1. July 2012 Your hosts: Jody Rothe, MetaStar Stephanie Sobczak, WHA

2.  Thank you to these organizations for sponsoring this webinar series: A special thank you to the Wisconsin Clinical Resource Center for serving as the home base for recorded webinars and materials related to the INTERACT II collaborative

3.  Readmissions in Wisconsin  Overview of INTERACT II  Convening a Team  Measuring  Case Review Tools  Data Entry  30 day Action Items Please be sure your phone lines are muted to keep background noise to a minimum.

4. Help patients heal without complication. Reduce all hospital readmissions by 20%

5. Which means 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

6. In one year in Wisconsin nearly 30,000 people experienced a potentially preventable readmission

7.  10,000 more residents will fall asleep on their own pillow.  Care is not interrupted  Nursing Homes, Hospitals and Home Health all work together for what’s best for the patients/residents.

8. Hospital Type To HomeTo SNFTo Home Health Agency Other Wisconsin PPS 26,219 13,6176,8313,7682,003 Wisconsin CAHs 2,339 1,379501133326 All Wisconsin Hospitals 28,558 14,9966,3323,9012,329 30 day All Cause, All Cases Readmissions to various sites (Medicare Beneficiaries only)

10. What past experience do you have in actively working on reducing readmissions to the hospital?  We have worked with other local organizations (hospitals, home health, community organizations, etc.)  We have worked on internal process improvements for many months  We’ve just started working on internal process improvements  We have not formally worked on reducing readmissions.

11. Invite & send Agenda to Webinar/ Conference Call 30 day Tasks 2 or 3 things to try Touch base Survey Serves as reminder Learning Content & Interaction or Guests Interim Coaching, Reminders and Support Data Submission & Analysis Day 30Day 15-ishDay 10Day 1

12. JulyOverview & Case Review Tools AugustCommunication Tools SeptemberEarly Warning Tools OctoberChange in Condition Tools NovemberResident Transfer Tools DecemberContinuous Improvement Tools

14.  Focused on Long-Term Care settings specifically  It is evidence based standard of practices  It is proven to work  It is a toolkit that can be customized to your facility

15.  http://interact2.net/ http://interact2.net/

16. 1.Is a charge nurse on your team? 2.Are at least two staff members involved in direct resident care on your team? 3.Can you have a social worker or admission/discharge planner on your team?

17. 17 Organizer Meeting Convener Data Reporter Can someone ensure there is a room to meet in with a phone, and a screen when needed? Print materials? Put dates on calendars? Can someone help define meeting topics and planned discussions? Can someone gather data for display? Can some be in charge sending data to Megastars?

18. 18 Documenter Implementation Leader Can someone track tests of change and decisions on adopting tools? Can someone help determine when and how to write the P & P and when and how to train others?

20. What type of representation is on your INTERACT II team?  Primarily organization leaders and managers  Managers only  Managers and front-line staff together  Mostly front-line staff and a manager

21. Three things are required for success: 1. Attendance on calls – Will be based on webinar login by facility 2. Submitting data – Outcome and Process measures Send data collected by the end of the month 3. Trying out and testing the tools in between monthly webinars. 21

24. Aims Measurement Change ideas Testing ideas before implementing changes

25. Plan: Systematically Review the past 5 hospital admissions or ER transfers.

27.  Are there common occurrences across the sampled residents?

28. From this review, can you summarize what your team would like to accomplish in the next 6 months? AIM Statement:

29. Are there any questions so far?

30.  Collecting data doesn’t have to be complicated  It can be extracted from your electronic record keeping system OR  A team member, or two, can take on a task of keeping track of each hospital admission or ER transfer

31. Date# Hospital Admissions # ER TransfersData Collector 7/12/1202 7/13/1200 7/14/1210 7/15/1201 This can be kept track of DAILY or WEEKLY

33.  Need to track improvement to enhance the learning  Answers: “How do we know these changes have made a difference?”  Shows were improvements can be targeted.

34.  Tracking Hospital Admissions and Transfers to ER per month. Number of Admissions & Transfers JulyAugSeptOctNovDec 20 15 10 5 0

35.  Linking Improvement to Interventions Number of Admissions & Transfers JulyAugSeptOctNovDec 20 15 10 5 0 SBAR Trial Stop & Watch Tools Trial Change in Condition Tools

36. Are you currently tracking your readmission rate or number of transfers to the hospital/ER? Yes No

37. https://www.metastar.com/web/custom/WiQCINTERACTdataentry.asp This is a secure web page provided by MetaStar for this INTERACT II collaborative

38.  Determine your data tracking method  Determine who will enter the data on the MetaStar website.  Team members will receive an e-mail with secure login information (will be sent by July 19 th )  Data should be entered by the 30 th of the month for the month prior (example: submit by July 30 for June data)  Aggregate data will be posted to the WCRC website.  You should track your own data from month to month

39. This will be your CMS provider number This will be sent to you from MetaStar (via e-mail)

41. 1. Case Review Tool 2. Example check sheet for data collection 3. Graph format for posting 4. Dr. Ouslander’s slides: http://innovations.cms.gov/Files/slides/rahnfr _hospitalizations_slides.pdf https://wcrc.chsra.wisc.edu

42.  Review 5 cases of transfers or readmissions from hospitals  Use the tool to analyze the factors leading to the readmission  Plan your team gatherings  Begin collecting data An on-line Feedback Tool will be send after August 1st to assess your progress on these tasks.

43. Thank you! See you next month Next month: Communication Tools