1. Reducing Readmissions Catholic Medical Center July 27, 2012

2. Highlights Data Lean Six Sigma Improvement Initiative QIO Improvement Initiative AMI, HF, Pneumonia Readmission Strategies Key Strategies Catholic Medical Center

3. CMC-US Readmission Rates 2007-2010 CMS Hospital Compare

4. CMC AMI, HF, Pneumonia 2011 Readmission Rates

5. LSS Initiative Key Findings CMC and highest referral SNF LSS project – SNF nurses more alert to change in condition as evidenced in labs, etc. – SNF Medical Director talks with ED Physician – Return to SNF if possible after ED visit – Continued meetings between CMC and SNF to refine communications and care process

6. QIO Community Initiative Northeast Health Care Quality Foundation (CMS QIO) led initiative on Transitions of Care – Two hospitals, five SNFs, four home health agencies and three ambulance services – Meetings, flow charts, collected data Improved communications between agencies – Discharge hand off checklist – Transfer report between agencies – SBAR report form for complete communication

7. AMI Strategies Discharge education with on-site interpreters Post-discharge cardiac rehabilitation and continuing education New England Heart Institute post-acute follow up

8. Heart Failure Strategies New England Heart Institute Cardiomyopathy Clinic was started 2003 – 2900 heart failure patients – Physician/APRN ongoing evaluations – Clinical outcomes, quality of life, education Hospital discharge education with scales, pill boxes

9. Pneumonia Strategies Discharge education Transitions of care to SNF, HH, PCP – Comprehensive communication – SNF Medical Director and ED physician communication with return to SNF if possible Follow up calls following discharge from acute care or SNF PCP follow up within two weeks

10. Key Strategies Discharge education – On-site interpreters Transitions of Care – Discharge hand off checklist – Transfer report Post-Acute Communication – Physician to physician calls for returns to ED

11. Catholic Medical Center Located in Manchester, NH, largest city in New Hampshire with a population of 110,000 330-bed, full-service health care facility with 25 subspecialties represented New England Heart Institute (NEHI) offering comprehensive cardiac services with 20 board- certified cardiologists and mid- level providers HealthGrades America’s 100 Best Hospitals, Cardiac Care and Coronary Intervention