Good Samaritan Hospital Readmission Risk Assessment and Intervention Algorithm John Robinson, MD, VP Medical Affairs, Good Samaritan Hospital Theresa Wnek RN, Clinical Process Management Consultant

Project Selection Approximately 28% of readmissions are avoidable At the federal level, they estimate these readmissions account for over 12 Billion dollars Focusing on readmissions and creating a more collaborative approach provides: Safe transitions of care; A more integrated discharge planning process; and Better adaptation of the patient to their post hospital setting This focus on readmissions aligns well with TriHealth’s Strategic plan to become a leader in Quality, Safety and Service 2

Situational Analysis Through the participation of the STAAR Program, PDCA and small tests of change methodology were used to improve clinical outcomes Perform enhanced admission assessment for post-hospital discharge needs Development of a Readmission Risk Assessment Tool Creation of a tool to align readmission risk level with interventions Refine post discharge follow up care The aim was to: Reduce 30 day all cause readmissions Improve on the following 4 HCAPHS scores by Clear communication by nurses Clear communication by doctors Talking to patients about help after discharge Providing written discharge instructions 3

Readmission Risk and Intervention Algorithm 4

Results A clearly defined method to guide patient interventions from admission to the post discharge care A 20% increase in Top Box Score for Nurse Communication A 2-3% Increase number of home care referrals A 14% Decrease number of interventions required post discharge 5