Cook Children’s Medical Center Readmissions Update Jenny Riddle RN, MHA, CPN, CCM, CSSGB

Who is Cook Children’s? Primary service area: six counties Serves children from: 120 counties Population of Tarrant Co.: 1.9 million Children 0-18: 531,083 Cook Children’s Health Care System: Cook Children’s Medical Center Cook Children’s Northeast Hospital Cook Children’s Physician Network Cook Children’s Home Health Cook Children’s Health Plan Cook Children’s Health Foundation Cook Children’s Pediatric Surgery Center We included this slide because we want you to have an idea of what our resources are. We do have a home health and a health plan Source: Claritas Demographics (2007)

Readmissions Bundle Elements Identify high risk populations of patients & develop specialized care plan. Schedule primary provider follow-up appointment prior to discharge. Post discharge phone call to reinforce discharge instructions. Discharge instructions contain a plan for potential problems. Provide Feedback to clinicians on any unplanned readmission. Following the prescribed SPS bundle elements –Want to discuss what we are doing.

High-Risk Population Identified – Asthma Admissions. Identify high risk populations of patients and develop specialized care plan. High-Risk Population Identified – Asthma Admissions. Ensure patients receive Asthma Action Plan when discharged CM places follow-up call

Schedule primary provider follow-up visit. Readmission Rapid Improvement Teams Meet bi-weekly Multi-disciplinary Ongoing PDSA work Discuss opportunities and barriers Audits on discharges Unique perspective of doing Health plan participation

Discharge instructions contain a plan for potential problems Updated Nursing Discharge Instructions Monthly audits with feedback to units

Post discharge phone call to reinforce discharge instructions. CM Staff follow up on all high risk patients DME orders Ostomy/g-button supplies/ wound care supplies and formula Therapy orders SNV or PDN  orders Readmission with  7 days Patients with prior services Five or more medications.

Post discharge phone call to reinforce discharge instructions. Call Center staff place follow up calls on discharged hospitalists patients. Did the patient receive any new Rx and were they filled? Any questions about giving the medications? Has a follow-up been scheduled? Any questions about discharge instructions?

Provide Feedback to clinicians on any unplanned readmission. E-mail Notification from Chief Quality Officer Send to discharging physician & Medical Director Your patient, Mary Smith was readmitted on April 3, 2016. Cook Children’s Medical Center is actively involved in reducing preventable readmissions. Any suggestions you might have to reduce preventable readmissions would be appreciated. Please feel free to e-mail me if you have feedback or questions about this patient or our work on readmissions. May say details of providing feedback.

Data Collection Readmission Report reviewed monthly by Multidisciplinary Readmissions Committee Readmissions within 48 hours, 7 days & 30 days Readmission Dashboard Monthly audit of 40 charts-30 discharges & 10 readmissions for compliance to bundle elements. Data collection right now is archaic. We have a lot of planning going in to gather this data in the future. We have dashboard Rachel’s dashboard. Discuss in committee meeting. Risk Terrain Modeling. Show picture or mention?

Readmission Dashboard

Readmission Rate

Readmission Bundle Compliance

Readmission Interventions CM runs daily readmission report. Family Interview completed by Social Work and Case Manager Opportunities identified to improve discharge care reported to units/readmissions team. Monthly meeting with Case Management/Social Work Team and Quality to review opportunities. Best practice

Social Work/ Case Management Readmission Interview Readmission Interventions Social Work/ Case Management Readmission Interview Specific

Readmission Best Practice Recommendations The Case Managers utilize a fault tree algorithm provided shared by Intermountain to assign preventable and non-preventable categories to all readmissions. Trends and outcomes are shared in the monthly readmission meeting. Quality meets with UR group monthly to review.

Readmission Requests for Assistance Readmission Review Committee Structure. Follow-Up Call Structure Who? When? Outcomes? Provider notification process High-Risk Population processes A smaller group meeting more regularly?

Questions?