1. Ty Cobb Regional Medical Center Reducing Readmissions

3. DEFINE Scope – Decrease 30 day readmission rate by 20% Project charter completed and approved Team members: Nursing, Case Management, Utilization Review

4. Charter discussion

5. MEASURE Line chart, Histogram, Xbar and R chart data reviewed by team members Process in control but not what we wanted Process Flow Mapping discussed Map completed

6. Initial Data

7. Process Map

8. ANALYZE “Sticky note” brainstorming Process map was separated into sections: Admission, Inpatient Care, Day of Discharge and Post Discharge Each member moved from chart to chart 52 thoughts added to flow map Developed a list of improvement priorities

9. Sticky note exercise Different map sections were placed around the room. Each team member was given a pen and a sticky note pad. They had 5 minutes to spend at each station writing as many suggestions or concerns as they could.

10. Before and After

11. IMPROVE/IMPLEMENT A problem list was developed and prioritized Specific task list was made Department involvement for each task was delineated using RASCIN chart

12. Task List Combine Readmission Risk Assessment and Case Management Assessment Provide in-service to Nursing staff on patient education techniques and use of “Teach-Back” method Create e-forms for documentation Concentrate post-discharge calls on “high risk” patients Better utilization of Home Health Care

13. RASCIN RASCIN Combine Risk Assessment and Social Services Assessment and implement Case Management Chief Nursing Officer None Educate Nursing Staff on Teach Back for Patient Education Medical Nurse Manager Chief Nursing Officer HEN ResourcesNursing None Develop eforms for education documentation Medical Nurse Manager Chief Nursing Officer Clinical IT/ HEN Resources Physicians None Concentrate discharge calls to high risk patients Case Management Chief Nursing Officer Utilization Review None Work with Home Health agencies to provide adequate resources at home Case Management Chief Nursing Officer Home Health Agencies None

14. Readmission Risk Assessment A “home needs” screening is completed on each patient on admission Any positive screen is referred to Case Management and an in-depth assessment is performed We simply added questions to that assessment that will determine risk of readmission High risk patients receive a detailed post discharge call

15. Teach Back Teach back is a method of education assessment that requires the patient to repeat back the instructions in their own words If the patient’s description differs from what was taught, re-education can occur at that time

16. Post Discharge Calls Post discharge calls are completed by Utilization Review staff a few days after patient discharge. Patients are contacted at home to see how they are progressing and to discuss medications, follow up appointments Any problems noted are sent to Case Management for resolution

17. Home Health Care Our overall goal is for each high risk patient to be evaluated for Home Health Care and to be referred if they could benefit from services

18. Home Health Benefits Reinforcement of hospital discharge information Periodic physical assessments to prevent disease from progressing to hospitalization level Patients can remain at home in familiar surroundings and still receive the care they need

19. Home Health Utilization

20. Latest Data

21. Success!!! 30 day Readmission Rate dropped from 0.0352 to 0.0128 Decrease of 63.6% Projected Financial loss prevention: $1,166,690.26

22. CONTROL Continue to evaluate control charts Policy development to standardize the discharge process

23. Thank you!! Tina Thomas RN Ty Cobb Regional Medical Center Lavonia, Georgia tina.thomas@tycobbhealthcare.com