1. National Readmission Prevention Collaborative Focusing on Readmissions David B. Edwards MD, FACP CMO Banner Home Care and Hospice CMO Banner Pharmacy Service System Lead Readmission Initiative

2. "If you chase two rabbits, both will escape." Anonymous Some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them. - Laurence J. Peter,

3. Banner Board Initiative Readmissions became an Board Initiative 2013 – All cause – CMS focused Diagnosis (updated for 2014) – Defined and Benchmarked (75 percentile performance) Management Incentive Program Facility level evaluations for individual leaders

4. Strategy Expected Clinical Practice= Standardization – Define (Easier) – Design (Harder) – Implement (Where the real work is) Bundles

5. Structure of the initiative and work teams Readmission Initiative Team – COPD workgroup – HF workgroup – Standardization of chart review workgroup – High risk trigger (analytic) workgroup – Medication Reconciliation workgroup – Teach-back workgroup – Bundle compliance workgroup

6. Developed high risk trigger for readmission > 3 Previous visits within 12 months (Inpatient, ED, Obs) Or both: – > 7 scheduled Medication (Non PRN) – > 2 Comorbidity(Charlson Comorbidity Index)

7. Developed high risk trigger for readmission

8. Created a "readmission bundle" 1.Teach the patient using teach back method 2.Perform a medication reconciliation 3.Set up an appointment for patients prior to discharge.

9. Analysis of Bundle Compliance Time Period: 15 Apr 2014 – 30 Jun 2014 Location: All Banner Facility (exclude Fairbanks) Population: –Encounter type: Inpatient, total 37,551 cases, 12,511 high risk (33.3%) –Exclude OB, Fairbanks Data Source – Cerner –Med Rec : Medication order Reconciled at discharge –Teach back: Patient education PowerForm - Teaching method = teach back –Follow up Appointment : Patient education – Follow up - appointment made before discharge

10. Medication Reconciliation for patients at high risk for readmission

11. Other bundle compliance

12. Bundle compliance

13. Social/political considerations in making this successful Good vs. Perfect Mystery vs. Puzzle – If you torture the data enough, it will confess.- Ronald Coase We have to do something different and now! Marking their territory

14. Next steps