Strategies to Prevent Rehospitalizations in Post-Acute Care

Strategies to Reduce Re-Hospitalization Change in Condition Monitoring Thursday Triage with at Risk List/Alert Charting System Advanced Care Management 72 hour Care Management Model Four Pillars of Care Improved clinical outcomes IDT Collaboration Leveraging technology Use of Amalga Operating System for data analysis EMR 2

Change in Condition Monitoring Thursday Triage with At Risk List/Alert Charting System Patients at Risk for Re-hospitalization All patients/residents assessed as at risk must have alert charting Alert charting must include VS, SBAR Note if COC, information specific to reason for the risk Alert charting each shift All new admissions are considered at risk for re-hosp Patient @ Risk Reason Follow-Up Hospital Affiliation 3

Advanced Care Management SBAR: Interact II* tool developed to improve nurse communications to physician Stop and Watch: Interact II* tool developed to improve nurse communications to physician Disease Specific Training: Developing expertise throughout the clinical team Care Management Meeting: IDT bedside visit within 72 hours of patient admit *Evaluation of INTERACT II - Funded by the Commonwealth Fund : Co-Principal Investigator: Dr. Gerri Lamb - Independence Foundation and Wesley Woods Chair Associate - Professor of Nursing Emory University 4

Four Pillars of Care Comprehensive assessment per status change Early identification of a change of status Improved documentation around changes in clinical status Enhanced communication among healthcare providers 5

Rehospitalization LC Summary Leveraging Technology Rehospitalization LC Summary This view shows the LivingCenter year to date percentage rate of rehospitalizations, the day of the week in which most of the rehospitalizations are occurring and the number of days they are in the LivingCenter before being rehospitalized 6 6

Questions 7