1. ACT Northwest Benton, Washington, Madison Counties
Caren Lyne RN MA
Director of Case Management NW Health
Rebecca Christensen RN
Population Health Management, Humana

2. What is ACT NW Multidisciplinary team:
Physicians, pharmacist, Skilled nursing team members, case management, social workers, home health, care givers, community health workers, physician therapist, dieticians, diabetic educators, congregation, food banks, non profits, city representatives….the community

3. Goals: Decrease Readmissions to acute care hospitals
Effect reductions through coordinated community efforts
quarterly meetings with subcommittees that meet monthly
Focus on reasons patients are readmitted
Implement community wide change

4. Data Analysis
Identified that the highest opportunity for decreasing readmissions in NWA was CHF patients
was with CHF based on data 2015

5. Causes for Readmission of CHF patients
Poor symptom management by patient and family due to limited knowledge
Complicated discharge instructions
Limited access to healthy foods
Medication Management-reconciliation
Lack of knowledge of community resources
Incomplete hand off information between levels of care

6. Sub Committee development
Three current work groups:
Medication reconciliation- beta site for Cornerstone meds to beds program at Northwest, movement toward statewide sub committee.
Communication between acute care and skilled nursing facilities focus on universal hand off, working through testing and implementation
Expanding care giver training and resources in the community working with UAMS and Schmieding Center to coordinate training sessions, other resources i.e. CaregiverAction.org

7. Interventions
Standardizing Congestive Heart Failure education materials across the region
Using the Green, Yellow, Red symptom management from AFMC expanded to Diabetes and COPD. Working to get this distributed to PCP’s
Enhanced patient and care giver knowledge by developing a guide for food banks and meals in NWA by county. Now expanding to the resource list to include all community resources
Enhanced care giver training, use of community health care worker and cross training with care giver training
Consistent hand off tool – universal transfer form
Enhanced medication reconciliation

8. Most recent data

9. Why and how to get involved
Social workers are an integral part of managing readmissions and community outreach: We need you on our team!
Next NWA coalition meeting is April 6th at 10 am in the Schmieding Center for Senior Health and Education
2422 No Thompson St. # B
Springdale
or call if you are interested in participating.