Thinking Differently about Hospital Readmissions Presented by Glenna Yaroch, MBA,PT Owner/President Home Instead Senior Care September 12, 2014

Senior Care Continuum

Nutrition Medication Management Doctor Appointments Warning Signs Four Areas of Focus

Personal Side of Care

Richmond, VA Re-Admissions Study

Partner with large for-profit hospital system 55 patient pilot study Primary diagnosis – Heart Failure 30 Day plan of care GOAL: Reduce hospital readmissions by 1% Pilot Study

Risk assessment done on each patient who had heart failure based upon their risk factors Categorized patients level of care - Decided on hours of care based upon the assessment Care plan created on all patients upon discharge Risk Factors and Assessment Limited Moderate Significant

Follow-Up Physician Visit Assistance Nutrition Management Warning Signs Monitoring and Notification Medication Management Care Management with Patient

Hospital readmission rate overall dropped 23.5% (16% to 12.5%) Total hours based on patient need and additional care available ( hours) Able to fill gap in education and compliance Outcome

Livonia, MI Glenna Yaroch

July 2012 to November 2012 with 2 non-profit hospitals - Hospital #1 part of the tenth largest national healthcare system in the U.S. and is a 304 bed acute care community hospital - Hospital #2 is a 220 bed medical/surgical hospital 30 Patient Study Primary diagnosis – CHF (Heart Failure) and COPD 30 Day plan of care (Day 1 is discharge from hospital) GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance Test and Goals Pilot Study

Main focus on patient-centered goals with action plans - Functional goals: drive, grocery shop, wedding, garden A care consultation to be done in the hospital with Home Instead Senior Care, to determine patient specific needs - Build trust, clarify discharge instructions, understand the program Base 30 day plan Week 1: one hour of service for five visits Week 2: one hour of service for four visits Week 3 : one hour of service for three visits Week 4: one hour of service for one or two visits Model

Teach-Back Show-Me Method Patients remember and understand <50% of what clinicians explain to them The model must shift from patient education to patient engagement Critical components for success: Medication management (reconciliation from discharge) Appointment with Primary Care Physician (first week home) Diet (salt) Monitoring vital signs (blood pressure, weight, fluid intake) Warning signs (red flags – red, yellow, green zones) Organization of medical records in the home

Outcomes

Person-centered solutions to reducesolutions to reduce hospital readmissionshospital readmissions