1. Readmission Immersion Project 2016
Tonya Meyer, RRT
Quality Management
Southeast Hospital

2. Southeast Hospital
Founded in 1928 as a small, 72 bed community hospital, grown to a highly respected 269 bed regional medical complex.

3. Southeast Hospital
We serve over 675,000 people in 25 counties of southeast Missouri and southern Illinois.

4. Southeast Health Mission statement:
Together we make a difference through our commitment to excellence in health care.
Quality Management Mission statement:
Through empowerment and teamwork we build the foundation of quality and patient safety by serving as a resource to promote ownership in excellence and performance improvement; continuously measuring using metrics essential to the strategic initiatives of Southeast Health.

5. Southeast Health Values: Vision Statement: Vision for Change
Access to Care
Leadership with Responsibility
Unity of Purpose
Excellence in Performance
Service Above Self
Vision Statement:
As a leading provider of health services, Southeast HEALTH is dedicated to continuous improvement of the region’s health status in a collaborative cost-effective manner

6. Background
In early 2015 our CMS pay for performance report indicated high readmission rates for HF, COPD and PN. A multidisciplinary team was assembled and a readmission performance improvement project was approved in January.
In September of 2015 we began participation in the HEN 2.0 readmission immersion project to reduce patient harm, the original project charter and team aim were revised.

7. Multidisc. Team Development
TEAM MEMBERS:
Tonya Meyer – Project Lead
Richard Crowley- Facilitator
Jan Rigdon- Executive Champion
Myrna Ward- Project Champion
Lori Merritt- ED
Julie Metzger-Case Management
Kay Litwicki-RDLD
Valorie Rhodes-SPCU Nurse Manager
Debbie Hoffman-Med tele Nurse Mgr.
Kelly Urhahn-Respiratory Therapy
Mary Beth Corgan-HF APRN
Vickie Schnurbusch-Home Care Services Administrator
Anita Smith-Cardiopulmonary Rehab Mgr.
Blake Urhahn-PharmD
Pauline Arnold-Exec. Dir. of Quality
Lalita Toeniskoetter-Case Management
Amanda Graviett-Administrative Assistant

8. Project Focus Initial Aim (January 2015): To reduce by 12/31/15:
PN readmissions from 15.06% to 13.20%
HF readmissions from 15.23% to 15.08%
COPD readmissions maintain at 15.50%
Revised Aim (10/01/2015):
To reduce all cause readmissions from 10.69% (July-Aug 2015 baseline) to 8.55% by 9/23/16.
Estimated Benefits:
Improve quality of care for patients
Improve patient satisfaction
Improve our pay for performance scores

9. “Without data you are just another person with an opinion. ”. W
“Without data you are just another person with an opinion.” W. Edwards Deming
Data

14. Barriers High disease specific readmission rates
Availability of real time internal data to track disease specific readmissions
Lack of tools for Case Managers reviewing readmissions daily –what do we do with this information?
Unable to mirror the HF APRN program for other disease specific diagnosis .

15. Key Solutions Development of internal reports
Daily readmission reviews
Electronic readmission risk assessment
Electronic patient readmission interview
Better transmission of screening referrals for dietary, respiratory therapy and cardiopulmonary rehab
Implementation and revision of COPD education orders
Cardiovascular service line HF program with APRN involvement
Implementation of a palliative care consult program
Risk based discharge follow up phone calls and follow up appointments-moderate or higher

16. “Inside every solution are the seeds of new problems.” John W. Gardner

17. Interventions-PDSA Cycles
Readmission risk assessment:
Develop an effective risk stratification tool for readmissions
Cycle 1 – trialing the validity of our tool
Cycle 2 – reassessing actions from cycle 1
Cycle 3- evaluating the effectiveness of education for awareness of risk scoring

18. Interventions-PDSA Cycles
Patient readmission interview- Develop a tool to identify why patients are readmitted within 30 days
Cycle 1- paper tool developed and trialed
Cycle 2-evaluated tool w/ additional changes
Cycle 3-determine trends in reasons for readmission – are we asking the right questions?
Medication to Bed trial- Provide new medication directly to the patient by pharmacy at bedside prior to discharge
Cycle 1 – trial conducted – trial suspended
Issues identified:
Time intensiveness of obtaining meds from retail pharmacy and payment
Pharmacy staffing

19. Interventions-PDSA Cycles
Follow up appointments- To ensure patients have follow up appointments scheduled in accordance with risk score prior to discharge
Cycle 1- Reeducation to physicians and nursing staff regarding risk scoring and interventions
Cycle 2-(currently ongoing)
Patients are not always discharged with a scheduled follow up appointment
Not all patients have a primary care physician
Medication Education-Provide more patient friendly information on the purpose and side effects of medications
Cycle 1- Micromedex handouts are not patient friendly
Cycle 2 – Evaluate the switch to Up To Date

20. Lessons Learned
Timely data is imperative to understanding population needs.
Start with a small pilot area – it’s easier to work out the kinks
Tools are useful but without interventions and staff education and understanding the readmission risk score means nothing.
Having interventions in place isn’t enough-there must be awareness, understanding and buy in from physicians and the multidisciplinary care team.

21. Spread and Sustainability
Multidisciplinary daily huddles occur on nursing units
Discharge follow up phone calls for patients at Moderate to
Complex risk for readmission
Daily readmission reports and review for Case Management and Quality
Patient readmission interview report for Case Management and Quality
Complex Care team review
Collaboration with PCP offices and community SNF’s
Continued sharing of data collected during daily reviews with the Readmission team, Performance Improvement committee, Quality Council and Senior Leadership

22. Team Accomplishments
Brought heightened attention to leadership regarding the impact of hospital readmissions
Actions decreased the all cause readmissions to same facility by 45.25%
Actions sparked the creation of a Transitions of Care Coordinator position
Actions facilitated open conversations and collaboration with area SNF’s
Collaboration with IT created useful reports, electronic risk assessments and electronic patient readmission interviews

23. Next Steps
“Change is the law of life and those who look only to the past or present are certain to miss the future.” John F. Kennedy
Increase and improve patient and family engagement
Development of a sound transition of care program to include focus on chronic disease management
Collaboration with community resources including SNF’s and primary care practices not affiliated Southeast Health
Research and understand health disparity impacting our region-develop actions to target this population

24. Questions tmmeyer@sehealth.org 573-331-6151 573-651-5557
Tonya Meyer, RRT