All Hands On Deck. Impacting Patient Readmissions

1. All Hands On Deck. Impacting Patient Readmissions Sherry Sweek, RHIA, CPHQ, CPMSM, Director, Quality Improvement Southeast Georgia Health System ssweek@sghs.org, 912.466.3265 October 2, 20013

2. Southeast Georgia Health System • Two hospitals: Brunswick-316 beds, Camden-40 beds • Two Nursing Homes: Brunswick-232 beds, St. Marys-78 beds • Three Immediate Care Centers • Physician Practices: over 90 physicians in primary care and specialty care practices • 2,300 team members • Focus today is experience at Brunswick facility

3. Session Learning Objectives • Discuss initiatives to impact readmissions. • Outline the steps to implement a successful engagement with Area Agency on Aging (AAA). • Identify the outcomes impacted by our local AAA interventions.

4. P D C A (Plan, Do, Check, Act)Quality Improvement Model • PLAN–What is driving readmissions, which patient populations are problematic? • DO-Implementation the action steps identified in the planning phase. • CHECK-Measure process and outcome indicators. Test. • ACT-Did we achieve results we expected? What other steps are needed?

5. Plan the Improvement • No organized plan to address readmissions • Case Management looking at 7 day readmissions, SNF bounce backs • Patient Education looking at readmissions for all patients for any reason • Quality focused on Heart Failure & Pneumonia • Utilize existing Quality Committee and structure meeting as working sessions for GHA HEN initiatives • Determine how to work with Area Agency of Aging to impact specific high-risk patient populations • Identify internal changes to complement work from AAA

6. Do the Improvement • Patient Education Coordinator interviewed readmitted patients over three months: 25% did not understand medications or have follow-up appointment. Implemented Patient Education folder and training for bedside nurse. • Renal patients accounted for 60% of Heart Failure readmissions, highest at risk group. Target with AAA. • SNF readmissions: 18% (60% of those from our system SNFs-Pneumonia). Work with • Post-Discharge Call program with Beryl Health • Schedule meeting with AAA to understand Bridge Program. Pilot on one unit, then expanded to two additional units with focus on Renal and Pneumonia patients

7. Area Agency on Aging Impact: Readmission Prevented

8. Check: Heart Failure Readmissions

9. 30-Day Readmissions-Brunswick Medicare patients only, readmit for any reason, readmit to any hospital in US as Inpatient status • All readmits: no different than US rate (no penalties) for 2nd year in a row

10. Check: HCAHPS Top Box Score August-low volume

11. Post-Discharge Calls: HCAHPS

12. Act on Results • Monthly meeting with AAA to discuss patient cases • Post-Discharge Calls moved to clinical calls in July 2013 • Patient Education folders expanded to Maternity in May 2013 • Nursing Leadership tracking communication with nurses and communication on medications as 2013 PI Project • Interaction with AAA has been great and the impact they have made in invaluable. We love having them on our team!!