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2 Trsitis: Hdl With Cr Sttwid Mtig: Sssi 2 f 3 Nvmbr 14, :00.m. 3:30 p.m. Turf Vlly Rsrt d Cfrc Ctr 2700 Turf Vlly Rd, Ellictt City, MD Tdy s mtig is wrkig mtig, prvidig tim fr yu d yur crss-ctiuum prtrs t idtify spcific wys i which yu c dvlp r xpd yur strtgis t rduc rdmissis. W hv structurd th wrkig mtig rud thr mjr typs f trsitis: trsiti frm hspitl t skilld ursig fcilitis, trsiti frm hspitl t hm hlth, d trsiti frm hspitl t hm, th myrid srvics d supprts i th cmmuity. Ths ctgris r mt t b brdly itrprtd, d t xclusiv f thr imprtt prtrs crss th ctiuum. I th itrst f highlightig ctibl bst-prctic strtgis tht yu my wt t csidr, w hv fcusd ths trsiti typs t llw yu d yur prtrs t idtify bst prctics, wys f msurig r shrig dt r cmmuictig, d cllbrtig but ptit ds d srvics tht yu my wt t immditly tst i yur sttigs. Extd d dpt ths ids t y d ll circumstcs rlvt t yur sttigs. Aftr ch pl, w will hv tim fr tbl wrk with yur prtrs. W rcgiz tht yu my t hv ll prtrs hr tdy. Us tdy s sssis t pl xctly wh t mt with, xctly wht th pprtuity fr imprvmt is, d xctly hw yu c gt strtd implmtig d msurig tht imprvmt. Th bjctivs fr this mtig r: 1. Crt highly ffctiv wrkig virmt fr hspitls d thir crss-ctiuum prvidr prtrs t dvlp shrt-trm cti pls fr imprvig spcific spcts f th fllwig trsitis: Hspitl t Skilld Nursig Fcilitis (SNF) Hspitl t Hm Hlth Hspitl t Hm 2. Dmstrt xmpl f prtfli pprch t imprvig cr trsitis, crss umrus sttigs, fr vrity f ptit ppultis. 3. Shr th sttwid rdmissi rducti gls d sttwid iititiv dshbrd t prmt cllctiv cti twrd cmm gl: rduc rdmissis by 10 prct by Ju 30, 2014.

3 AGENDA 8:00 Chck i d Ctitl Brkfst 9:00 Wlcmig Rmrks: Prtrship i th Nw Er f Cr Dlivry Crml Cyl, Prsidt & CEO, Mryld Hspitl Assciti Mssgs frm Mryld Cr Trsitis Strig Cmmitt Mmbrs Isbll Firth, LifSp Ntwrk Dvid Hrrcks, Chspk Rgil Ifrmti Systm fr ur Ptits (CRISP) Jff Richrds, Mtl Hlth Assciti f Mryld Di Fy, Mryld Hlth Srvics Cst Rviw Cmmissi Cllbrtiv Updt d Gls fr th Dy Amy Butwll, MD, MPP, Cllbrtiv Hlthcr Strtgis 10:00 Brk 10:15 Trsiti 1: Hspitl t Skilld Nursig Fcilitis Jhs Hpkis Hlth Systm prtrship pl & tbl wrk 11:00 Trsiti 2: Hspitl t Hm Hlth Nw Yrk Mthdist Hspitl prtrship pl & tbl wrk 12:15 Luch 1:00 Trsiti 3: Hspitl t Hm Adult Dy Mdicl Srvics: Estr Sls Ptit Ctrd Mdicl Hm: Clvrt Itrl Mdici Grup Pllitiv Cr: Chspk Pllitiv Mdici Phrmcy Srvics: Wshigt Advtist Hspitl 2:15 Brigig it Tgthr: Th Prtfli Apprch Frdrick Mmril Hspitl prtrship pl 3:00 Acti Pls: Hw Will W Gt Thr? Wht w strtgis d prtrs will yu dd t yur prtfli? 3:30 p.m. Adjur

4 Opig Sssi: Prtrship i Nw Er f Cr Dlivry, Ldrship Mssgs Nts but th w Ctrs fr Mdicr & Mdicid Srvics (CMS) wivr & impct th mdt t rduc rdmissis: Wht is th xpctti fr rdmissi rducti i Mryld? Hw ft will CMS mitr prgrss? Wht ds this m fr my hspitl? My gcy/rgizti? Nw pprtuitis? Nts frm Strig Cmmitt mmbr mssgs: Nw prtrship, w ids fr cllbrti Nts rgrdig Trsitis: Hdl With Cr iititiv gls: Rduc ll-cus, ll-pyr rdmissis by 10% by Ju Ambitius but chivbl. Ju 2013: 7,357 rdmissis, 13.2%. Gl by Ju 2014: 6,622 rdmissis (10% = 735 fwr rdmissis), 11.9%.

5 Trsiti Typ 1: Hspitl t Skilld Nursig Fcility (SNF) Imprvig th trsiti frm hspitl t pst-cut fcility (skilld ursig, chric hspitl, iptit rhbilitti fcility, d thr similr fcility-bsd cr) is high-lvrg pprtuity fr imprvmt fr th fllwig rss: 1. Rdmissi rts r grlly highst btw hspitls d pst-cut fcilitis. 2. Wrm hdffs c b implmtd, with pprtuitis fr clrificti. 3. Cliicl chgs c b idtifid d ddrssd i th fcility, r vi trt d rtur frm ED. Bst prctics t imprv th trsiti frm hspitl t SNF iclud: Kw yur dt fr th hspitl d ch SNF. Jitly rviw rdmissi vts btw hspitl d skilld ursig fcility. Frm SNF wrkig grup fr fficicy with umrus prvidrs d t hc lrig. Us rdmissi rviws t grt spcific wys t imprv hdffs d ED trsfrs. Implmt urs-t-urs wrm hdffs; hspitl urs t cll SNF <24hr. t circl bck. Prvid ph/pgr umbr fr qustis d clrifictis. Sd writt hrd cpis f pi mdicti prscriptis t trsfr. Sd 3-dy supply f rctics d thr difficult t bti mdictis t SNF. Adpt th pricipl tht th rcivr dfis wht ifrmti thy d t ssum cr. Rfr t th INTERACT-3 hspitl-snf xmpl trsfr dcumt. SNFs dpt INTERACT-3 prctics. Wrk with ED tms t us th INTERACT frms; trt d rtur rthr th rdmit. Esur sf trsiti frm SNF t hm usig similr hspitl-hm prctics. Grt ids frm Jhs Hpkis Hlth Systm prtrship iclud: Hw thy gt strtd Hw thy structur thir mtigs Spcific cti/imprvmts Hw thy msur d trck imprvmt

6 Trsiti 1: Hspitl t SNF- Acti Plig Wrksht This wrksht is suggstd guid t hlp yu idtify pprtuitis fr imprvmt. 1. Kw yur dt & rviw rdmissi vts Hspitls: D yu trck rdmissis frm SNFs (d/r thr fcilitis)? By fcility? Hspitls: Wht is yur hspitl s rdmissi rt frm SNFs? SNF/fcility: D yu trck (r)dmissis t th hspitl? SNF/fcility: Dscrib hw yur fcility msurs cut (r)hspitlizti. Bth: D yu rviw rdmissis frm SNF? Tgthr? Bth: D yu us structurd frmt? Ivlv bth hspitl d SNF? Ptit/fmilis? 2. Idtify pprtuitis fr imprvmt Hspitls: Wht imprvmt ffrts d yu hv i plc? Hw r thy wrkig? SNF/fcility: Wht imprvmt ffrts d yu hv i plc? Hw r thy wrkig? Bth: D w/thr prtrs r fcilitis r prfssils d t b ivlvd? Bth: Hv yu csidrd wrm (vrbl) hdffs? Hspitls: Hv yu csidrd prvidig ctct ifrmti fr clrificti? Hspitls: D ll SNF ptits lv with dcumtd gls f cr? Bth: D yu jitly rviw mdictis t idtify y tht my b difficult t bti? SNF: D yu us th INTERACT tls? Which s? Hspitl: If ys (bv), hv yu trid yur ED stff t us INTERACT tl? Spcific ACTION STEPS w will tk t imprv ur hspitl-snf trsitis:

7 Trsiti Typ 2: Hspitl t Hm Hlth Th trsiti frm Hspitl t Hm Hlth (urs, thrpist, mdicl scil wrk, hm hlth id) is high lvrg pprtuity fr imprvmt fr th fllwig rss: 1. Scd highst rts f rdmissi (scd t SNF, typiclly) 2. By dfiiti, ptits hv rdmissi risks (d skilld cr, multipl cmrbiditis) 3. Cliicis schduld t prvid fllw up s ftr dischrg r imprtt sst Bst prctics t imprv th trsiti frm hspitl t hm hlth iclud: Kw yur dt fr hspitl d fr ch gcy. Jitly rviw css f rdmissis frm hm hlth d grt ids fr imprvmt. Frm hm hlth wrkig grup t mt with svrl gcis t c d shr lrig. Hv hm hlth liis mt with th ptit, crgivr d stff prir t dischrg. Prvid first ctct withi hurs; csidr dily ctct by ph fr first 14 dys. Frt-ld th pisd by prvidig itsifid ctct by ph d i prs t iititi. Prvid ptits d crgivrs with symptm-spcific cti pl with custmizd if. Prvid cll m first istructis t th ptit d crgivrs. Esur ll ptits hv primry cr prvidr d fllw up withi 3-5 dys schduld. Esur mdictis r clrifid withi 48 hurs f pisd iititi; sclt if dd. Esur quipmt d prscriptis r rcivd; sclt if dd t mgr. Discuss gls f cr, rs fr hspitlizti, hm cr gls d ptit gls. Obti rdrs fr thr disciplis, t prvid hd t t trtmt pl. Crt high-risk lrt systm s -cll stff r ifrmd f high risk ptits. Shr rdmissi risk ssssmts cductd iptit with pst-cut prvidrs. Grt ids frm th Nw Yrk Mthdist Hspitl prtrship iclud: Hw thy idtify ptits t high risk f rdmissi Hw thy idtify supprtiv srvic ds Hw thy ddrss psychscil ds

8 Trsiti 2: Hspitl t Hm Hlth- Acti Plig Wrksht This wrksht is suggstd guid t hlp yu idtify pprtuitis fr imprvmt. 1. Kw yur dt d rviw rdmissi vts Hspitls: Wht is yur hspitl s rdmissi rt frm hm hlth? Hm Hlth: D yu trck (r)dmissis t th hspitl? Hm Hlth: Dscrib hw yur gcy msurs cut (r)hspitlizti. Bth: D yu rviw rdmissis frm hm hlth? Tgthr? Bth: Wht r th mjr rss why hm hlth ptits r rdmittd? 2. Idtify pprtuitis fr imprvmt Hspitls: Hv yu implmtd y imprvmts t th trsiti t hm hlth? Hspitls: Hv yu ttmptd t brd yur umbr f rfrrls fr hm hlth? Hw? Hm Hlth: Wht imprvmt ffrts d yu hv i plc? Hw r thy wrkig? Bth: Wht thr prtrs might b ivlvd? (.g. gcis with bhvirl hlth skills) Hm Hlth: D yu sur ctct withi hurs? Hm Hlth: D yu us CRISP t fid ut wh yur ptit hs g t ED? Hm Hlth: Hw c ptit with chg i cliicl sttus vid th ED? Hspitl: Hw c th ED wrk with hm hlth t fcilitt trt d rls? Spcific ACTION STEPS w will tk t imprv ur hspitl-hm hlth trsitis:

9 Trsiti Typ 3: Hspitl t Hm Th trsiti frm hspitl t hm th htrgus virmt f cmmuity-bsd srvics d (r)stblishmt with utptit prvidrs is th mst cmm trsiti typ. It is ls frught with chllgs fr ptits, crgivrs, d cmmuity-bsd prvidrs lik. Ptits shuld t lv th hspitl withut: A fllw up ppitmt 3-5 dys fllwig dischrg A ctct umbr (hspitl r thrwis) t cll with qustis pst-dischrg A clr, ccurt mdicti list, with cfirmd bility t bti mdictis A vrblizd udrstdig wht thy wr hspitlizd fr & slf-cr istructis Bst prctics t imprv th trsiti frm hspitl t hm iclud: Idtify ptits t high risk f rdmissi bsd cliicl, utilizti, d scil fctrs. Idtify th lrr: d t ssum th ptit will rti ifrmti. Us tch-bck with ptits/crgivrs. Esur gls f cr discussis r cmmuictd t rcivig cliicis. Cmplt dischrg summry t th tim f dischrg. Esur fllw up ppitmts r md prir t dischrg. Esur fllw up f sm srt (ph, visit, ffic) ccurs withi hurs fr high risk ptits. Prvid dirct likg t xistig cmmuity bsd cr mgrs (PCMH, BH, pyr, tc). Prvid trsitil cr fr high risk ptits withut cmmuity bsd cr mgrs. Us hspitl-bsd r cmmuity phrmcists d stff t ssist with mdicti mgmt. Prvid bdsid dlivry f mdictis t rduc brrirs t dhrc. Kw srvics d supprts vilbl lclly d ptimiz vilbl rsurcs. Grt ids frm th Hspitl t Hm pl iclud:

10 Trsiti 3: Hspitl t Hm Acti Plig Wrksht This wrksht is suggstd guid t hlp yu idtify pprtuitis fr imprvmt. 1. Kw yur dt & rviw rdmissi vts Hspitls: Wht is yur hspitl s rdmissi rt frm hm? Hspitls: D yu rviw rdmissi vts frm hm? D rdmissi rviws iclud itrviws f utptit prvidrs d ptit/crgivr prspctivs? Bth: Wht r th mjr rss why ptits r rdmittd frm hm? 2. Idtify pprtuitis fr imprvmt Hspitls: Hv yu implmtd y imprvmts t th trsiti t hm? Hspitls: Ar th bv imprvmts trgtd t subgrup, r implmtd fr ll? Prtrs: Wht imprvmt ffrts d yu hv i plc? Hw r thy wrkig? Prtrs: Wht cmpriss ffctiv trsiti it yur cr? Bth: Wht thr prtrs shuld b ggd? (dult dy, bhvirl hlth, phrmcy) Bth: D yu hv dirct pit f ctct with lcl bhvirl hlth? PCMHs? Prtrs: D yu us CRISP fr ED/dmit/dischrg tificti? Fr viwig rprts? Bth: D yu hv ptit/crgivr dvisrs vilbl t prvid guidc? Spcific ACTION STEPS w will tk t imprv ur hspitl-hm trsitis:

11 A Prtfli Apprch t Rducig Rdmissis Hspitls mkig msurbl prgrss twrd rducig rdmissis hv multi-fctd pprch. Th xmpls w hrd tdy fcus ll ptits, r umrus subgrups f high-risk ptits, crss multipl trsiti typs. All tms msur d trck prfrmc rgulrly. Grt ids frm Frdrick Mmril Hspitl s Prtfli f Strtgis Idtify spcific ACTION STEPS yu c tk t brd yur prtfli f strtgis: Ky: A: Lvig th hspitl F: Trsiti frm cmmuity t hspitl B: Likg t cmmuity bsd cr & srvics G: Trsiti frm SNF t hspitl C: Admissi & cr i pst-cut fcilitis H: Assssmt i ED frm SNF D: Trsitil Cr I: Assssmt i ED frm hm E: Lvig th SNF/fcility

12 rd s prp d w r Qulity s ti i l Assc ), th Mdicdicid Srvic C Hspit ryld lumbi (DFD dicr & M CMS plicy. M th C M f f r f t lf s rflct ic r y h tr t il is r b D s C s gis dti f th ct with th d t c d r Strt tr lthc Dlmrv Fui, udr ctts prst H v ti b d r m c b lu ) ll C C h s. T by C l Cr (DFM District f Srvic vlpd d Hum ws d ti fr Mdicryld d th l i r h lt t This m rv Fudiztis fr M rtmt f H by Dlmmt Org th U.S. Dp Imprv gcy f (CMS), -MD/DC-CT-0 10SOW

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