Texas Regional Template: Readmissions Workgroup Organization: Children’s Health, Children’s Medical Center

The Texas Regional Hospitals Baylor Scott & White McLane Children’s Medical Center Children’s Health, Children’s Medical Center Children’s Memorial Hermann Hospital Cook Children’s Medical Center Covenant Children’s Dell Children’s Medical Center of Central Texas Driscoll Children’s Hospital Medical City Children’s Hospital Texas Children’s Hospital (Houston) The Children’s Hospital of San Antonio

History Participate in SPS PHIS to Benchmark Readmissions Pioneer HAC; stopped submitting data in 2015 2017 Re-commitment to participate in Readmission HAC work PHIS to Benchmark Monetary penalty from State (2015 Readmission rate)

Gaps in Process Gaps Managing care transitions - lack of resources Med reconciliation challenges – admission thru discharge Patient education – lack of standardization

Readmissions Bundle Elements

Optimizing Transitions to Eliminate Readmissions OTTER Workgroup Established interprofessional group Q3 2016 Initial meetings 2X/month Members Physicians (attending, hospitalist, community-based, etc) Nurses Case Management Patient Education Data Intelligence Identified two patient populations to pilot bundle Standard Bundle High Risk Bundle

Readmission Data Collection Methods Population Standard Bundle Hospitalist-based pediatric specialty unit High Risk Bundle Based on CRG score CRG 9 Catastrophic Conditions Population is primary complex pulmonary patients, trach/vent, etc Developing EPIC Report based on bundle elements Trigger Tools – Investigating how to leverage EPIC to trigger bundle use / alert when readmitted, etc

Readmission Interventions Next Steps: Revise Existing Post Discharge Phone Call Process Pilot discharge call process; automated initial call with opportunity to talk with live RN if a problem Investigate capability of incorporating some standardized scripting Determine capability of existing resources, including StarKids Standardize Discharge Instruction Plan Accurate med list, identification of patient changes, escalation information Implement Teach-Back method Evaluate capability to incorporate social determinants of health into process Determine High Risk Group Mitigation Strategy Determine ability to schedule follow up appointment Investigate a process for providing feedback to clinicians

Readmission Best Practice Recommendations Collaborate with STAR Kids program Evaluate the impact of assessing social determinants of health as part of discharge process Social Factors Demographics SES Social Environment Behavioral Sociocognitive (health literacy, language proficiency) Neighborhood

Readmission Requests for Assistance Information Sharing Challenges Successes

Questions?