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Reducing Hospital Readmissions

Reducing Hospital Readmissions

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Reducing Hospital Readmissions

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  1. Reducing Hospital Readmissions August 2014 Regional Networking Meetings Breakout Session

  2. Readmissions & Family CaregiversRhonda Clark, MSN, RN ~ QI Specialistrclark@tha.com

  3. Caring for Those We Love

  4. Total Admissions and Readmissions by Patient Point of Origin, HY2 2013

  5. Discharge Status From Index Admission HY2 2013

  6. Family Caregiving

  7. “Family caregivers have become unpaid and untrained lay nurses, routinely providing complex care such as medication management, infusions, injections, wound care, and monitoring of medical equipment.”-- Carol Levine

  8. Women (traditional caregivers) have entered the workforce in record numbers since the 1960s • Families are smaller • Patients have increasingly complicated care • Increased chronic illnesses • Shorter hospital stays • Hospice and palliative care underutilized • Increased technology associated with treatment

  9. Increased costs for medical care • Long waiting lists for home and community-based services • Stringent income and asset eligibility criteria for long term care

  10. Impact on Family Caregivers • Higher risk for: • Clinical depression • Stress-related illnesses such as high blood pressure, immune system deficiencies, cardiac problems, headaches, fatigue • Poor self care • Financial strain • Problems at work

  11. In A Nutshell… • Most readmissions come from home • Most home care is provided by family members • Family caregivers carry a heavy load for which they may not be adequately prepared or with which they cannot effectively cope • Family caregiving will continue to increase as population grows and ages

  12. What can we do to help prepare and support family caregivers?

  13. Caregiver Advise Report Enable (CARE) Act • Three elements documented in record: • Name of family caregiver (upon admission) • Family caregiver notification of patient discharge or transfer • Explanation and live instruction on the medical tasks family caregivers will provide at home • Such as wound care, transfers, injections, medication management

  14. New Project RED Component:Tool 7 • Family engagement in discharge planning • http://www.bu.edu/fammed/projectred/Project%20RED%20Revised%20Toolkit%209-2012/REDTool7FamilyCaregiversUnitedHospital%20Fund.pdf

  15. Ways We Can Help • Assess needs • Provide training or connect with resources to meet needs • Follow up • Partner with organizations in community for: • Family caregiver training courses • Family caregiver support groups • Respite services

  16. Caregiver Action Network

  17. Family Caregiver Alliance

  18. National Council on Aging

  19. AARP

  20. Carol Levine • Director of United Hospital Fund’s Families and Health Care Project • Editor of Always on Call: When Illness Turns Families Into Caregivers • Prolific author on family caregiving

  21. Blog for AARP: • http://www.aarp.org/home-family/home-family-experts/carol-levine/ • Blog for Health Affairs: • http://healthaffairs.org/blog/author/levine/ • Blog for United Hospital Fund: • http://www.uhfnyc.org/news/initiatives/family-caregiving?c=char_1&d=uu&e=1

  22. Next Step in Care