1. Readmissions Experience Hunterdon Medical Center CMO Roundtable October 2014

2. Background Hunterdon Medical Center is a 176 bed hospital in west-central New Jersey It is part of Hunterdon Healthcare, which also includes Hunterdon Regional Community Health (home care, visiting nurse, and hospice) and Mid-Jersey (for profit arm) Hunterdon Healthcare partnered with the Hunterdon Physician Practice Association, an IPA, to form Hunterdon HealthCare Partners

3. Background Readmissions Committee work began in 2011 in anticipation of CMS penalties to begin in fiscal 2012 Focused on CHF first as we had the highest rate out of the three First looked at patient education

4. AMI

5. CHF

6. Pneumonia

7. Patient Education Created forms for nursing to document education during the inpatient stay Used a “stop light” system for patient self- assessment after discharge Tried to institute a discharge “test” for teach-back

9. Why Are Patients Readmitted We had our patient care managers complete a short questionnaire with readmitted patients Did the questionnaire with 50 patients Did not see any real trends

11. CHF Study Conclusions –37% of these patients left HMC without an appointment to see their doctor on the first admission –16% of these patients left HMC without an appointment to see their doctor on the second admission –60% of these patients were 81 years of age or older –64% of these patients were discharged to home

12. Partnering with Post-Acute Providers Post Acute Providers were added to the Committee INTERACT II (Interventions to Reduce Acute Care Transfers) Program introduced at one nursing home –Program to identify early changes in resident status that could lead to hospitalization –Tools available through http://interact2.net/

17. Expansion of the Committee Role In September 2012, the Committee decided to look globally at readmissions and to look at processes around readmissions including: –Discharge checklists –Transfer of Information –Medication Reconciliation

18. Risk Stratification We beta tested a program called Crimson RealTime from the Advisory Board Company Using historical billing data, the software was designed to: –Identify patients at high risk via a proprietary algorithm –Identify CHF, Pneumonia, MI patients

20. Care Co-ordination Across the Continuum Set up a meeting with our inpatient Patient Care Managers and our Care Coordinators in the primary care offices Had them exchange phone numbers The Care Coordinators are informed when a high risk patient is admitted and when they are discharged

21. Exchange of Information At discharge, the unit coordinator will fax (don’t judge me) the discharge medication reconciliation and the discharge instructions to the PCP office (we are looking into a scan/e-mail system) It is an expectation that discharge summaries are dictated at the time of discharge—our hospitalists have this built into their bonus calculation

22. Follow-up Through our IDS, we created an expectation that high risk patients have a follow up appointment within 3 business days and moderate risk patients within one week We have not been universally successful in getting f/u appointments made prior to the patient leaving the building

23. Follow-up Our Clinical Nurse Leaders make phone calls 1-2 days after discharge and ask whether patients have their post-acute appointments made and whether they have filled their discharge prescriptions Care Coordinators will also reach out in a similar manner

24. Other Factors Our Home Health Company has invested in 20 telehealth monitors for CHF patients We have had our word processing department “push” discharge summaries out to the PCP of record

25. Next Steps Getting our inpatient EHR (Quadramed QCPR) to talk to our outpatient system (NextGen), especially regarding medications, and medical documentation Continue to improve our patient education functions Continue to improve communication between Hospitalist and PCP Filling discharge prescriptions in outpatient pharmacy Greater acceptance of Palliative Care and Hospice services by both physicians and families

26. Readmits—Medicare AMI 2012 thru 2014

27. Readmits—Medicare CHF 2012 thru 2014

28. Readmits—Medicare Pneumonia 2012 thru 2014

29. Readmits—Medicare 2012 thru 2014

30. Readmits—All Payers 2012 thru 2014