1. © 2005 Baylor Health Care System Smoothing the Transition Paula Chaloupka, MSN, RN, ACM, NEA-BC Director of Social Work and Care Coordination Baylor All Saints Medical Center at Fort Worth Fort Worth, Texas Sean Burton and Matt Zavadsky MedStar Emergency Medical Services Fort Worth, Texas

2. © 2005 Baylor Health Care System Goal: Decrease readmissions from Long Term Care Began quarterly meetings with our top 12 nursing homes we referred to Theme: Have a Heart CHF education and a heart healthy meal Host with questions at each table to elicit concerns

3. © 2005 Baylor Health Care System Concerns with transfers from Acute to LTC Bottle neck Friday at 5p No pharmacy available after 5p Inconsistent report

4. © 2005 Baylor Health Care System Concerns with transfers from LTC to Acute Don’t know what happened at LTC Don’t know DNR status

5. © 2005 Baylor Health Care System Solutions for Improved Communication Work to transfer earlier in the day, earlier in the week Ensure triplicate prescriptions are sent with patient Complete Extended Care Referral Form Complete Referral Transfer Form from INTERACT II Document DNR status on the INTERACT II form Use neon colored envelopes for transfer papers

6. © 2005 Baylor Health Care System Provided Educational Opportunities LTC’s are raising the bar of their care so the patient can stay and receive appropriate care and not transfer unnecessarily to the hospital More LTC’s are using the INTERACT II tools and SBAR training with staff We provided presentations at our luncheons by CNS, Social Work, Dietitian, Wound Care nurse and Care Coordination (Case management) which could also be given to LTC staff. We provided forms and a teaching DVD for participants to use at their facilities

7. © 2005 Baylor Health Care System Topics Presented by BASMC at the LTCs Congestive Heart Failure Sepsis Pain Management Advance Care Planning Medical Power of Attorney Hospice Palliative Care Nutrition Wound Care

8. © 2005 Baylor Health Care System Transition to Readmission Prevention Task Force Facilities that were active participants in our quarterly nursing home meetings were invited to join our hospital task force Additional community representatives from LTAC, Hospice, Home Healthcare, Area Agency on Aging and EMS (Medstar) were included Representatives attended the hospital training on patient education and our readmission prevention process We are doing case studies for the team to identify learning opportunities Our readmission rate decreased for the FY12 from 14.5% to 13.4% for CHF, AMI and Pneumonia

9. © 2005 Baylor Health Care System Contact Information Paula Chaloupka, MSN, RN, ACM, NEA-BC Director, Social Work and Care Coordination Baylor All Saints Medical Center at Fort Worth 817-922-1054 paula.chaloupka@baylorhealth.edu Interventions to Reduce Acute Care Transfers http://www.interact2.net