Reducing Bounce Back Lorissa MacAllister Zhuoyang Li Pramit Sengupta Georgia Tech Health System Institute Hospital to Home: Maintaining Continued Healing

BOUNCE BACK DEFINED A readmission is defined as a hospitalization that occurs shortly after a discharge; which is most often measured as within 30 days but it could be shorter or longer. Such readmissions are often but not always related to a problem inadequately resolved in the prior hospitalization.

Enormous Cost

Identifying Patient Population The hospitals identify and target patients at the highest risk for readmissions, particularly heart failure patients, the very elderly, patients with complex medical and social needs, and those without the financial resources to obtain post-hospital care.

Problem Statement Patients bounce back to hospital after discharge because they are not able to maintain the regiments of treatment at home. There are multiple problems for not being able to maintain the regiments of treatment at home. These are: lack of education, care- giver support, insufficient training to transition, not following the care plan, lack of ability to problem solve changes. Hospital to Home: Maintaining Continued Healing

Hospital to Home: Industry Identified Problems Education for the family and patient Being able to go home and have support that you need for continuous care Transition of E monitoring and continuity of care Remembering your care plan Being able to problem solve changes, self care

Education for the family and patient: Education Educate the patient about his or her diagnosis throughout the hospital stay

Education for the family and patient: Unconscious Incompetent Health Making the right choices for the right reasons.

Home Support for continuous care: Community Health Providers Align hospitals’ efforts with those of community providers to provide a range of care. While this may be best achieved in integrated systems, such cooperation can be facilitated through collaborative relationships among hospital and community providers.

Organize post-discharge services Home Support for continuous care: Post Discharge Services

Transition Continuity of care: Systems Level Solution

Transition Continuity of care: Transition Solution

Remembering your care plan: Discharge Instructions Easy to understand discharge instruction

Protocol of change followed by Physicians in hospitals. – Chief complaint – Present illness – Past history – Social history – Occupational history Being able to problem solve changes: Self Care

SOLUTIONS Kit of Care. Simulation of a Day. Problem decision tree. Network of care

Kit of Care Identify roles (primary and secondary care gives Segmented by time of day – Medication – Instructions – Activities – nutrition Could be both physical and virtual

Simulation of a day Role play in the hospital prior to leaving care delivery. Shadow the nurse. No discharge delay Problem solving

Problem Decision tree Phone numbers to call instead of ED Allow clear decisions to be made Empowering self care

Network of caregiver and tracking The patient keeps record of what they are doing Each care giver primary and secondary is alerted that care is complete or not complete.

Lorissa MacAllister Zhuoyang Li Pramit Sengupta