MHA Immersion Pilot Project Reducing All Cause Readmissions at Ste. Genevieve County Memorial Hospital

Hospital Information/Team Members 25 Bed CAH Smallest clinical cancer research in the USA Over 100 providers available in our small community Brandie-Social Services Missy-QI Director Laura-Pharmacy Sheila-IS Julie-Clinic RN Kim-Case Manager Hirschel-Med/Surg Director Dr. Noguera-Hospitalist Wanda-Home Health Laura-ER Director Carrie-RT Director Chrissy-RT Janice-Dietician

Project Focus/Problem Statement Our project goal is to reduce all-cause Readmissions within our 25 bed critical access hospital: To evaluate the cause of reoccurring patients who have failed the discharge plan To address concerns from primary care physicians post discharge Improve patient safety and coordination of care

What initial barriers were identified to project implementation? Patient and family engagement EMR limitations (Meditech 6.0) Multi-disciplinary team awareness External stake holder involvement Communication issues-across all levels of care Processes initiated without sustainability/accountability Staff buy-in

Percent of Project Quarterly Tasks Completed List first quarter task completion 100% List second quarter task completion 100% List third quarter task completion 100%

Key Solutions Implemented Developed a process improvement team Initiated a High Risk Screening tool in our EMR to identify those who are at high risk for readmission and posted on the status board Created consistent chronic disease education across all levels of care Implemented a daily multidisciplinary patient care team huddle Focused on Pharmacy education for all high risk and readmit patients Re-launching of staff education on Teach-back Accurate and accessible discharge medication lists and medication safety focus at all levels Coordinated accurate medication reconciliation at admission, at any change in the level of care and at discharge Implemented post discharge phone calls within 2 days and follow up appointments within 3-5 days of discharge Developed a new discharge process i.e. Smart Discharge Readmission Concurrent Reviews (RAT team)-discuss patients concurrently

Key Lessons Learned Engage your discharge partners (including nursing homes) from the beginning Verify administration support and involvement to endorse change. Engage your front line leaders. Effective change requires a team! The need for ongoing re-education was necessary to sustain progress. There are limitations to EMR adaptability and reporting Conflicting priorities are a challenge and impacting initial buy-in, clinical staff’s availability and scheduling, and the overall engagement of our team

Results

Return on Investment Identified that education was an issue; therefore we are investing in our patients through education across the spectrum. i.e. CHF, Medication, Joint replacement Saving education materials through consistent education. Utilizing our care team partners for education i.e. Cardiac Rehab educating CHF; Ortho educating Joint replacement; Pharmacy education for Medications

Team Accomplishments Implementation of High Risk Screening tool Foster good communication between the Intra- disciplinary team Medication Reconciliation Pharmacist educating poly-pharmacy and high risk patients Teachback Follow up phone calls

Sustainability and Spread Plan Focus on standardizing additional education on other chronic diseases i.e COPD, Diabetes, Pneumonia Audit follow up phone calls, teachback, follow up appointments and discharge summaries sent to out of town PCP. Spread Intra-disciplinary huddle to other departments

Next Steps/Future Plans Patient engagement Initiating Transitional Care support Sustainability Additional relationship development with our external stakeholders