1. Risk Assessment - What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH 1 Presented by Washington State Hospital Association Safe Table, 7/10/13

2.  Pierce County Community – Readmission Reduction pilot project (August 2012)  Research for Readmission Risk Tools  Adapted a tool from Mary Naylor’s readmission risk tool  Started using it in April, 2013  Goal  Risk assessment on 100% of patients  Implement Care Management Strategies related to risk 2 Background Presented by Washington State Hospital Association Safe Table, 7/10/13

3. Tool Check the following that are true. Points Age 80 or older1 No funding source1 More than 4 Chronic Conditions1 Active Behavioral / psychiatric health issue1 Six or more prescribed medications1 Two or more hospitalizations within the past 6 months1 Readmitted within 30 days1 Inadaquate support system1 Low health literacy1 Documented history of non adhearence to the therapeutic regimen1 Require assistance with ADL's1 Substance / ETOH abuse1 CM / MSW / Physician determination6 Take the sum of the points and enter the total Score Low0 to 2 Medium2 to 4 High5 to 6 Intensiveabove 6 3 Presented by Washington State Hospital Association Safe Table, 7/10/13

4. Process Care Management assessment within 48 hours of admission Readmission Risk Score Completed and Documented in Epic Risk Score listed on hospital censes Case Manager prioritizes patients according to scores Care Conference arranged Referrals Made Discharge Report sent to PCP including Readmission Risk Score PCP offices prioritizing their patients follow up phone calls based on readmission risk score 4 Presented by Washington State Hospital Association Safe Table, 7/10/13

5. Intensive Readmission Risk Care Conference Evaluate Skilled Nursing Facility versus Home Health Referrals Palliative Social Work Pharmacy Medication Reconciliation Community Referrals Follow up appointment made for patient to be seen by PCP within 2 days Care Management Discharge Summary Completed 5 Presented by Washington State Hospital Association Safe Table, 7/10/13

6. High Risk Readmission Risk Care Conference Recommended Evaluate Skilled Nursing Facility versus Home Health Referrals to Consider Social Work Palliative Community Referrals Follow up appointment made for patient to be seen within 2 to 4 days Care Management Discharge Summary Completed 6 Presented by Washington State Hospital Association Safe Table, 7/10/13

7. Medium Readmission Risk Evaluate Skilled Nursing versus Home Health Community Referrals Out patient palliative care consult for goal setting For CHF assess for Heart Failure Clinic follow up PCP appointment for follow up within 5-7 days (Unless patient is cognitively impaired, patient would arrange their own follow up appointment. CM to confirm that appointment is made) Care Management Discharge Summary Suggested 7 Presented by Washington State Hospital Association Safe Table, 7/10/13

8. Low Risk Readmission Risk Skilled Nursing versus Home Health Community Referrals For CHF assess for Heart Failure Clinic follow up PCP follow up within 7-10 days (patient to make unless cognitively impaired) PCP to determine if Palliative Consult needed Care Management Discharge Summary not required 8 Presented by Washington State Hospital Association Safe Table, 7/10/13

9. Lessons Learned 9  We had to add the ability for MD, Social Worker, Case Manager to score higher at their discretion (Example Trauma patients)  Adjust the scores as they overlapped Presented by Washington State Hospital Association Safe Table, 7/10/13

10. Validation 10  Review readmitted cases weekly and do chart review to  Validate the effectiveness of the tool  Identify education and training opportunities Presented by Washington State Hospital Association Safe Table, 7/10/13

11. Next Steps 11  Continue to monitor validity of the tool  Maintain risk assessment completed on 100% of admission  Revise the tool as necessary per the findings Presented by Washington State Hospital Association Safe Table, 7/10/13