ACT Delta The ACT Delta chose 4 topics that we feel are barriers for our patients being able to get the resources needed in our region of the state. Transportation: Many complex factors play a role in readmissions, but sometimes it’s as simple as the patient “doesn’t have a ride”. Patients who are unable to get to follow-up visits, pharmacies, and outpatient therapies will not be able to successfully manage their conditions outside of the hospital. ACT Delta has identified this simple, yet crucial barrier as something we must work together to overcome for our patients. The transportation subcommittee is working together to identify resources for our patients in order to ensure essential outpatient needs can be accessed post hospitalization. Caregiver Training/ Support: High risk readmission patients face many struggles to manage chronic conditions. These patients often face these struggles with the help of caregivers. These caregivers must be recognized as a very important part of the readmission reduction efforts. The caregiver team is working together to identify how we can better identify caregivers, their needs, and resources that ensure they can successfully care for their loved ones at home.

Handoff Process Between Levels of Care: Medical professionals recognize there are many issues involved in hand-offs. It is crucial that essential medical and social information is passed along to the receiving caregiver. ACT Delta is working together with the other Coalitions to develop a Universal Transfer Form that can be easily used by all healthcare settings. This form will follow the patient from one setting to another. Physician Education Regarding Readmission Reduction Efforts: Physicians play a vital role in readmission reduction efforts. Members of this committee are working on how they can have a meaningful conversation with physicians in our region about this matter. Their struggles are determining the best way to define the issues and understanding the best way to communicate resources to the physicians. This ACT Delta committee has identified some possible physician champions to utilize as sounding boards as they begin to move forward with productive goals in physician interdisciplinary communication goals.

Reducing Readmissions: As we all know readmissions is something that will always be at the forefront of healthcare conversations and data. The question is how do we control and manage it? By sharing ideas and processes, ACT Delta has been trying new things to see if they can answer that question. Two of the coalition Home Health agencies have had their staff trained in the Diabetes Empowerment Education Program (DEEP). This will allow our home bound population and their caregiver the opportunity to have a better understanding of managing their diabetes. Readmission data has been tracked over the past year and we are projecting that with the initiation of DEEP in the home, this rate will further decrease. Utilization of a 30 day call log for the patients who are new to Home Health, recently rehospitalized or experiencing new complex problems. This process has already proven itself successful by avoiding unnecessary emergency room visits. By calling daily, early problems are easily identified and necessary interventions can be initiated with collaboration with the Primary Provider.

All ACT Delta coalition members were excited to share with each other The Zone Tools for COPD, CHF, and DM.  These tools were provided by TMF and have made education for patients/family/caregivers more streamlined and direct by using a simple red, yellow or green zone to identify actions that need to be taken. We are currently partnering with The Greater Delta Alliance for Health to have our Resource Guide updated. Making all current resources available known to referral sources will help eliminate obstacles on both ends. ACT Delta meets quarterly beginning in January, on the third Wednesday. If you are in our region we would love to have you join us.

La Juan Scales, RN, BSN scalesl@chicotmemorial.com Director, Chicot Memorial Medical Center Home Health Lake Village, AR 71653 Lauren Ashford, LMSW lauren.ashford@chicotmemorial.com Chicot Memorial Medical Center