1. Texas Regional Template: Readmissions Workgroup Organization: Children’s Health, Children’s Medical Center

2. The Texas Regional Hospitals
Baylor Scott & White McLane Children’s Medical Center
Children’s Health, Children’s Medical Center
Children’s Memorial Hermann Hospital
Cook Children’s Medical Center
Covenant Children’s
Dell Children’s Medical Center of Central Texas
Driscoll Children’s Hospital
Medical City Children’s Hospital
Texas Children’s Hospital (Houston)
The Children’s Hospital of San Antonio

3. History Participate in SPS PHIS to Benchmark
Readmissions Pioneer HAC; stopped submitting data in 2015
2017 Re-commitment to participate in Readmission HAC work
PHIS to Benchmark
Monetary penalty from State (2015 Readmission rate)

4. Gaps in Process Gaps Managing care transitions - lack of resources
Med reconciliation challenges – admission thru discharge
Patient education – lack of standardization

5. Readmissions Bundle Elements

6. Optimizing Transitions to Eliminate Readmissions OTTER Workgroup
Established interprofessional group Q3 2016
Initial meetings 2X/month
Members
Physicians (attending, hospitalist, community-based, etc)
Nurses
Case Management
Patient Education
Data Intelligence
Identified two patient populations to pilot bundle
Standard Bundle
High Risk Bundle

7. Readmission Data Collection Methods
Population
Standard Bundle
Hospitalist-based pediatric specialty unit
High Risk Bundle
Based on CRG score
CRG 9 Catastrophic Conditions
Population is primary complex pulmonary patients, trach/vent, etc
Developing EPIC Report based on bundle elements
Trigger Tools – Investigating how to leverage EPIC to trigger bundle use / alert when readmitted, etc

8. Readmission Interventions
Next Steps:
Revise Existing Post Discharge Phone Call Process
Pilot discharge call process; automated initial call with opportunity to talk with live RN if a problem
Investigate capability of incorporating some standardized scripting
Determine capability of existing resources, including StarKids
Standardize Discharge Instruction Plan
Accurate med list, identification of patient changes, escalation information
Implement Teach-Back method
Evaluate capability to incorporate social determinants of health into process
Determine High Risk Group Mitigation Strategy
Determine ability to schedule follow up appointment
Investigate a process for providing feedback to clinicians

9. Readmission Best Practice Recommendations
Collaborate with STAR Kids program
Evaluate the impact of assessing social determinants of health as part of discharge process
Social Factors
Demographics
SES
Social Environment
Behavioral
Sociocognitive (health literacy, language proficiency)
Neighborhood

10. Readmission Requests for Assistance
Information Sharing
Challenges
Successes

11. Questions?