1. Strategies to Prevent Rehospitalizations in Post-Acute Care

2. Strategies to Reduce Re-Hospitalization
Change in Condition Monitoring
Thursday Triage with at Risk List/Alert Charting System
Advanced Care Management
72 hour Care Management Model
Four Pillars of Care
Improved clinical outcomes
IDT Collaboration
Leveraging technology
Use of Amalga Operating System for data analysis
EMR 2

3. Change in Condition Monitoring
Thursday Triage with At Risk List/Alert Charting System
Patients at Risk for Re-hospitalization
All patients/residents assessed as at risk must have alert charting
Alert charting must include VS, SBAR Note if COC, information specific to reason for the risk
Alert charting each shift
All new admissions are considered at risk for re-hosp
Risk
Reason
Follow-Up
Hospital Affiliation 3

4. Advanced Care Management
SBAR: Interact II* tool developed to improve nurse communications to physician
Stop and Watch: Interact II* tool developed to improve nurse communications to physician
Disease Specific Training: Developing expertise throughout the clinical team
Care Management Meeting: IDT bedside visit within 72 hours of patient admit
*Evaluation of INTERACT II - Funded by the Commonwealth Fund : Co-Principal Investigator: Dr. Gerri Lamb - Independence Foundation and Wesley Woods Chair Associate - Professor of Nursing Emory University 4

5. Four Pillars of Care Comprehensive assessment per status change
Early identification of a change of status
Improved documentation around changes in clinical status
Enhanced communication among healthcare providers 5

6. Rehospitalization LC Summary
Leveraging Technology
Rehospitalization LC Summary
This view shows the LivingCenter year to date percentage rate of rehospitalizations, the day of the week in which most of the rehospitalizations are occurring and the number of days they are in the LivingCenter before being rehospitalized 6 6

7. Questions 7