1. A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association NYSPFP Preventable Readmissions Pilot Project Hospital Storyboard Companion Guide August 2014

2. NYS PARTNERSHIP FOR PATIENTS Instructions o This storyboard will be used to tell other hospitals about your team’s experience with one or more of the pilot phases **: Phase 1 – On Admission, Phase 2 – During the Hospital Stay, or Phase 3 – Discharge Day and Beyond, of the NYSPFP Readmissions Pilot. ** Please note: hospitals are welcome to do more than one storyboard. o Please highlight your team’s experience with planning and implementing one or more of the pilot phases: (i.e., Phase 1, Phase 2, or Phase 3), including: o Successful strategies and tips o Challenges faced by your team o Data and outcomes o Key lessons learned (good, bad and “pearls”) o Next Steps for spread and hardwiring 2

3. NYS PARTNERSHIP FOR PATIENTS Hospital and Team Information o Hospital Name and Demographics: o Location; number of beds; services; notable community characteristics especially as related to preventing readmissions o Describe Your Hospital Readmission Team: o Come up with a creative team name - List of team participants (name, title, discipline) o Insert a team picture on the page provided 3

4. NYS PARTNERSHIP FOR PATIENTS Indicate the Pilot Phase Being Summarized Address your summary in the context of the Phase Objectives: o Phase 1 – Admission o Identify patients on admission who are at risk for readmission using an “any risk” assessment approach. o Assemble a multidisciplinary team to address interventions that will mitigate risks for readmission. o Phase 2 – Hospital Stay o Prepare patient and caregiver for discharge, beginning at admission. o Conduct ongoing patient reassessment to identify new or changing risk factors. o Ensure systems for multidisciplinary communication, coordination, planning, and evaluation. o Utilize teach-back or other patient educational approach. o Phase 3 - Discharge o Ensure patient and family/caregiver are fully prepared for post hospital care. o Provide timely and thorough communication to post hospital providers.

5. NYS PARTNERSHIP FOR PATIENTS Highlight Your Successful Strategies & Tips for the Phase o Phase 1 (for example) o Successes with team assembly and established role responsibility o Integration of the “any risk” assessment approach o Tips for early identification and mitigation of risk o Phase 2 (for example) o Strategies for strong and fluid team communications o Tips for patient/family inclusion as part of the team o Successful patient/family education validation practice 5

6. NYS PARTNERSHIP FOR PATIENTS Highlight Your Successful Strategies & Tips for the Phase (continued) o Phase 3 (for example) o Final verification of patient/family preparation for discharge o Timely, and thorough communication to the post- discharge provider(s) o Thorough medication reconciliation with all discrepancies addressed o Post-discharge follow-up PCP and/or specialty appointment arranged pre-discharge o Post-discharge patient/family calls with 48-72 hours 6

7. NYS PARTNERSHIP FOR PATIENTS Describe Challenges (for example) o What were challenges and barriers encountered: o Staff education and engagement o Referral timeframes not met o Inconsistent follow-through and lack of feedback o Communication vehicles not used o No formal steps to reassess patient’s risk o Describe steps to overcome challenges and barriers: o Held a team focus group o Changed communications vehicle o Multi-disciplinary daily rounding, daily goal sheets, etc. 7

8. NYS PARTNERSHIP FOR PATIENTS Key Lessons Learned o Describe some new understandings that resulted from your participation in the pilot phase work. For example: o Nursing admission assessment could be adapted to include an “any risk” approach. o The disciplines were able to establish risk mitigation plans earlier in the stay due to the timely on admission risk identification process. o Specific members of the team must be responsible for medication reconciliation at every transition to ensure it is completed. 8

9. NYS PARTNERSHIP FOR PATIENTS Steps to Spread and Hardwire o Share plans to continue your readmission prevention efforts hospital-wide. For example: o What areas still need to be “rapid” tests of change? o How will you expand process improvements from one unit to the next? o How will you formalize the new processes? o What steps will be taken to monitor new processes put in place? o What two-way feedback mechanism will be in place for the team, patient and families for continued process improvement? 9

10. NYS PARTNERSHIP FOR PATIENTS Outcomes and Data o Insert data here, demonstrating outcomes from pilot phase. For example: o Unit readmission rate trends before and after pilot phase implementation o Pilot unit readmission rate as compared to hospital overall rate o Readmission reasons before and after pilot phase implementation o Percent of post-discharge follow-up appointment made prior to discharge o Percent of post-discharge follow-up phone calls made within 72 hours of discharge 10

11. NYS PARTNERSHIP FOR PATIENTS Data Aggregate Tool & Available Reports 11

12. NYS PARTNERSHIP FOR PATIENTS Available Reports 12

13. NYS PARTNERSHIP FOR PATIENTS Next Steps o Choose a Team Name (optional) o Contact your NYSPFP Project Manager for assistance o Storyboard Due Date: September 22, 2014 o Please send completed Storyboard to your NYSPFP Project Manager. o Register and attend regional in-person educational conference Register 13