Ty Cobb Regional Medical Center Reducing Readmissions

1. Ty Cobb Regional Medical CenterReducing Readmissions

3. DEFINE • Scope – Decrease 30 day readmission rate by 20% • Project charter completed and approved • Team members: Nursing, Case Management, Utilization Review

4. Charter discussion

5. MEASURE • Line chart, Histogram, Xbar and R chart data reviewed by team members • Process in control but not what we wanted • Process Flow Mapping discussed • Map completed

6. Initial Data

7. Process Map

8. ANALYZE • “Sticky note” brainstorming • Process map was separated into sections: Admission, Inpatient Care, Day of Discharge and Post Discharge • Each member moved from chart to chart • 52 thoughts added to flow map • Developed a list of improvement priorities

9. Sticky note exercise Different map sections were placed around the room. Each team member was given a pen and a sticky note pad. They had 5 minutes to spend at each station writing as many suggestions or concerns as they could.

10. Before and After

11. IMPROVE/IMPLEMENT • A problem list was developed and prioritized • Specific task list was made • Department involvement for each task was delineated using RASCIN chart

12. Task List • Combine Readmission Risk Assessment and Case Management Assessment • Provide in-service to Nursing staff on patient education techniques and use of “Teach-Back” method • Create e-forms for documentation • Concentrate post-discharge calls on “high risk” patients • Better utilization of Home Health Care

13. RASCIN

14. Readmission Risk Assessment • A “home needs” screening is completed on each patient on admission • Any positive screen is referred to Case Management and an in-depth assessment is performed • We simply added questions to that assessment that will determine risk of readmission • High risk patients receive a detailed post discharge call

15. Teach Back • Teach back is a method of education assessment that requires the patient to repeat back the instructions in their own words • If the patient’s description differs from what was taught, re-education can occur at that time

16. Post Discharge Calls • Post discharge calls are completed by Utilization Review staff a few days after patient discharge. • Patients are contacted at home to see how they are progressing and to discuss medications, follow up appointments • Any problems noted are sent to Case Management for resolution

17. Home Health Care • Our overall goal is for each high risk patient to be evaluated for Home Health Care and to be referred if they could benefit from services

18. Home Health Benefits • Reinforcement of hospital discharge information • Periodic physical assessments to prevent disease from progressing to hospitalization level • Patients can remain at home in familiar surroundings and still receive the care they need

19. Home Health Utilization

20. Latest Data

21. Success!!! • 30 day Readmission Rate dropped from 0.0352 to 0.0128 • Decrease of 63.6% • Projected Financial loss prevention: $1,166,690.26

22. CONTROL • Continue to evaluate control charts • Policy development to standardize the discharge process

23. Thank you!! Tina Thomas RN Ty Cobb Regional Medical Center Lavonia, Georgia tina.thomas@tycobbhealthcare.com