1. MHA Immersion Pilot Project
Reducing All Cause Readmissions at
Ste. Genevieve County Memorial Hospital

2. Hospital Information/Team Members
25 Bed CAH
Smallest clinical cancer research in the USA
Over 100 providers available in our small community
Brandie-Social Services
Missy-QI Director
Laura-Pharmacy
Sheila-IS
Julie-Clinic RN
Kim-Case Manager
Hirschel-Med/Surg Director
Dr. Noguera-Hospitalist
Wanda-Home Health
Laura-ER Director
Carrie-RT Director
Chrissy-RT
Janice-Dietician

3. Project Focus/Problem Statement
Our project goal is to reduce all-cause Readmissions within our 25 bed critical access hospital:
To evaluate the cause of reoccurring patients who have failed the discharge plan
To address concerns from primary care physicians post discharge
Improve patient safety and coordination of care

4. What initial barriers were identified to project implementation?
Patient and family engagement
EMR limitations (Meditech 6.0)
Multi-disciplinary team awareness
External stake holder involvement
Communication issues-across all levels of care
Processes initiated without sustainability/accountability
Staff buy-in

5. Percent of Project Quarterly Tasks Completed
List first quarter task completion 100%
List second quarter task completion 100%
List third quarter task completion 100%

6. Key Solutions Implemented
Developed a process improvement team
Initiated a High Risk Screening tool in our EMR to identify those who are at high risk for readmission and posted on the status board
Created consistent chronic disease education across all levels of care
Implemented a daily multidisciplinary patient care team huddle
Focused on Pharmacy education for all high risk and readmit patients
Re-launching of staff education on Teach-back
Accurate and accessible discharge medication lists and medication safety focus at all levels
Coordinated accurate medication reconciliation at admission, at any change in the level of care and at discharge
Implemented post discharge phone calls within 2 days and follow up appointments within 3-5 days of discharge
Developed a new discharge process i.e. Smart Discharge
Readmission Concurrent Reviews (RAT team)-discuss patients concurrently

7. Key Lessons Learned
Engage your discharge partners (including nursing homes) from the beginning
Verify administration support and involvement to endorse change. Engage your front line leaders. Effective change requires a team!
The need for ongoing re-education was necessary to sustain progress.
There are limitations to EMR adaptability and reporting
Conflicting priorities are a challenge and impacting initial buy-in, clinical staff’s availability and scheduling, and the overall engagement of our team

8. Results

9. Return on Investment
Identified that education was an issue; therefore we are investing in our patients through education across the spectrum. i.e. CHF, Medication, Joint replacement
Saving education materials through consistent education.
Utilizing our care team partners for education i.e. Cardiac Rehab educating CHF; Ortho educating Joint replacement; Pharmacy education for Medications

10. Team Accomplishments Implementation of High Risk Screening tool
Foster good communication between the Intra- disciplinary team
Medication Reconciliation
Pharmacist educating poly-pharmacy and high risk patients
Teachback
Follow up phone calls

11. Sustainability and Spread Plan
Focus on standardizing additional education on other chronic diseases i.e COPD, Diabetes, Pneumonia
Audit follow up phone calls, teachback, follow up appointments and discharge summaries sent to out of town PCP.
Spread Intra-disciplinary huddle to other departments

12. Next Steps/Future Plans
Patient engagement
Initiating Transitional Care support
Sustainability
Additional relationship development with our external stakeholders