1. Safe Transitions North Memorial Using Society of Hospital Medicines BOOST Toolkit To Improve Patient & Family Engagement

2. 2010 NMR Data Readmits w/in 30 days = 3,452 Readmits w/in 30 days = 3,452 Unique Patients Readmitted = 2,249 Unique Patients Readmitted = 2,249 Readmits w/in 72 hours = 654 Readmits w/in 72 hours = 654 ED visits w/in 30 days = 2, 273 ED visits w/in 30 days = 2, 273 ALOS 1 st visit = 4.13 ALOS 1 st visit = 4.13 ALOS 2 nd Visit = 4.23 ALOS 2 nd Visit = 4.23

3. Digging A little Deeper - CHF 474 CHF patients 474 CHF patients 574 Hospitalizations 574 Hospitalizations 22% Home Health Referrals 22% Home Health Referrals 7% Seen by Cardiologists Within 7 days 7% Seen by Cardiologists Within 7 days 12% Seen by NM Primary Care Clinics Within 7 days 12% Seen by NM Primary Care Clinics Within 7 days

4. A6 Daily Report Who Are Our Patients At Risk For Readmission?

5. Patient and Family Engagement White Boards White Boards Serve as a communication tool. Serve as a communication tool. Used by all disciplines and patient/family. Used by all disciplines and patient/family. Helps care team and patient/family focus on goals. Helps care team and patient/family focus on goals.

6. Patient and Family Engagement Patient/Family Centered Rounds Patient/Family Centered Rounds Identification of high risk patients Identification of high risk patients Rounding script used to develop plan for hospitalization and safe transition to home. Rounding script used to develop plan for hospitalization and safe transition to home.

7. Patient and Family Engagement Follow-Up Appointments Follow-Up Appointments Teach Back & Patient Education Materials Teach Back & Patient Education Materials Medication Reconciliation Medication Reconciliation Home Health Phone Call 24-48 hours post discharge Home Health Phone Call 24-48 hours post discharge Palliative Care Optimization Palliative Care Optimization Family Care Conferences Family Care Conferences

8. Teach Back & Patient Education Patient Education At Bedside Patient Education At Bedside RN conducting education rather than nurse educator RN conducting education rather than nurse educator Teach Back added as methodology for patient educational assessment Teach Back added as methodology for patient educational assessment Teach Back regarding medications & discharge instructions Teach Back regarding medications & discharge instructions CHF Binder used during Teach Back and to build redundancy between hospital and clinic CHF Binder used during Teach Back and to build redundancy between hospital and clinic

11. Key Learnings Follow up appointment compliance in 7 days tripled by assisting in coordinating appointments Follow up appointment compliance in 7 days tripled by assisting in coordinating appointments Need the same tool for risk stratification across system Need the same tool for risk stratification across system Need system staffing model to support care coordination across enterprise Need system staffing model to support care coordination across enterprise Need community to help in preventing hospitalizations Need community to help in preventing hospitalizations Need to "un-teach" how to conduct Teach Back Need to "un-teach" how to conduct Teach Back Need learning environment to help support change effort Need learning environment to help support change effort

12. Questions?? John Degelau, MD John Degelau, MD John.Degelau@northmemorial.com John.Degelau@northmemorial.com John.Degelau@northmemorial.com Sonne Rivers, BSN, MA Sonne Rivers, BSN, MA Sonja.Rivers@northmemorial.com Sonja.Rivers@northmemorial.com Sonja.Rivers@northmemorial.com Society of Hospital Medicine Society of Hospital Medicine http://www.hospitalmedicine.org http://www.hospitalmedicine.org