PREVENTING HEART FAILURE READMISSIONS
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- Jessie Carr
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1 PREVENTING HEART FAILURE READMISSIONS Tanya Sprinkle, BSN, RN, CCM Patient and Family Services Coordinator Michelle Roseman, NHA, MBA Chief Operating Officer/Catawba Regional Hospice Juanita Zwiener, RN, CCM, CRRN CareLink Navigator IREDELL HEALTH SYSTEM! Not-for-profit hospital located in Statesville, N.C.! 199 acute care beds! 48 skilled nursing beds! Home Health Agency Iredell Home Health! Iredell Physician Network, LLC STEP 1 Established Community Coalition! October 2012 Kick-off meeting! 30+ participants (HH, SNF, 3 rd Party Payers, Community Agencies)! Reviewed Community-wide Demographics and Readmissions data! Obtained commitment from participants to engage in Root Cause Analysis! Established Steering Team! Added 2 nd Hospital in Community to Coalition December
2 STEP 2 Conducted Root Cause Analysis! Focus Groups (Community Service Providers, Hospital Discharge Planners, Beneficiaries, Hospital Executives, Hospital Clinical Teams, Community Physicians, Palliative Care Providers, Community Care Coordinators)! Hospital Patient Tracers! Chart Reviews (Hospital 55 reviews, HH 40 reviews, SNF 20 reviews)! Analysis of Medicare Claims-based Data STEP 3 Shared / Analyzed RCA Findings! RCA Findings presented to Community Coalition April 2013! 30+ participants (HH, SNF, 3 rd Party Payers, Community Agencies)! Follow-up Steering Team Meeting to review RCA findings and determine initial area(s) of focus RCA FINDINGS! Lack of Patient & Family Education on Disease Process! Lack of Resources and Services! The need to improve the Discharge Planning Processes! Lack of Communication across the Continuum of Care! Lack of Access / MD Follow Up 2
3 STEP 4: Improvement Strategies Developed RCA Finding #1 Lack of Patient & Family Education on Disease Process! Transition from lengthy Education booklets to Easy-to- Read 1-3 pg. educational materials from Cerner EHR to address low literacy level! Staff Education on education techniques, including Teach-back! Emphasis on ongoing education instead of discharge instruction.! Engaged Respiratory Care staff in education of respiratory patients (i.e., COPD, Pneumonia)! Launching Pulmonary Rehabilitation program. RCA Finding #2 Lack of Resources and Services! Established bi-weekly meetings with Medicaid Managed Care representatives to develop individualized care plans for patients with 30-day readmissions and/or high Emergency Dept. utilization! Community Agencies invited to perform inservice education for Case Management / SW staff.! Working with Blue Medicare to provide patient discharge information day after discharge to facilitate case mgmt. 3
4 RCA Finding #3 Need to Improve Discharge Planning Processes! Restructured Case Mgmt./SW Dept. to separate Utilization Review & Discharge Planning functions and increase discharge planning resources.! Increased Weekend staff coverage! Standardized documentation in EHR! Established new performance expectations for Discharge Planning staff including expectations for initial assessment, prioritization of patients, and follow-up assessment.! Implemented Discharge Risk Assessment Screening Tool to prioritize patients RCA Finding #4 Lack of Communication Across the Continuum of Care! Worked with IS Dept to improve processes for communicating patient information to post-acute care providers. (Ongoing)! Established process for Nurse-to-Nurse report for patients transferred to extended care facilities.! Communicating with Medicaid AccessCare to initiate case mgmt. services for high risk patients proactively instead of waiting until readmission has occurred.! Notifying PCPs of high-risk patients and need for f/u within 7 days of discharge.! Continue with Community Coalition meetings / data sharing quarterly. RCA Finding #5 Lack of MD Access / Follow-up! Placed increased emphasis on Discharge Planner identifying PCP for unattached patients.! Placed increased emphasis on Discharge Planner scheduling follow-up appointments for Community Clinic patients! Discharge Planner entering Follow-up Within 7 days into EHR Discharge Instructions when high-risk patient identified.! Provided MD education on importance of early follow-up.! Partnered with CareLink to initiate Nurse Navigation program July
5 CareLink Referrals Readmission Rate Comparison Readmission Rate Summary Oct Oct CareLink Readmission Rate 16.85% (45/267) Excluding Pts. Not Seen Before Readmitted 14.94% (39/261) Pts. D/C'd to Other Providers 26.50% (31/117) Pts Unable to Contact / Refused 19.83% (23/116) Overall Readmission Rate 19.80% (99/500) THE RESULTS: OBSERVED TO EXPECTED READMISSION RATES 5
6 LESSONS LEARNED! It takes a village!! There is no magic bullet.! There s no need to re-invent the wheel.! You can t undo systems in six months that took years to create.! Slow and steady wins the race. QUESTIONS? [email protected] [email protected] [email protected]
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