DISCHARGE PLANNING ENHANCED S A N F O R D W O R T H I N G T O N M E D I C A L C E N T E R
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1 DISCHARGE PLANNING ENHANCED S A N F O R D W O R T H I N G T O N M E D I C A L C E N T E R
2 INTRODUCTIONS Laura Hoffman, MSN, BA, RN, CNML Director of Inpatient Services at Sanford Worthington Erica Berger, MSW, LICSW Manager of Social Services at Sanford Worthington
3 OBJECTIVES Examine impetus for change at SWMC and apply principles to your organization Explore multifaceted and multidisciplinary approaches used at SWMC to improving discharge planning and how these might benefit other organizations Identify challenge areas and a future direction for more successful discharge planning outcomes
4 IMPETUS FOR CHANGE Patient Protection and Affordable Care Act (2010, Amended 2015) Linking payment to quality outcomes including readmissions Evidenced-based literature suggesting comprehensive discharge planning and follow up care to help prevent readmissions (Naylor, et al., 2011) Quarter 3 (July-Oct) 2013 Readmission rate 8.3%
5 ANALYSIS CURRENT PRACTICE Began by utilizing Centers for Medicare & Medicaid Services survey worksheet toolkit Enrollment-and- Certification/SurveyCertificationGenInfo/Download s/survey-and-cert-letter attachment-3.pdf Surveyor Worksheet Discharge Planning.pdf
6 CMS WORKSHEET RESULTS (BRIEF SUMMARY) Couldn t answer yes for all questions, i.e. DC planning documented in EMR (not consistently done) Eval included post-dc care needs met in pre-hospital environment (not consistently done) Eval completed timely to allow for arrangements of posthospital services as needed
7 ACTION PLAN Patient rounding RN, pharmacist, physician Know needed more support for RN = social worker Interdisciplinary team involvement Post-hospital contact care transition team and follow up phone call
8 PATIENT ROUNDING Care coordinator RN focused primarily on discharge planning o Meets with patients to assess patient DC goals o Recognize resources patient has and will need to meet DC goals Hospitalist o Assessments and plan of care discussion o Answers questions, elicits family involvement Pharmacist o Began with ½ days on unit o Focus in on high-risk medications, patient education
9 TOOLS FOR DC PLANNING Patients don t know what they don t know!! AHRQ Are You Ready To Go Home brochure.pdf
10 INTERDISCIPLINARY TEAMWORK IDT team meets daily current practice focused on DC plan Realized need to enhance IDT team breakout sessions discuss contributions of each discipline and set expectations for participation Later focus = DC plan, Length of stay, and plan of care
11 DOCUMENTATION TOOL Created template to document daily IDT conferences Serves as communication tool for others viewing chart Meets COP requirement for CMS
12 TEMPLATE EXAMPLE The patient was discussed with the interdisciplinary team today. Members of the care team include: Charge Nurse, Occupational Therapist, Pharmacist, Physical Therapist, Provider, Respiratory Therapist, Social Worker, Unit Manager, UR, Supervisor, Home Health, WOCN, CNO. Insurance: Medicare Status: Inpatient Working Diagnoses: COPD CHF/Pneumonia Length of Stay: Day 1 of 6 Family Involvement/Support: Spouse Community Services (prior to admission): Home Health: Sanford Baseline Self-Care Capacity (prior to admission): Minimal Current Self-Care Capacity: TBD Hospital Referrals: Physical Therapy Community Service Referrals: Home Health: Sanford Transportation: Family/Friends LACE Score: 9
13 READMISSION PREDICTOR TOOL LACE tool readmission predictor o L = length of stay (# days in the hospital) o A = acuity level (observation vs inpatient) o C = comorbidities o E = emergency room visits in last 6 months Incorporate in IDT daily care conferences Gives RN and team common language to work from LACE > 10 = high risk for readmission
14 CARE TRANSITIONS Through chart review of readmitted patients realized need for better post-hospital follow up How can we reach patients with high LACE score? Developed CT team o RN - Health coach at clinic provide touches to patients each week for 4 weeks (LACE > 10) o Offer health coach services free for 4 weeks o Way to see what PCPs are talking about with patient and measure compliance with f/up visits
15 FOLLOW UP PHONE CALLS All patient discharged to home & English speaking get follow up call hours after discharge Those with LACE score > 10 get call within 24 hours Use standard template o Ability to get to follow up appointment o Questions regarding discharge instructions o Ability to get prescriptions filled o Questions about overall health or how to care for self
16 RESULTS 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% SWMC Inpatient Readmission Rate Q = 8.3% Goal = 6.2% Q = 4.1%
17 FUTURE IN DISCHARGE PLANNING Better manage post-hospital follow up on patients from different health systems Post-hospital follow up for patients discharged to nursing homes/snf Helping patients address mental health needs & substance abuse Need for palliative care
18 ZDOGGMD IMPORTANCE OF DISCHARGE PLANNING ZDOGGMD You Tube Video Parody of Readmissions
19 REFERENCES Naylor, et al., The importance of transitional care in achieving health reform. Health Affairs, 30(4), Statute (Patient Protection and Affordable Care Act of 2010, Amended 2015).
20 QUESTIONS??
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