Shawnee Mission Medical Center Kim Fuller, MSW, MBA, CCE Janet Ahlstrom, MSN, ACNS-BC.

TRANSITIONS IN CARE

AKA

REDUCING READMISSIONSShawnee Mission Medical Center

Kim Fuller, MSW, MBA, CCE

Janet Ahlstrom, MSN, ACNS-BC

SHAWNEE MISSION MEDICAL CENTER

PREVENTING RE-HOSPITALIZATION WITHIN 30 DAYS

Selected populations:

Congestive Heart Failure

Pneumonia

Acute Myocardial Infarction (AMI)

OUR JOURNEY IHI Collaborative on Reducing Readmissions in

2009/2010.

Developed multidisciplinary internal team to participate in the Collaborative and to begin designing program.

Did chart reviews of readmissions to assess patterns, failure points, potential interventions and conducted tests of change.

Discovered many readmissions coming back from SNF’s, so invited key partners to join Collaborative.

JOURNEY CONTINUED…. Split internal team and external community

partner group into separate meetings.

Justified initial addition of an FTE by quantifying potential cost to the bottom line following implementation of CMS penalties.

Hired .5 MSW and .5RN and Transition Coach role fully implemented in August, 2011.

SMMC PROGRAM4 MAIN FOCUS AREAS Enhanced Admission Assessment for

Post Hospital Needs

Effective Teaching and Enhanced Learning

Real – time Patient and Family Centered Handoff Communication

Post-Hospital Care Follow Up

INTERNAL TEAM Membership includes:

Nursing representation from cohort areas for CHF, AMI and Pneumonia.

PharmacySocial Work/Utilization ReviewAsk a Nurse Call CenterSMMC Home HealthCardio-Vascular ServicesNursing Education

EXTERNAL TEAM Membership includes

Home healthSkilled nursing facilitiesAssisted Living FacilitiesHospicePrivate DutyLTACEmergency Medical Response

EXTERNAL TEAM FOCUS Case studies of readmissions from various

facilities, identifying breakdowns and creating new processes.

Education re: disease specific protocols provided to SNF’s. i.e. importance of daily weights and use of the zone chart for CHF patients.

Development of common hand off tool that meets needs of hospital and external agencies.

Strategies to increase involvement of palliative care and hospice when appropriate.

EXTERNAL TEAM FOCUS Education about national movement toward

use of Transportable Physician orders for End of Life treatment wishes.

Development of special interest sub-committees to concentrate and problem solve issues that are unique to different settings.

Trend readmission data specific to various agencies/facilities to use in forming stronger community partners with those that have lower readmission rates.

TRANSITIONS IN CARE

Shawnee Mission Medical Center

Melanie Davis-Hale, LMSW

Cathy Lauridsen, RN, BSN

TRANSITION COACH 0.5 Social Worker/ 0.5 RN Identify high risk patients in hospital Initiate individualized program Follow for 30 – 45 days regardless of

setting Facilitate smooth TRANSITIONS Early intervention with any readmissions Meet weekly with physician champions

at SMMC Provide education for patients and

healthcare team partners

IDENTIFYING HIGH RISK PATIENTS Currently utilizing the Better

Outcomes for Older adults through Safe Transitions (BOOST) Tool

Collaborative Care Team (CCT) process at SMMC

Chart review of Electronic Medical Record

BOOST TOOL8P screening tool: Problem Medications –(anticoag, insulin, aspirin, digoxin)

Punk (depression) - screen positive or diagnosis

Principle diagnosis – COPD, cancer, stroke, DM, heart failure

Polypharmacy - >5 or more routine meds

Poor health literacy - inability to do teachback

Patient Support – support for d/c and home care

Prior Hospitalization - non-elective in last 6 months

Palliative Care – pt has an advanced or progressive serious illness

PRE AND POST HOSPITAL CARE AND FOLLOW UP

Initial contact with patients/family during the hospitalization.

Schedule follow-up PCP/Specialist appointment prior to hospital discharge.

Follow patient across all levels of care for up to 45 days post discharge.

Phone/in person home visits.

Continually assess patient needs post discharge.

FOUR PATIENT CENTERED ELEMENTS FOR TEACHBACK Medication management

Follow up with PCP/Specialist

Patient centered record

Knowledge of Red flags and how to respond

STRATEGIES FOR SUCCESS Develop a relationship with patient and/or

family prior to hospital discharge Identifying patients’ healthcare goals Matching patients to Social Worker or RN

based on patient needsSocial Worker

Financial needs Psycho-Social needs Community resources

RN Patient/Family/Caregiver Education Facility/Service Provider Education Symptom management

STRATEGIES FOR SUCCESS Interventions to prevent readmission based

on patients’ discharge planPatient Discharges to SNF/LTAC/Acute

Rehab Visit/phone call to patient, patient’s nurse, social

worker, PT/OT, Medical Director.Ensure patient has seen Medical Director within 72

hours Identify medication issues/concerns/changes and

other areas of symptom management.Awareness of patient discharge plan from facility

Maintain communication with patient’s PCP/specialist Prepare patient for transition to lower level of

care/home

STRATEGIES FOR SUCCESS

Patient Discharges to Home with Home Health Collaborate with Home Health Agency/Case

Manager to develop care plan to prevent readmission

Ensure patient attends follow-up PCP/specialist appointment

Patient Discharged to Home Continue post-discharge education to

patient/family/caregiver Identify medications issues/concerns Identify and referred to needed services Encourage self-management when possible

CHALLENGES Identifying patients that will code out as

CHF, Pneumonia, AMI

Continually educating service providers on role of transition coach

End of life issues

PROGRAM RESULTS

CHF PNA AMI Other DRGs

50

157

60

154

141

42

August 2011 - December 2011

Total # of Patients Followed by Transition Coaches

Total # of Medicare Patients Discharged from SMMC

PROGRAM RESULTS

August September October November December

38% (5/13)

17% (4/23)

35% (8/23)

47% (8/17)

25% (7/28)

31% (4/13)

0% (0/9)

13% (1/8)

0% (0/8)

17% (2/12)

SMMC CHF Readmission RatesAugust 2011-December 2011

Non-Transition Coach Transition Coach

PROGRAM RESULTS

August September October November December

23% (6/26)

23% (3/26) 11% (3/27)

0% (0/17)

10% (3/30)

100% (1/1)

0% (0/2)

33% (1/3)

0% (0/3)

17% (1/6)

SMMC PNA Readmission RatesAugust 2011-December 2011

Non-Transition Coach Transition Coach

PROGRAM RESULTS

October November

23% (3/13)

0% (0/4)0% (0/3) 25% (0/4)

SMMC AMI Readmission RatesOctober 2011-November 2011

Non-Transition Coach Transition Coach

PROGRAM RESULTS

SNF30%

Home30%

Home Health40%

Where Transition Coach Patients Read-mitted From

August 2011-December 2011

PROGRAM RESULTSPt originally admitted to hospital for:

Pt admitted from: Pt discharged to: Readmission reason:

PNA Home SNF Dehydration

CHF Home w/ Home Health SNF CHF

CHF SNF SNF CHF

CHF Home Home w/ Home Health CHF

CHF Home Home w/ Home Health Hemorrhage of Gastrointestinal

CHF Home w/ HH Home w/ Home Health Transient Cerebral Ischemia

CHF Home Home w/ Home Health A-Fib

PNA Home Home Mitral Valve Disorder

CHF Home Home CHF

PNA Home Home Pulmonary Embolism

CONTACT INFORMATION Kim Fuller

913-676-2293 [email protected]

Janet Ahlstrom 913-676-2032 [email protected]

Cathy Lauridsen 913-676-8611 [email protected]

Melanie Davis-Hale 913-676-2168 [email protected]