1. Thinking Differently about Hospital Readmissions Presented by Glenna Yaroch, MBA,PT Owner/President Home Instead Senior Care September 12, 2014

4. Senior Care Continuum

6. Nutrition Medication Management Doctor Appointments Warning Signs Four Areas of Focus

7. Personal Side of Care

8. Richmond, VA Re-Admissions Study

9. Partner with large for-profit hospital system 55 patient pilot study Primary diagnosis – Heart Failure 30 Day plan of care GOAL: Reduce hospital readmissions by 1% Pilot Study

10. Risk assessment done on each patient who had heart failure based upon their risk factors Categorized patients level of care - Decided on hours of care based upon the assessment Care plan created on all patients upon discharge Risk Factors and Assessment Limited Moderate Significant

11. Follow-Up Physician Visit Assistance Nutrition Management Warning Signs Monitoring and Notification Medication Management Care Management with Patient

12. Hospital readmission rate overall dropped 23.5% (16% to 12.5%) Total hours based on patient need and additional care available (81-100 hours) Able to fill gap in education and compliance Outcome

13. Livonia, MI Glenna Yaroch

14. July 2012 to November 2012 with 2 non-profit hospitals - Hospital #1 part of the tenth largest national healthcare system in the U.S. and is a 304 bed acute care community hospital - Hospital #2 is a 220 bed medical/surgical hospital 30 Patient Study Primary diagnosis – CHF (Heart Failure) and COPD 30 Day plan of care (Day 1 is discharge from hospital) GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance Test and Goals Pilot Study

15. Main focus on patient-centered goals with action plans - Functional goals: drive, grocery shop, wedding, garden A care consultation to be done in the hospital with Home Instead Senior Care, to determine patient specific needs - Build trust, clarify discharge instructions, understand the program Base 30 day plan Week 1: one hour of service for five visits Week 2: one hour of service for four visits Week 3 : one hour of service for three visits Week 4: one hour of service for one or two visits Model

16. Teach-Back Show-Me Method Patients remember and understand <50% of what clinicians explain to them The model must shift from patient education to patient engagement Critical components for success: Medication management (reconciliation from discharge) Appointment with Primary Care Physician (first week home) Diet (salt) Monitoring vital signs (blood pressure, weight, fluid intake) Warning signs (red flags – red, yellow, green zones) Organization of medical records in the home

17. Outcomes

18. Person-centered solutions to reducesolutions to reduce hospital readmissionshospital readmissions