MHA Immersion Pilot Project Mercy Hospital Springfield Improving Transitions of Care and Reducing Hospital Readmissions for Total Hip and Knee Arthroplasty Brenda Huddleston, RN, BSH, Quality Improvement Analyst Dr. Brian Neely, MD, FAAFP, Hospitalist Mercy Orthopedic Hospital

Total Hip and Knee Arthroplasty Readmissions Readmissions are above CMS expected rate, resulting in a large financial penalty and reduced hospital quality rating. Readmission rate negatively impacts contracting discussions with insurers and employers. Readmissions are also disruptive to patients and their families, and result in lower satisfaction with care.

Mercy Hospital Springfield Tertiary hospital and Level 1 trauma center 34,062 acute discharges 12,437 inpatient and 25,789 outpatient surgeries 92,836 ED visits

Goal Medicare all-cause 30 day unplanned readmission rate < 2% for elective Total Hip and Knee Arthroplasty.

What initial barriers were identified to project implementation? Difficulty coordinating care across both inpatient and outpatient spectrums. Postoperative communication delays and inconsistency. Inconsistent medication reconciliation. Perception that we cannot prevent readmissions or impact what happens after discharge. Increased difficulty of impacting decisions after patient arrival to the Emergency Department.

THA/TKA Key Solutions Implemented Conducted real-time readmission patient interviews to obtain the patient’s perspective. Instituted a standardized bowel regimen to proactively reduce opioid-induced post-operative constipation and ileus. Implemented an electronic smart phrase to pull the readmission risk score into progress notes. Designed and implemented a smart phrase utilizing the Charlson comorbidity score to aid with preoperative decision making.

THA/TKA Key Solutions Implemented Redesigned the process and frequency of post- discharge phone calls. Implemented a “hotline” number for post- surgical patients to call regarding any follow-up needs or concerns. Monthly detailed chart review of every readmission to assess trends for contributing factors and opportunities for improvement. Monthly tracking sheet displayed for surgeons and advanced practice professionals.

Key Lessons Learned Listen to the voices of the patient and family. Develop inpatient and outpatient coalitions and partnerships for shared learning, barrier mitigation and sharing of successes. Develop data infrastructure and analytics for real-time solutions, and in a user-friendly format for consistent use. A proactive, consistent team-based approach is required to impact patients prior to their arrival to the Emergency Department.

Mercy Hospital Springfield THA/TKA Medicare all Cause Unplanned Readmission

Return on Investment Inpatient and outpatient multidisciplinary team approach helped us embrace a spirit of teamwork. Patients and families were excited to be part of the process and the information obtained was an integral part of our improvement process. Improved insight into why readmissions occur and how we can reduce readmissions that we once considered impossible to impact.

Team Accomplishments Marked and continued reduction in both Medicare and Overall Readmission Rates. Increased engagement of surgeons, nursing, administration, and support staff aligned with a common goal. Choosing a defined focus and scope allowed the team to make rapid changes in direction based on initial results and feedback, and will function as a basis for wider upcoming changes.

Sustainability and Spread Plan Front-line staff, physicians, and leaders share accountability for success. Continue structured team to focus on improvement activities and sustainment of interventions. Quality improvement topic prominent during huddles. Organizational metrics used to track improvements. Continue monthly case review.

Next Steps/Future Plans Sepsis team to evaluate the impact of pneumonia cohort expansion (aspiration pneumonia, sepsis with pneumonia POA) and identify opportunities for improvement. Address variation in providers’ documentation and the impact on risk adjustment. Establish community partnerships to identify community resources and resiliency. Enhance readmission risk score to include socioeconomic factors.