1. Hospital Story Kristen van Bergen-Buteau, CPHQ Assistant Director, Quality Services Littleton Regional Hospital New Hampshire

2. About Us Located in Littleton NH since 1907 25-bed Critical Access Hospital – General Med/Surg & Intensive Care Units – Agnes Norris Family Birth Center – 24 hour Emergency Department with Level III Trauma Center – Surgical services, including orthopedics joint replacement excellence program, endoscopy and – Outpatient ancillary services include new fixed MRI, 64-slice CT, nuclear medicine & clinical/pathology lab services for both patients and as a reference lab for facilities throughout NH & VT Outpatient Sleep & Oncology/Infusion Centers 11 provider-based primary and specialty care practices on campus (26 employed practitioners) 111 members of the Medical Staff 2

3. What Did We Test? Post discharge follow-up calls Follow-up appointments made prior to discharge Inpatient interviews of patients during readmission Electronic access to provider records for admission/discharge notification Immediate dictation & distribution of Discharge Summaries at time of discharge Medication Reconciliation list sent with Discharge Summary 3

4. What Have We Learned So Far? Improvements in process don’t necessarily mean immediate improvements in readmission rates! “Hot Spotters” exist, but we can’t reduce their utilization until we establish cross-continuum plans No significant trends in readmissions by diagnosis, but opportunities are similar regardless of primary reason for utilization 4

5. What Barriers Did We Encounter? Patient “non-compliance” “Non-compatible” medical records systems 30-day rule Medications “Different” needs for receiving providers Lack of a social safety net 5

6. How Did We Overcome These Barriers? Patient “non-compliance” – It’s a misnomer! We just need to ask the right questions to identify their barriers “Non-compatible” medical records systems – Look closer, and think outside the box (but within the rules) 30-day rule – It’s okay to dictate and sign SOONER! Medications – Electronic Reconciliation forms in paper format – Polypharmacy & cross-reactions “Different” needs for receiving providers – Not really – it’s all about communication & shared vocabulary Lack of a social safety net – “Hot Spotters” have many socioeconomic barriers in a rural area with few resources 6

7. How Are We Doing Now? 7

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11. What Can Others Learn From Our Journey? Start collaborating across the continuum – NOW! – Multiagency meetings to identify collective opportunities (LTC, ALF, HH, PCT, etc) – Task forces focused on specific transitions in care and on specific “Hot Spotters” Be willing to use LOTS of Rapid Cycle Improvement – every form & script is a draft and that’s okay Think outside the silos – there ARE resources we’re not tapping in rural areas, but most are NOT health-care related 11

12. 12 Do Not Try This At Home (Suggestions for What Not to Do…) Insist on cleaning up internal processes before any other cross-continuum work can begin – “Neat” and “Sterile” are two very different standards!! Get bogged down in data Fix the whole system at one time

13. 13 Next Tests of Change Multi-agency Interdisciplinary Care Plans for “Hot Spotters” Task Forces for specific transitions in care Follow-up calls and appointments for Emergency Department patients New Patient Education/Discharge Instruction product Sooner post-discharge appointments (within 7 days) and more same-day appointments for high risk patients Clearer communication about who can implement a treatment plan (Admission vs. return to NH or HH) Earlier PCT/Hospice intervention Paramedic home visits

14. 14 Teach Back Summary: We’re only just getting started Collaboration is key to success Patients and ALL of their providers need to be engaged

15. 15 Teach Back Questions?