presentation on teamwork for avoiding potentially avoidable readmissions

KEY QUESTIONS

What are the barriers to seamless care transitions for your

patients?

In a perfect world what intervention, if implemented, would be

most effective for your patients?

What intervention can you realistically implement?

What can you contribute to the work of this coalition in

decreasing avoidable readmissions in our community?

Fragmentation of data

Inappropriate end of life care

Medication issues

At-risk patients not properly identified at discharge

Lack of post-discharge follow-up

Lack of disease-specific protocols

Lack of Patient Self Management

Lack of community awareness

DRIVERS OF RE-HOSPITALIZATION

IMPLEMENTATION: GETTING TO WORK

Invite a patient(s) / family(ies) to participate

Design metrics and evaluation strategy

Engage in staff education/outreach

Develop protocols, policies, forms, tools, etc., from intervention

model

Redesign care processes as needs identified

INTERVENTION SELECTION- ROOT CAUSE

ANALYSIS (RCA)

Identify patient population with highest percentage of

readmission

Identify Drivers of Readmission in this patient population

Identify potential interventions to address the identified drivers of

readmission

Evaluate Evidence-Based Intervention Models to determine the

best fit for your unique drivers

1. Better Outcomes for Older Adults through Safe Transitions (BOOST) – Society

of Hospital Medicine

2. STate Action on Avoidable Re-hospitalizations (STAAR) – Institute for

Healthcare Improvement (MI, WA, MA, OH)

3. Re-Engineered Discharge (Project RED) – Boston University

4. Geriatric Resources for Assessment and Care of Elders (GRACE Team Care

Model) – Indiana University (Steven Counsell MD Medical Home Model)

INTERVENTION MODELS

5. Transitional Care Model – Mary Naylor (Home Health patient coaching)

6. Best Practices Intervention Package for Transitional Care Coordination

(Home Health QI Initiative)

7. Interventions to Reduce Acute Care Transfers (INTERACT) – Florida Atlantic

University (Nursing Facility)

8. Care Transitions Intervention (CTI) – Dr. Eric Coleman (Physician Office)

INTERVENTION MODELS

SELECTING INTERVENTIONS

What are your primary drivers of readmission?

What driver(s) does this intervention address?

What is your goal for the intervention?

How does the selected intervention improve the quality and safety

of patient care, transitions of care, and post-acute-care follow-up?

Driver

1. Fragmented Documentation

2. Inappropriate End-of-Life Care

3. Medication Errors

4. High-Risk Patients Poorly

Identified

5. Lack of Post-Discharge

Follow up

6. Lack of Disease-Specific Protocols

7. Poor Patient Self-Management

8. Lack of Community Awareness

Intervention

1. Standardized Transfer Forms

2. Discharge Risk Assessment Tool

3. Personal Health Record

4. Discharge Risk Assessment Tool

5. Coaching, Follow-up Scheduling

6. Protocol Improvement Project

7. Personal Health Record,

Coaching

8. Community outreach campaign

DESIGNING INTERVENTIONS TO ADDRESS DRIVERS

MONITORING THE WORK

Intervention Phase

Monitor interventions

Measure progress

Reassess and evaluate processes

Keep stakeholders informed

Think about where you will get data

Financial operations

Patient profiles/medical record/Information Services

Process information

Patient satisfaction

Patient interviews

Staff interviews

CALIBRATING TOO MUCH DATA WITH TOO LITTLE TIME

Think about where you will get data:

Length of Stay

Readmission rates

Payer mix

Cost-per-case and admission

Occupancy rate

Readmission by diagnosis

Denial rates for discharge readiness

Patient Satisfaction Surveys (H-CAHPS)

FINANCIAL OPERATIONS

Think about knowing when and from where patients

are readmitted

Medical record

Admission source

Patient interview

Discharge disposition

Discharge risk assessments

PATIENT PROFILES

Think about processes that impact and are impacted by readmission

Holding in ER, ICU, recovery

Denied days for delay in discharge

ER diversion rates

Discharge planning process

Bed turnover measures

Patient education

Referrals

PROCESS INFORMATION

PATIENT SATISFACTION

Think about how a patient’s perception impacts readmission (H-CAHPS)

Medication management

• Question # 16

• Question # 17

Discharge Planning

• Question # 19

• Question # 20

Think about how staff can give you their perspective on

processes that impact their work and readmissions

Discharge process

Discharge risk factors

Patient education

Tools

Opportunities

Solutions

STAFF INTERVIEWS

Think about questions you can ask the patient that

will help you understand readmission

Reason for readmission

Discharge process

Discharge risk factors

Patient efficacy – response to education

Solutions

PATIENT INTERVIEWS

Index Admission: The initial inpatient admission within a given 30-day period.

Readmission: A patient readmitted to an inpatient bed within 30 days of

discharge from the previous inpatient hospitalization (index admission).

Outcome: An expected change that results from an intervention, reflecting an

effect on root cause.

Improvement: Meeting a benchmark set at intervention implementation or

achievement of statistical significance over a defined time period.

DEFINITIONS

SURVEYING THE WORK

Surveillance Phase

Analyze data

Adjust interventions

Report data to stakeholders

Monitor – Improve – Report activities

”…the secret of the care of the patient is in caring

for the patient.”

Francis W. Peabody, MD (1881-1927)

REMEMBER

Definition: Patient Experience

The sum of all interactions, shaped by an

organization’s culture, that impact patient

perceptions across the continuum of care

TEAMWORK IN VALUE-BASED CARE

Patients are starting to discover that

their healthcare is not nearly as good as

it should be.

TEAMWORK IN VALUE-BASED CARE

Patients are starting to discover that their

healthcare is not nearly as good as it should

be.

Value-based care is the right thing to do,

and it’s not that hard.

TEAMWORK IN VALUE-BASED CARE

• Patients are starting to discover that their healthcare is not

nearly as good as it should be.

• Value-based care is the right thing to do, and it’s not that

hard.

• Value-based care will make any healthcare provider stand

out from the crowd.

TEAMWORK IN VALUE-BASED CARE CARE

1. Providers and patients know each others’ names.

2. Patients’ opinions are actively sought, listened to and

honored where possible (a suggestion box, patient

satisfaction survey or mission statement doesn’t

constitute being value-based — if you think they are then

you aren’t value-based).

3. Patients tell you that their doctors and other team

members really listened to what they had to say (again, if

you think satisfaction surveys qualify, you aren’t there yet).

TEAMWORK IN VALUE-BASED CARE

1. Patients are treated as the most important

member of the healthcare team and taught how

they can best contribute to the team’s success.

2. Providers feel that their patients are actively

involved in their own care.

3. You see a significant improvement in patient

health status, health literacy / adherence/ self-

management, engagement, level of utilization

and patient/provider experience.

TEAMWORK IN VALUE-BASED CARE

CALL TO ACTION

Reduction in preventable readmissions cannot be

accomplished by individuals or providers working in

isolation.

Determine which post-acute care providers readmit

patients to your facility most often and why.

For a free copy of this deck with

notes please contact:

CJ Fulton

618-579-9192

healthideation@gmail.com