Readmission Immersion Project 2016 Tonya Meyer, RRT Quality Management Southeast Hospital

Southeast Hospital Founded in 1928 as a small, 72 bed community hospital, grown to a highly respected 269 bed regional medical complex.

Southeast Hospital We serve over 675,000 people in 25 counties of southeast Missouri and southern Illinois.

Southeast Health Mission statement: Together we make a difference through our commitment to excellence in health care. Quality Management Mission statement: Through empowerment and teamwork we build the foundation of quality and patient safety by serving as a resource to promote ownership in excellence and performance improvement; continuously measuring using metrics essential to the strategic initiatives of Southeast Health.

Southeast Health Values: Vision Statement: Vision for Change Access to Care Leadership with Responsibility Unity of Purpose Excellence in Performance Service Above Self Vision Statement: As a leading provider of health services, Southeast HEALTH is dedicated to continuous improvement of the region’s health status in a collaborative cost-effective manner

Background In early 2015 our CMS pay for performance report indicated high readmission rates for HF, COPD and PN. A multidisciplinary team was assembled and a readmission performance improvement project was approved in January. In September of 2015 we began participation in the HEN 2.0 readmission immersion project to reduce patient harm, the original project charter and team aim were revised.

Multidisc. Team Development TEAM MEMBERS: Tonya Meyer – Project Lead Richard Crowley- Facilitator Jan Rigdon- Executive Champion Myrna Ward- Project Champion Lori Merritt- ED Julie Metzger-Case Management Kay Litwicki-RDLD Valorie Rhodes-SPCU Nurse Manager Debbie Hoffman-Med tele Nurse Mgr. Kelly Urhahn-Respiratory Therapy Mary Beth Corgan-HF APRN Vickie Schnurbusch-Home Care Services Administrator Anita Smith-Cardiopulmonary Rehab Mgr. Blake Urhahn-PharmD Pauline Arnold-Exec. Dir. of Quality Lalita Toeniskoetter-Case Management Amanda Graviett-Administrative Assistant

Project Focus Initial Aim (January 2015): To reduce by 12/31/15: PN readmissions from 15.06% to 13.20% HF readmissions from 15.23% to 15.08% COPD readmissions maintain at 15.50% Revised Aim (10/01/2015): To reduce all cause readmissions from 10.69% (July-Aug 2015 baseline) to 8.55% by 9/23/16. Estimated Benefits: Improve quality of care for patients Improve patient satisfaction Improve our pay for performance scores

“Without data you are just another person with an opinion. ”. W “Without data you are just another person with an opinion.” W. Edwards Deming 2015-2016 Data

Barriers High disease specific readmission rates Availability of real time internal data to track disease specific readmissions Lack of tools for Case Managers reviewing readmissions daily –what do we do with this information? Unable to mirror the HF APRN program for other disease specific diagnosis .

Key Solutions Development of internal reports Daily readmission reviews Electronic readmission risk assessment Electronic patient readmission interview Better transmission of screening referrals for dietary, respiratory therapy and cardiopulmonary rehab Implementation and revision of COPD education orders Cardiovascular service line HF program with APRN involvement Implementation of a palliative care consult program Risk based discharge follow up phone calls and follow up appointments-moderate or higher

“Inside every solution are the seeds of new problems.” John W. Gardner

Interventions-PDSA Cycles Readmission risk assessment: Develop an effective risk stratification tool for readmissions Cycle 1 – trialing the validity of our tool Cycle 2 – reassessing actions from cycle 1 Cycle 3- evaluating the effectiveness of education for awareness of risk scoring

Interventions-PDSA Cycles Patient readmission interview- Develop a tool to identify why patients are readmitted within 30 days Cycle 1- paper tool developed and trialed Cycle 2-evaluated tool w/ additional changes Cycle 3-determine trends in reasons for readmission – are we asking the right questions? Medication to Bed trial- Provide new medication directly to the patient by pharmacy at bedside prior to discharge Cycle 1 – trial conducted – trial suspended Issues identified: Time intensiveness of obtaining meds from retail pharmacy and payment Pharmacy staffing

Interventions-PDSA Cycles Follow up appointments- To ensure patients have follow up appointments scheduled in accordance with risk score prior to discharge Cycle 1- Reeducation to physicians and nursing staff regarding risk scoring and interventions Cycle 2-(currently ongoing) Patients are not always discharged with a scheduled follow up appointment Not all patients have a primary care physician Medication Education-Provide more patient friendly information on the purpose and side effects of medications Cycle 1- Micromedex handouts are not patient friendly Cycle 2 – Evaluate the switch to Up To Date

Lessons Learned Timely data is imperative to understanding population needs. Start with a small pilot area – it’s easier to work out the kinks Tools are useful but without interventions and staff education and understanding the readmission risk score means nothing. Having interventions in place isn’t enough-there must be awareness, understanding and buy in from physicians and the multidisciplinary care team.

Spread and Sustainability Multidisciplinary daily huddles occur on nursing units Discharge follow up phone calls for patients at Moderate to Complex risk for readmission Daily readmission reports and review for Case Management and Quality Patient readmission interview report for Case Management and Quality Complex Care team review Collaboration with PCP offices and community SNF’s Continued sharing of data collected during daily reviews with the Readmission team, Performance Improvement committee, Quality Council and Senior Leadership

Team Accomplishments Brought heightened attention to leadership regarding the impact of hospital readmissions Actions decreased the all cause readmissions to same facility by 45.25% Actions sparked the creation of a Transitions of Care Coordinator position Actions facilitated open conversations and collaboration with area SNF’s Collaboration with IT created useful reports, electronic risk assessments and electronic patient readmission interviews

Next Steps “Change is the law of life and those who look only to the past or present are certain to miss the future.” John F. Kennedy Increase and improve patient and family engagement Development of a sound transition of care program to include focus on chronic disease management Collaboration with community resources including SNF’s and primary care practices not affiliated Southeast Health Research and understand health disparity impacting our region-develop actions to target this population

Questions tmmeyer@sehealth.org 573-331-6151 573-651-5557 Tonya Meyer, RRT tmmeyer@sehealth.org 573-331-6151 573-651-5557