ACT Northwest Benton, Washington, Madison Counties Caren Lyne RN MA Director of Case Management NW Health Rebecca Christensen RN Population Health Management, Humana

What is ACT NW Multidisciplinary team: Physicians, pharmacist, Skilled nursing team members, case management, social workers, home health, care givers, community health workers, physician therapist, dieticians, diabetic educators, congregation, food banks, non profits, city representatives….the community

Goals: Decrease Readmissions to acute care hospitals Effect reductions through coordinated community efforts quarterly meetings with subcommittees that meet monthly Focus on reasons patients are readmitted Implement community wide change

Data Analysis Identified that the highest opportunity for decreasing readmissions in NWA was CHF patients was with CHF based on data 2015

Causes for Readmission of CHF patients Poor symptom management by patient and family due to limited knowledge Complicated discharge instructions Limited access to healthy foods Medication Management-reconciliation Lack of knowledge of community resources Incomplete hand off information between levels of care

Sub Committee development Three current work groups: Medication reconciliation- beta site for Cornerstone meds to beds program at Northwest, movement toward statewide sub committee. Communication between acute care and skilled nursing facilities focus on universal hand off, working through testing and implementation Expanding care giver training and resources in the community working with UAMS and Schmieding Center to coordinate training sessions, other resources i.e. CaregiverAction.org

Interventions Standardizing Congestive Heart Failure education materials across the region Using the Green, Yellow, Red symptom management from AFMC expanded to Diabetes and COPD. Working to get this distributed to PCP’s Enhanced patient and care giver knowledge by developing a guide for food banks and meals in NWA by county. Now expanding to the resource list to include all community resources Enhanced care giver training, use of community health care worker and cross training with care giver training Consistent hand off tool – universal transfer form Enhanced medication reconciliation

Most recent data

Why and how to get involved Social workers are an integral part of managing readmissions and community outreach: We need you on our team! Next NWA coalition meeting is April 6th at 10 am in the Schmieding Center for Senior Health and Education 2422 No Thompson St. # B Springdale Email clyne@nw-health or call 479-757-4751 if you are interested in participating.