Readmissions Race: Improving the Discharge Planning

Readmission Race: Checkpoint Call
Improving the Discharge Planning Process
October 22, 2012
12:00 to 12:45 pm CST
Welcome and Overview
• Welcome, thank you for joining us today!
• Housekeeping
– This webinar is being recorded and will be archived.
– You will receive a PDF of today’s presentation, as well as a
link to fill-out the evaluation and a summary of Q&A.
– For questions: please reach out to your state lead or email
us: [email protected]
• Agenda
– Improving the Discharge Planning Process
– Hospital Sharing and Coaching
– Q&A
• Tasha Gill, MPH, HRET
• Denise Remus, PhD, RN, Cynosure Health
• Amy E. Boutwell, MD, MPP, Collaborative
Healthcare Strategies
• Misti Wedding, RN, Medical/Surgical/ICU
Nurse Manager, Harrison Memorial Hospital
Readmissions Race:
Improve the Discharge Planning Process
Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
Terminology Matters
• Discharge planning process….
– Implies we in the hospital make the plans
– Discharge is rather unilateral in nature
• Transition to the next setting of care….
– Reminds us there is a next setting with needs
– Transition is more bilateral in nature
Improving Transition Process Matters
• A lot of focus on NEW work and NEW tools
Transitional care coaches
Transitional care Nurse Practitioners
Disease-specific clinics
Medical home care managers
• We have a lot of opportunity to improve our DAILY work:
– 81% of patients requiring assistance with basic functional needs failed
to have a home-care referral
– 64% said no one at the hospital talked to them about managing their
care at home
Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices.
Marblehead, MA: HCPro, Inc.; 2006.
42 million family caregivers
46% perform nursing tasks
75% of them manage medicines
33% of them do wound care
66% of the patients had no VNA
Available at:
“We ask caregivers to do things that would make even
nursing students tremble…….
As hospitals discharge patients quicker and sicker…..
family caregivers are responsible for medical and nursing care
including medication management and wound care.”
~ Susan Reinhard
SVP & Director, AARP Public Policy Institute
“Despite frequent encounters with the acute care system, family
caregivers were not prepared for the medical and nursing tasks they
were expected to provide at home…
“We asked family caregivers how they learned to manage their family
members’ medications and 61 percent said, ‘I learned on my own.’
Clearly, professionals need to do a better job of training family
~ Carol Levine
Director of Families and Health Care Project
United Hospital Fund
Step 1: Study your existing process
• * WARNING: Do not get stuck in process mapping quicksand!
• This does not need to take months
– I have seen hospitals take over 18 months
– Aim for basic blueprint in 2-3 meetings
• This does not need to be done perfectly with complete review
and consensus prior to starting improvements
– Many teams do not start on clear tests for too long
– Aim for first test of change “by Tuesday”
Step 1: Study your existing process
Describe the existing steps and tasks involved in the discharge planning
process currently
– Involve multiple stakeholders input
Admitting RN
Floor RN
Floor CM/discharge planner
Floor Nurse Manager
Resident MD (they do most “teaching” discharges)
NP/PA if part of floor team (they do most discharges)
Attending MD (especially those that discharge “non-teaching” patients)
– Don’t forget the “receivers” on your cross-continuum team!
Home health, hospice
Outpatient providers, when available (don’t always need MD; practice manager/RN)
Step 2: Compare to Best Practice
1. Role Definition, Responsibility & Standardization
– Discharge Advocate
– Checklist or “bundle”
2. Enhanced Assessment of Risk
– Patient/caregiver/provider interview for readmitted patients
– Expanded view of risk, and assessment techniques
3. Enhanced Teaching & Learning
– Teach-back/ personal health record
– Identify the appropriate learner/ engage caregiver
4. Timely Communication
– Communication with PCP at admission and d/c; same-day summary
– Warm handoffs to clinicians for complex/high risk
5. Timely Follow-Up
– 24-48h contact for complex/high risk ; availability for contact
– Follow up 3-5 days
Step 3: Implement Tests of Change
Examples of tests you could implement today:
1. Enhanced assessment
Identify Learner
Use your data systems: daily readmission reports; high utilizer reports
Risk screens include: BOOST 8P or STAAR readmission interview
As the patient/family “who will help you with your care/medications…?
It is NOT always the visitor at the bedside, NOT always the spouse
Use Teach-Back
– Use the entirety of the hospital stay to engage in education
– Ask the patient/learner to describe medications, care plan, follow up when & why
Timely communication
– Warm handoffs with SNFs
– Clinical synopsis sent to receiving MD at time of discharge (real-time)
– Make follow up appointment(s) for the patient prior to discharge
– Coordinate follow up phone call <72h to review medications, plan, questions
Three recent excellent transitional process improvements
“SNF Circle Back”
Multi-hospital system in North Carolina
Pilot in one hospital; commitment to spread system-wide if effective
Problem: early readmissions from SNF
warm handoffs to SNF
Call back to SNF 3-24 hours after transfer to answer questions
RCA revealed SNF-readmission patters
Hospital readmission champion met with SNFs to discuss shared goals
Hospital (with some leadership effort) asked SNF to participate in this communication
RN calls nurse at SNF
SW or care coordinator calls for follow up clarification 3-24 hours after transfer
Daily workflow (with some modifications for weekends, done next business day)
Follow up calls are scripted and documented in Allscripts system
Pilot on paper with 1 RN and 1 SW
Pilot expanded to RN call report to SNF
Pilot expanded to add follow up calls
Pilot expanded to build questions into Allscripts
Expand to all; new standard of practice
Source: Emily Skinner, Carolinas Healthcare System
SNF Circle Back -2
SNF Circle Back Questions
1. Did the patient arrive safely?
2. Did you find admission packet in order?
3. Were the medication orders correct?
4. Does the patient’s presentation reflect the information you received?
5. Is patient and/or family satisfied with the transition from the hospital to
your facility?
6. Have we provided you everything you need to provide excellent care to
the patient?
– Transitions are a PROCESS (forms are useful, but only a tool to achieve intent)
Source: Emily Skinner, Carolinas Healthcare System
Transition to SNF Medication Safety
• 2007, medication events, patient complaints re: d/c process
• Evaluated medication orders
• Found that only 8% of their patients had NO errors
Medication reconciliation was complete >90% of the time!
• Common medication errors:
Formulation errors
Incorrect dose
Missing medications
Insulin dosing errors
Source: Bruce Thompson, AHRQ Innovations Exchange
Transition to SNF Medication Safety-2
• New Process: Enhanced medication review
MD orders Pharm D and CCSNF
• Identify patients being d/c to SNF
• When bed available, MD, Pharm D and CC paged
• MD has 4 h to enter d/c orders
• CC scans orders hourly; paged Pharm D when entered
• Pharm D & CC have 2 hours to review; clarify with MD
• When errors are noted, resident AND attending are paged
• Outcomes: enhanced review group had 5.7% readmissions v. 10.2%
• High patient satisfaction, high physician satisfaction
Source: Bruce Thompson, AHRQ Innovations Exchange
Thank you!
Amy Boutwell, MD, MPP
President, Collaborative Healthcare Strategies
Faculty, HRET HEN Readmissions Race
Co-PI, AHRQ Reducing Medicaid Readmissions Project
Physician Consultant, CMS QIO Care Transitions Theme
[email protected]
617 710 5785
Readmission Race: Checkpoint Call
Improving the Discharge Planning Process
Misti Wedding, RN, Medical/Surgical/ICU Nurse
Manager, Harrison Memorial Hospital
Harrison Memorial Hospital
Who We Are…
• Speaking; Misti Wedding, RN, Harrison Memorial Hospital Medical/Surgical/ICU Nurse
• Cynthiana, Kentucky, 61 beds, private not-for-profit hospital
• A full-service regional medical center meeting the needs of residents of seven
central Kentucky counties
• HMH and its employees are accredited members of the following organizations, showing
that we meet or exceed strict guidelines for healthcare quality:
• The Joint Commission
• College of American Pathologists
• American College of Radiology for– CT,
Mammography, Nuclear Medicine, MRI
• Fifty-eight percent of hospital staff are
clinical staff members who have multiple
certifications and licensures
Reducing Readmissions
• Our readmission rate for Congestive Heart Failure
(CHF) is higher than the state and the nation.
• Medicare Readmission Rate ( 10/1/08-6/30/10)
• HMH rate for CHF – 26.2 %
• KY rate for CHF – 25.3%
• U.S. rate for CHF – 24.8%
• Goal: Reduce CHF Readmissions by 20% by
December 2013
Reducing Readmissions
• Improve discharge process
– Multidisciplinary team participation
– Community Collaborative against readmissions
– Improve patient compliance
– Standardize discharge process
– Provide CHF patients with the Heart Healthy
– Increase patient safety and improve patient
Improving the Discharge Planning
• Multidisciplinary team approach
• Nurses
• Physicians
• Pharmacists
• Information Technologists
• Dieticians
• Case Managers
• Everyone contributes to the discharge process
Improving the Discharge Planning
• Community Collaborative
• Quarterly meeting with Nursing Homes, Hospice,
Home Health, Physicians, Nurse Practitioners, and
our readmission team members.
• Improve communication.
• Standardize discharge process decreasing
preventable readmissions.
Improving the Discharge Planning
• Discharge teaching and planning begins on admission
• Utilize the teach-back method
• Follow-up phone calls to patients and nursing homes
after discharge. Bedside nurse verifies phone number
with patient at discharge.
• Ensuring patients have the means to be compliant
• Can they afford the prescribed medications?
• Do they have a scale to weigh on daily?
• Are they able to obtain transportation to their
follow-up appointments?
Improving the Discharge Planning
• Heart Healthy Handbook
• CHF discharge instructions
• Low sodium diet with sample menu
• Medication list (Pharmacist review)
• Calendar of appointments
• After hospital care plan
• Weight log
• Scale provided if unable to obtain one
• CHF magnet with heart healthy reminders
• Teach-back method utilized
• Checklist for discharging nurse to complete
Calendar of Appointments
After Hospital Care Plan
Heart Failure Daily Weight Log
CHF Discharge Checklist
Heart Healthy Reminders
Improving the Discharge Planning
• CHF discharge process changes effective
October 1st
• CHF patients are contacted after discharge by
a nurse
– Can they verbalize the instructions they were
– Example: Mrs. Jones can you tell me when your
appointment is with Dr. Besson?
Lessons Learned
• Hard to receive and maintain physician
• Interim team meetings are beneficial to
keeping the interest and process flowing
• Team approach requires the division of
labor and the relinquishing of control
thereby encouraging ownership and buyin.
• Meister, C., 2012. “Re-engineered discharge” A
conversation about Barriers & Opportunities.
K-HEN Kickoff Conference. Retrieved from
Coming Up….
• Upcoming Readmissions Race Events
Eric Coleman, MD
Eric Coleman, MD
Date and Time
Monday, November 05,
12:00 – 1:30 PM, Central
Monday, November 26,
12:00 – 12:45 PM, Central
Hospital Sharing & Coaching
Providing Transitional Care
• Thank you for joining us!

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