Hospital Story Donna Collins, RN,MS/ CPHQ, Quality Manager, Weeks Medical Center, NH.

Slides:

Advertisements

Similar presentations

American Cancer Society Patient Resource Navigation Program Brandon Costantino University of Maryland Medical Center.

Advertisements

Readmissions Experience Hunterdon Medical Center CMO Roundtable October 2014.

2.11 Conduct Medication Management University Medical Center Health System Lubbock, TX Jason Mills, PharmD, RPh Assistant Director of Pharmacy.

Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.

Care Continuity and Patient Care Transitions Kari DiCianni, Director of Innovations & Research.

5/24/20151 Fitting the Pieces Together Utilizing a Hospitalist in the ED to Reduce Admissions Presented by: Patty Williamson, CFO Isidoros Vardaros, M.D.

Improving care transitions at Harborview Medical Center Frederick M. Chen, MD, MPH Chief of Family Medicine Associate Professor, University of Washington.

Risk Assessment - What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH 1 Presented by Washington State Hospital Association.

Proposed Meaningful Use Criteria for Stage 2 and 3 John D. Halamka.

National Readmission Prevention Collaborative Focusing on Readmissions David B. Edwards MD, FACP CMO Banner Home Care and Hospice CMO Banner Pharmacy Service.

Presentation by Bill Barcellona Sr. V. P

A Model to Reduce Acute Care Readmissions Susan Weber, RN Chief Nursing Officer Angela Venditte, LPN, CMCO Assurance HealthCare.

INITIATING DISCHARGE PLANNING PRIOR TO ADMISSION Start Date: October 5, 2012 Report Date: April 5, 2013 Executive Sponsors: David Mountjoy, Dennis McGowan,

Barriers to Care Transitions Each health plan has different forms and different requirements for authorizations Multiple health plan formularies Providers.

The Big Puzzle Evolving the Continuum of Care. Agenda Goal Pre Acute Care Intra Hospital Care Post Hospital Care Grading the Value of Post Acute Providers.

Wentworth-Douglass Hospital Story Kimberly Chapman, RN, MS, CNL, PCCN Discharge Advocate for Project RED Wentworth-Douglass Hospital Dover, NH Monique.

Care Coordination What is it? How Do We Get Started?

PREVENTING READMISSIONS OF CONGESTIVE HEART FAILURE PATIENTS Daidreanna Whiteman Senior Project Columbus State University Summer 2014.

Memorial Hermann Healthcare System Clinical Integration & Disease Management Dan Wolterman April 15, 2010.

Wayne County Hub Discharge Planning Valerie Langley, RN, Nurse Manager Wayne County Hub NC Department of Corrections May 2, 2007.

Safe Transitions Of Care STOC 2011 MHA Pilot- 4Q 2010 Transition responsibility belongs to the sending clinician/organization, until the receiving practitioners.

Reduction Of Hospital Readmissions Hany Salama, MD Diplomat ABIM IM Hospice and Palliative Care Sleep Medicine.

Ambulatory Infusion Center Business Plan

Effective and Supportive Transitions of Care: The Care Teams Role in Reducing Admissions Jim Kinsey, Planetree Presented to Texas Center for Quality and.

5 th Annual Lourdes Cardiology Services Symposium: Cardiology for Primary Care.

Excellent Transitions: Reducing Readmissions Lana McKinney RN, Continuity of Care Service Director Mark Taylor MD, Hospital-Based Services Kaiser Permanente.

TOBACCO CONTROL INITIATIVE HCSD Disease Management Program Quarterly Meeting April 26, 2005 Sarah Moody Thomas, PhD Statewide Clinical Lead.

Interdisciplinary Teamwork in a Transitional Primary Care Clinic Tamara Malm, PharmD, MPH, BCPS September 18, 2015.

Essential Interventions for Improving Transitions of Care Presented By:Cheri Lattimer, RN, BSN - Executive Director, NTOCC & CMSA NTOCC is a 501(c)(4)

Accountable Care Organizations at UCSF Adrienne Green, MD Associate Chief Medical Officer, UCSF Medical Center.

Project RED The Re-Engineered Discharge JCR’s AHRQ-funded Project Florida Hospital Association June 4, 2010 Deborah M. Nadzam, PhD, FAAN Project Director.

A NEW APPROACH TO PATIENT- CENTERED CARE Family Health & Sports Medicine Albert Puerini, MD.

Practice Transformation in a Physician Organization Mary Barton Durfee, M.D. September 17, 2009.

The Christ Hospital Inpatient Palliative Care Consult Service Easing the Burden of Serious Illness.

Fresh Approaches to Patient Education Susan Savastuk MEd, BSN Stroke Program Coordinator Neuroscience Institute Bloomington Hospital Bloomington, IN 1.

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association NYSPFP Preventable Readmissions Pilot Project.

Waukesha County DHHS Clinical Services Division. Project Aims Reduce the number of patients readmitted within 30 days of hospital discharge readmission.

Accelerating Reform Initiative Developing Integrated care: Fayette Companies and Heartland Community Health Center Mike Bolye.

Hospital Discharge Transitions: Follow-up in Primary Care for High Risk Medicaid patients CFCC PCMH High Risk Patient working- group.

Hospital Story Kristen van Bergen-Buteau, CPHQ Assistant Director, Quality Services Littleton Regional Hospital New Hampshire.

Carroll County Memorial Hospital Mindie Stovall LPN, CPHQ Director of Quality and Clinic Nurse Staff.

Latino Health Summit Presentation

HLNDV Spring Institute 2014 May 2, 2014, 1:15-2:45pm Readmission Session.

ADAPTING TRANSITIONAL CARE PROGRAMS WITH PERSON-CENTERED INTERVENTIONS TO IMPACT READMISSION RATES June Simmons, MSW President and CEO, Partners in Care.

Quality Improvement and Care Transitions in a Medical Home Maryland Learning Collaborative May 21, 2014 Stephanie Garrity, M.S., Cecil County Health Officer.

MiPCT Embedded Case management Barriers to developing an embedded Case Management program.

Ty Cobb Regional Medical Center Reducing Readmissions.

Reaching Outside the Hospital to Create Community Partnerships Marcia Colone, Ph.D., MS, LCSW, ACM System Director, UCLA Health, Los Angeles, CA Patient.

Inputs Outputs Outcomes ActivitiesParticipantsShort TermIntermediateLong Term Georgia Hospital Association Disseminate information on best practices in.

Care Management: Developing an Integrated Model of Care.

Readmissions Driver Diagram OHA HEN 2.0. Readmissions AIMPrimary Drivers Secondary DriversChange Ideas Reduce Readmissions Identify patients at high-risk.

Inpatient Palliative Care A hospital service at SOMC where patients can benefit from palliative care consultative services during their hospitalization.

Improving Transitions of Care from Hospital to Home: A Health Care Reform Priority Gina Gill Glass, MD, FAAFP Barbara J. Roehl, MD, MBA, CAQ Geriatrics.

Improving The ABI Transition Experience Hospital to Home/Community Elly Nadorp, MSW.,RSW

Population Health Initiatives: Community Paramedicine Program Lauren Parker, Administrative Fellow.

 Proposed Rule by the Centers for Medicare & Medicaid Services on 11/03/2015Centers for Medicare & Medicaid Services11/03/2015  Revises the discharge.

CJR McLeod Regional Medical Center

MHA Immersion Pilot Project

CTC Clinical Strategy and Cost Committee

Engaging a Microsystem to Reduce 30-Day Readmissions on an Acute Care Unit Erin Johnson, MSN, RN, Sara Stetz, MSN, RN.

Peg Bradke and Rebecca Steinfield

Using the SafeMed model for transitions of care approach

Using the SafeMed model for transitions of care approach

Safe Transitions of Care

Optum’s Role in Mycare Ohio

Southern WV Health System

Stroke Protocols Ensure Efficient Patient Intake, Diagnosis, Treatment

Roadmap to Readmission Reduction: Sharing Resources

Chronic Disease Transitional Care Northridge Hospital Medical Center

Presentation transcript:

Hospital Story Donna Collins, RN,MS/ CPHQ, Quality Manager, Weeks Medical Center, NH

About Us Weeks Medical Center, 25 bed CAH Single entity w/ full service hospital, OP oncology, 4 office practices, home health, hospice Catchment area – primarily older population w/ multiple co-morbid conditions Lowest per capital income in State of NH Long standing history - high re-admission rate

What Did We Test? Follow-up appointments scheduled within 4 days of discharge; appointment phone line established for weekend discharges Earlier referral to Home Care/Hospice/Palliative Care services Post discharge patient phone calls by outpatient case manager/nurses Transition of care summaries ( H&P, discharge summary, discharge medications, instructions) sent to PCP; EMR preparation prior to follow-up visit 3

What Have We Learned So Far? Aligning the readmission reduction goal throughout the organization elevates the goal to a priority status- CEO driven Hospital, office and home health team leaders and representatives are essential ( CMO, CNO, Office Practice Director) A new communication/coordination infrastructure is required- change in employee roles/functions in all care settings Patient and family involvement with follow-up care gets you far but not 100% 4

What Barriers Did We Encounter? Hospital, office and home care information systems are not integrated Medication Reconciliation is still a burden; most patients are discharged on >9 medications Patients and families are optimistic for cure; often prefer acute hospital care late in disease process – delayed referrals to Hospice 5

How Did We Overcome These Barriers? Expanded roles and responsibilities of admitting/communication, case management and clinic nurses to build transition bridge Continuing development of Medical Home model Continuing development of Palliative care program Involvement of Home care and hospice staff in design Patient education regarding palliative care options 6

How Are We Doing Now? YearQuarterNum.Den.% Goal = 6.7% % 4.9% 7.0% 8.5% 5.4% % % % % 7 Readmissions within 30 days

Weeks Medical Center Acute Care Readmission

What Can Others Learn From Our Journey? Share team activities/ updates with medical staff- they are concerned about re-admissions and will offer valuable improvement suggestions Conduct case reviews using a standardized tool; helpful in identifying subtle quality issues and barriers Refer cases into QA peer review process if indicated Re-visit basic processes to check all are functioning well- consistency in patient activity orders; PT/OT evaluations 9

10 Do Not Try This At Home (Suggestions for What Not to Do…) Attempt to implement major changes without MD input and involvement Assume that one or two strategies will fix the problem ( we know it can’t) Implement new work processes without adequate staff education and training