the hospital • Acuity particularly for nursing care much higher • Nurses going to get patients from the ER/ICU • Additional Duties like hanging own blood, rounding with MDs • Staffing remained based on midnight census as compared to bed turns

12. Doing Better Work • Higher patient Satisfaction • Higher Staff Satisfaction—nursing, IMS, ancillary • Much Better Communication with Home Health and PCPs. • Appts made prior to discharge • Much Higher rate of pt understanding and “teach back” • RCA attitude for any readmission in 72 hrs • Reduction in Readmission Rate • Better PCP Satisfaction • Lower rates of specialized testing cancellation • Dramatic reduction in medication errors • Earlier D/C times leads to earlier ICU transfers which “unloads” whole house patient flow backlogs.

13. The Bottom Line • FY ’09 IMS goal to reduce Variance days by 15% was seen as a very aggressive goal • IMS Unit reduced Variance Days by 66% after 1 yr of service!! • Absolute reduction of 545 days. Variance days per case was 1.19, now 0.12 [18 mos]!! 6C went from 0.94 to 0.4 Var day/case in 12 mos and 5N went from 0.76 to 0.51 in 6 mos. • This allowed PH to care for an additional 110 pts without adding any beds or staff on 6N alone. Average hospital COLLECTIONS for an IMS pt is $9,800 implying an addition to net collections of over $1million. • Functional equivalent of adding 1.5 hospital beds • This one unit palpably changed whole house pt flow. • Readmissions decreased: < 70 pop readmit rate 3.97% vs 13.05%; > 70 11.17% vs 15.9% While CMI went from 1.3 up to 1.45 and LOS declined • 4% Improvement in RN retention • Dramatic decrease in costly medication errors

14. All I Ever Needed to Know About Fixing American Medicine I Learned in Daily Life • Do Unto Others—Patient Centered Care • You Never Knew So Much About the Wheel Until you Tried to Reinvent it • Do Something Different Wrong—Doing things the way you’ve already done them won’t get you anywhere different from where you are • If You Want a Solution that Works, Ask the People that Live with the Problem • Taking exceptional care of people is the best business plan— “No Mission No Margin” • The best recruitment plan is a retention plan • Match the job to the person who can do it best • Genius Tends to be Elegant

15. Creating Safe Discharges is Like Being an American In the Stock Market We all know the job—Save for retirement We’re offered some excellent tools (401K) There is a ton of information out there It confuses the experts No one and everyone “owns it” Success depends on getting the basics right and on doing the maintenance work between decision points

16. Eminent Domain Medicine Has Focused on Episodes and Domains of Care and Responsibility We Need to Focus not on how well we did “our job” rather on patient outcome We are all responsible for the whole shebang, though we choose to subdivide responsibility for our own convenience Make the Most of the “Inpatient Moment” We Already Have All the Help we need to cure what ails medicine—it is sitting in this room