Reducing Hospital Readmissions: Strengthening Community Care in Nevada
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The Nevada Partnership for Value-Driven Healthcare collaborates with HealthInsight to address hospital readmissions. This initiative emphasizes patient-centered care by understanding local needs and challenges in healthcare transitions. Key strategies include effective communication, enhanced post-hospital assessments, and teaching methods that empower patients and families. Essential elements involve coordinating care transitions, focusing on end-of-life issues, and promoting shared information among stakeholders. By fostering community involvement, Nevada aims to improve patient outcomes and reduce readmissions through collaborative, evidence-based practices.
Reducing Hospital Readmissions: Strengthening Community Care in Nevada
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Presentation Transcript
ReadmissionsBreaking the Cycle The Nevada Partnership for Value-Driven Healthcare And HealthInsightMarch 30, 2011
What we know • The patient is at the center • The answers are local • Coordination and change are challenging for everyone • Building a supportive environment is about building community Homeward Bound: California Healthcare Foundation
What you now know • Nevada’s Readmission status • Readmission Root Causes • Transitions of Care basics • Current data and the project goal
What NPV brings • Evidence-based best practice research • Collaborative coordination on an outcomes based project to improve the quality and safety of patient care delivered in Nevada • Data sharing mechanism
Intervention examplesWhat is working • Care Transitions – communication across the continuum of care (hand-offs) • Teach back – strategic transfer of information from caregiver to patient • EOL – focus on end of life issues (advance directives, patient and provider education)
Transitions of Care • Enhanced assessment of post-hospital needs • Effective teaching and Enhanced learning • Real-time handover communications • Mechanism to ensure timely post-hospital care and follow-up IHI’s Four Cornerstones
Teach Back - fundamentals • Listen to the patient • Determine patient/family needs up front • Make sure the patient/family understands • Do not allow “passive patients”
Teach Back • During hospitalization – to educate patient/family about diagnosis and care • At Discharge – to educate patient and caregivers on continued needs • Post-discharge – reinforce compliance of discharge instructions and teaching
End-of-life • Patient education surrounding options • Ensure that patient’s wishes are understood and honored • Training in palliative care
Readmission Reduction “Success in reducing readmissions lies in effectively partnering to not only achieve better outcomes but also to reduce the fragmentation and lack of support that so often comes with transitions between providers and care settings.” Amy Berman, Program Officer, The John A. Hartford Foundation
