1. Introduction The Readmission and Transition of Care teams at Scott & White Hospital – Brenham combined in an effort to develop, in the absence of a Case Management Model, a process aimed at optimizing care coordination through collaboration with outside facilities, community resources, and physicians. Three high-risk patient populations were identified through data analysis: - Elderly long-term care facility patients - Clients of the State Supported Living Center - Patients without a Primary Care Provider Opportunities for avoiding readmission: - Improving patient history and medication reconciliation upon admission - Improving coordination of care during admission and upon discharge - Improving timely follow-up appointments

2. Methods 1)Participated in Scott & White Healthcare system meetings and used evidenced based practice and current research to provide a basis for understanding the timeframe of admissions, validating data analysis findings and determining future state. Research tells us that the likelihood of readmission occurs if the patient: 1)Is readmitted within 7 days or < - Incomplete Medical Management; Wrong Site of post-acute care <14 days – 20 days – Medication Problems; Socioeconomic Factors, Physician follow-up <20 days – 30 days – Patient non-compliance; Disease trajectory; 2) Has multiple visits to the ED, and 3) Physician f/u occurs > 5 days following discharge

3. Methods Data Analysis (Numerator = number of admit/readmit core measure patients (Pneumonia, CHF, MI) seen in the ED at least once during previous 6 months prior to admission/Denominator = number of patients admitted with core measure diagnosis) Identification of Primary Care Physician (Numerator = number of admits with no PCP (stated by patient and/or not listed)/Denominator = number of patient admits during two week audit) Based on 2 week audit during the months of February, April, May, and August, 2012 March – October 13, 2012

4. 2)Revised Medication Reconciliation process – Home Medication list for Outpatient departments – full medication reconciliation of Inpatient admits – based on revised regulatory requirements. 3)Developed Patient Assessment for Subsequent (Re)admission form (adapted from htttp://www.ohri.ca., March 1, 2010) – used to identify readmissions and/or those patients at high risk for readmission – focusing on CHF, Pneumonia and MI diagnosis; Social Worker and Utilization Review nurse, as part of the internal collaboration process provide information related to current length of stay and identify those patients who may be high risk for readmission and if the patient is a readmit, what occurred to bring them back to the hospital. Results

5. Results 4)Implemented daily admission audits identifying “real-time” readmissions; readmit cases discussed at Physician Case review, often while patient is still hospitalized.

6. 5)Identified ways to increase utilization of community resources including the Washington County Community Clinic and Scott & White Primary Care physician group. Results Sept – Oct, 2012/Jan – Feb, 2013 Washington County Community Clinic Inpatient f/u In 2012, the Community Clinic provided f/u care for 65 patients referred from the Emergency Department; In January – February, 2013, 10 patients have been seen – March 2012, implemented process for formal, written referral to Community Clinic provider via ExitCare (ED discharge instructions). (Data provided by Washington County Community Clinic) Inpatients with no PCP – referred to S&W Primary Care Dec, 2012 - March, 2013

7. 6)Collaborative monthly “open dialogue” meetings with the State Supported Living Center and Long-term care facilities resulting in development of trust and determination of mutual goals; coordinated through Quality Department and community facility Administration. - Meetings cancelled if key decision makers are not able to attend - Hospital membership ad hoc based on agenda topics - Smaller groups vs. larger groups - Hospital flexes internal schedules to accommodate facility time constraints – rotating meeting facility – breakfast meetings - Developed understanding of regulatory requirements of each facility – different for all Results Decreased surgery cancellations due to inadequate prep Decreased cancellation of EEG tests – implementation of testing coordinator Identification of need to provide clients with “personal likes” when coming to hospital – reducing agitation during wait time

8. Conclusions SCOTT & WHITE HOSPITAL BRENHAM As a result of this initiative, physicians and staff have an increased awareness of readmissions at Scott & White Hospital - Brenham. High-risk patients are being identified in a more timely manner and appropriate discharge plans initiated. Open communication and collaboration between community facilities is positively impacting patient safety through a willingness to understand what is required of each facility to meet the needs of their patients/clients and openly discuss opportunities in an effort to improve the care and safety of the patients/clients served in this community. PEPPERresources.org

9. Development of Transition of Care Coordination within next 6 months – Hospitalist’s piloting program on patients under their care Implementation of bedside care coordination upon admission and discharge – possible liaison for long-term care facilities Determine options for including trained Care Coordinators into Transition of Care model Evaluate Transition of Care Coordination of Hospitalist pilot program determining expansion timeline and next steps Continue collaborative meetings with community facilities Evaluate for potential increase in Community Clinic resources Future Plans

10. 2010 – Scott & White Healthcare System assumed ownership of Trinity Medical Center. The name was changed to Scott & White Hospital – Brenham; Serve Seven County Area: Washington, Grimes, Austin, Brazos, Burleson, Lee, Waller Level III Trauma Center and designated as Advance (Level III) Stroke Center – May 2012 Received the Texas Healthcare Quality Improvement Silver Award for improving performance on national quality measures and achieving improvement on Core Measures and HCAHPS – May 2012 Recognized September 19, 2012, as a Top Performer on Key Quality Measures as one of top 18% of Joint Commission accredited hospital that report core measures for the calendar year 2011. 218 respondents participated in the 2012 CULTURE OF SAFETY SURVEY– Texas Center for Quality & Patient Safety “Partnership for Patients Program” identifying Management Support for Patient Safety, Teamwork within Units, Supervisor/Manager Expectations & Actions Promote Patient Safety and Patient Safety Grade with a score of 80% or higher 2012 Triennial Survey - the Administrative Surveyor recognized significant growth in creating of a “Culture of Safety”.