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HOSPITALTO HOME ~ Perfecting Transitions HOSPITAL TO HOME ~ Perfecting Transitions H 2 H Mary McDonough RN, Practice Administrator Ann Skelton, MD, Chief,

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Presentation on theme: "HOSPITALTO HOME ~ Perfecting Transitions HOSPITAL TO HOME ~ Perfecting Transitions H 2 H Mary McDonough RN, Practice Administrator Ann Skelton, MD, Chief,"— Presentation transcript:

1 HOSPITALTO HOME ~ Perfecting Transitions HOSPITAL TO HOME ~ Perfecting Transitions H 2 H Mary McDonough RN, Practice Administrator Ann Skelton, MD, Chief, Department of Family Medicine

2 Why? The transition from hospital to home is one of the most problem-prone and costly aspects of medical care in the U.S.

3 49% experience medical errors 42% medication continuity error 23% experience adverse event 62% pending tests without follow up 1% DC summaries available 72 hours 42% patients able to state diagnosis 37%understand reason for medications H2H - The Challenge

4 H2H - What Helps? Availability of discharge summary Short interval to first follow up Transition coaches Communication of unresolved problems Patient education Monitor drug therapy & overall condition Re-engineering the Discharge, Checklist

5 Increase patients with: Discharge summary completed at time of discharge Medication reconciliation completed at discharge Follow up visit booked at time of discharge Decrease readmission rates Improve patient and family understanding of diagnoses and medications Trial a novel approach to follow up visits and achieve patient satisfaction with those visits H2H - Goals

6 H2H - Methods Multidisciplinary planning group, inpatient and outpatient Current and optimal workflow Communication with stakeholders 6 month pilot

7 H2H - Hospital Workflow Registry for FMC patients admitted to our service Update medications in EHR on admission and discharge Complete DC summary at time of discharge Book appointment for H2H visit at discharge with explanatory brochure Communication to office via EHR on admission and discharge

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9 H2H - Office Workflow RN reviews H2H desktop daily RN calls patient/family within 48 hrs to: –Review medications –Address questions, outstanding issues, concerns –Confirm follow up H2H appointment RN H2H phone note

10 H2H – RN H2H Phone Note PCP: Hospital Admit Date: Hospital Discharge Date: Admit Symptoms: Discharge Diagnosis: Secondary Diagnoses: Any major events while hospitalized: Abnormal labs/studies during hospitalization: Medication Reconciliation: Y/N Pending diagnostic/lab results: Planned care needs: Follow up appointments and/or testing:

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12 H2H - Group Visit Group visit for all FM Center patients discharged in prior week Every Wednesday morning at 9 am Multidisciplinary team

13 H2H – The Team Social worker Health educator RNs Medical Office Assistants Resident and attending physician Pharmacist Care manager Translators

14 8:30 – 9:00Team huddle 9:00 – 9:15Introductions Discuss hospital experience Resources 9:15-9:45Med review, reconciliation, adherence, literacy (RN, MD, pharmacist) 9:45-10:15Physician exam, assessment, plan 10:15-10:30Schedule follow up appointments, tests Patient survey, wrap up Team debrief and refine for coming week H2H - Group Visit

15 Where?

16

17 Medications Added to Medication List: 1) Gemfibrozil 600 Mg Tabs (Gemfibrozil).... One tab by mouth twice daily, 30 min before meals for cholesterol 2) Simvastatin 40 Mg Tabs (Simvastatin).... 1 tab by mouth at bedtime, for total of 50 mg for cholesterol 3) Allopurinol 100 Mg Tab (Allopurinol).... Take one pill daily for gout 4) Warfarin Sodium 10 Mg Tabs (Warfarin sodium).... One tab by mouth daily at 6:00 pm to thin blood 5) Toprol Xl 50 Mg Tab Cr (Metoprolol succinate).... One tab by mouth daily for blood pressure

18 Medications Added to Medication List (continued): 6) Wellbutrin Xl 150 Mg Tb24 (Bupropion hcl).... One tab by mouth daily for depression; rx dr boyack 7) Lamictal 150 Mg Tabs (Lamotrigine).... 2 by mouth at bedtime for depression rx. psych, dr. boyack 8) Spiriva Handihaler 18 Mcg Caps (Tiotropium bromide monohydrate).... Take one inhalation per day for breathing 9) Ventolin Hfa Aers (Albuterol sulfate aers).... 2 puffs four times daily as needed for breathing 10) Nicoderm Cq 21 Mg/24hr Ptch24 (Nicotine).... Apply one patch daily to quit smoking Medications removed from Medication List: 1) Prilosec 20 Mg Cpdr (Omeprazole)..... Take 1 by mouth q day 2) Hydroxyzine Hcl 25 Mg Tabs (Hydroxyzine hcl)..... 1-2 tabs by mouth q 6 hours

19 Pharmacist Checks adherence Checks literacy

20 175 FMC Patients Admitted to FM Inpatient Service –Excluded expired, hospice, transfer service before discharge, surgical follow up or out of town = 162 DC summary in 24 hours: Increased from 85% to 98% FU visit within 2 weeks: 96% overall Eligible patients attended group visit: 57% H2H - Outcomes

21 Pilot: 30 day readmission rates –Service as a whole: Decreased from 14.2% to 12.6 % –Nursing facility: 4.8% –Office, not H2H follow up: 9.4% –H2H visit for follow up: 2.4% –FMC patients, overall4.9% Readmission rates June 09- September 10 –FMC patients8.9% –H2H visits for follow up6.7%

22 Annual added cost of process is $30, 212 Annual gross revenue from H2H visits is $30,368 Annual cost savings from reducing readmissions from 14.2% to 12.6% = $158,884 Imagine if we could reduce all to 4.9% = $917,194 H2H – Financial Impact

23 Q3. Understood which medications to take and how when left hospital Q4. Understood medications after group visit Agree Strongly Agree 87% to 100% H2H – Patient Survey

24 Q5. Understood plans for care, including doctor’s visits, tests, therapy after discharge Q6. Understood plans after group visit Agree Strongly Agree 89% to 100% H2H – Patient Survey

25 Q7. I would recommend this type of visit to help with going home Agree Strongly Agree 100% H2H – Patient Survey

26 H2H – Patient Comments “Better understanding of services and how to employ these” “Learned a lot more about things and understood better” “Questions were answered” “Finding out about all my meds”

27 H2H – Physician Survey Improvement in: –Discharge summary availability94% –Medication reconciliation94% –Efficiency of office visit after discharge94% –Scheduling follow-ups & consults89% Comments: –“incredibly helpful” –“catching things that used to fall through the cracks” –“med list up-to-date... has been HUGE” –“more time and responsibility on inpatient team”

28 H2H - Lessons Learned Patient’s perceptions & expectations of visit Partnerships improve care Families matter Health information Training & standardization (staff/physicians) Frequent readmissions, or our “superutilizers” – how do we support their care in the community?

29 H2H – Next Steps Focus on “superutilizers” Spread initiative to other patient groups –Rehabilitation facility discharges –Patients hospitalized on other services Spread model to other practices

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