1. Another Look at Readmissions Katie Westman, RN, CNS United Hospital

2. Caring for the person…in context System Health care team Significant others Illness

3. Reason for Readmissions O Progression of disease O Unrelated to original hospitalization O Preventables O Medications, medications, medications O Lifestyle – smoking, for example O Access – primary knowledgeable about disease state, regular testing, healthy foods, exercise, patient education, social support, finances

4. Tactics O Better assessments in the acute care setting O Identifying “hidden” needs (medication adherence, cognitive abilities, mental health issues, literacy) O Cognitive assessments O Transition conferences O Involving support system O Comprehensive discharge planning O Redesigning the discharge process O Simplifying and communicating O Involving patients and support systems O Appropriate placement

6. Questions to Think About Before the Conference Here are some things to think about as you plan to transition from the hospital: O 1. Who usually helps you with your everyday activities at home? O Food? Medicine? ADLs? O How would you contact that person? O 2. Who helps you make decisions about your health care? O 3. Whom do you call when you have questions or concerns about your health? O How do you get to your health care appointments? O 4. Do you have any concerns about how you will pay for your health care needs?

7. O Transition care support O Transition coaches, APRNs, community support O Transition communications O Allina transition conferences O http://www.hospitalmedicine.org/ResourceR oomRedesign/RR_CareTransitions/PDFs/PAS S.pdf http://www.hospitalmedicine.org/ResourceR oomRedesign/RR_CareTransitions/PDFs/PAS S.pdf

8. RARE Campaign