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Your Health. Our Passion – for Life
Reducing the 30-Day Readmission Rate at Trillium Health Centre Avoidable Hospitalization Working Group – June 23, 2011
Amir Ginzburg Physician Director, Patient Safety and Quality
Susan Bisaillon Executive Director, Clinical Operations
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778,979 Patient Visits
33,798 Inpatient
Admissions
790 Beds
4,305 Staff, 715 Physicians, 1,100 Volunteers
$462.6-million budget
330,801 outpatient
diagnostic services Regional lead for: Cardiac, Vascular,
Neurosciences, Stroke, HPB,
Specialized Geriatric Services,
Palliative Care,
Sexual Assault/Domestic Violence
21 Operating Rooms
36,377
Surgical Procedures
141,103 Emergency
and Urgent Care Visits
3,986 Births
Primary
Secondary
Tertiary
Acute
307,075
Outpatient Visits
Fast Facts: Trillium Health Centre 2010/11
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Readmission Rates by LHIN, 2006-2009
MH-LHIN
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Readmissions by CMG, 2006-2009
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
2006 2007 2008 2009
Cardiovascular
Congestive Heart Failure
COPD
Cerebrovascular Accident
Diabetes mellitus
Gastrointestinal
Pneumonia
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How Did We Get Here?
Chronic disease management (e.g., DM)
Patient education (e.g., AMI)
Palliative care
Transitions (program-specific)
Inpt and outpt focus on preserving cognition and improving function
Seniors strategy
Flow / ALC Next slides
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MH-LHIN: Highest concentration of
seniors by 2016 is in Trillium’s catchment
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ALC patients by day 2009-2011
Sustaining our ALC percentage
June 3, 2011 – 5%
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QIP Target FY2011/12
Reduce 30-day readmissions in
patients with selected CMGs
from 12.3% (baseline) to 11.5 %
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Organizational Strategy
Provincial and
internal data
Literature Review
Catalogue current
leading state
30 diagnostic
interviews
Driver Diagram
Inputs Strategy
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No Needless Harm
30-day Readmissions Draft 2
Transition and Re-admission Team (TReaT)
Leverage Flo Collaborative discharge processes to
develop a care pathway for transition of care
Patient Navigator role for dedicated discharge
planning
Nursing and allied health discharge summaries
Increase remote access to EPR for local family
physician
No Needless Harm
30- day
readmissions
AIM Process MeasuresBIG DOT
Collaborative discharge planning with CCAC and other
community partners ( e.g. Supports for Daily Living,
Restore)
ProjectsPlanned
ProjectsIn Progress
ProjectsCompleted
For 2011/12 the
30- day
readmission rate
for selected
CMGs will be
11.5%
Effective
transitions to the
community
Inpatient rehabilitation programs (e.g. Stroke
Rehabilitation, Short/Medium/Long term
Rehabilitation)
Ambulatory ( e.g. Cardiac, COPD, Stroke and other
outpatient rehabilitation programs)
Develop formal communication strategy to educate
families on discharge best practices
Transitions outreach team
Automate LACE Index in EPR with e- whiteboard visual
management
Follow up clinics within 30 days
( e.g. Surgery Medicine)
Seniors Outreach Teams ( Geriatrics,
Seniors Mental Health)
Multiple strategies, see “No Needless Pain” driver
diagram
Senior Intervention Team (SIT) in ED
Infection prevention and control
Expand follow up telephone communication programs
(currently in Surgery , Orthopedics Cardiac Tele- ask)
Anti-microbial stewardship
Medication safety Required Organizational Practices
( e.g. dangerous abbreviations, narcotic safety, drug
concentration standardization, admission
medication reconciliation )
Multi disciplinary team- based clinics for key
populations ( e.g. Heart Function Clinic, Oncology
Clinic, Diabetes Management Centre, Stroke
Prevention Clinic, Chronic Airway Diseases Clinic)
Outreach
Programs
Leverage LHIN MRP Collaborative to improve
completion of physician discharge summaries within 48
hrs
Support of providers including nurse practitioners
for patient education and discharge planning (e.g.
Medicine, Respirology, Oncology, Cardiac,
Neurosurgery, Spine)
Right care
in hospital
Confusion Assessment Method (CAM) Pilot
Identification of
patients at risk of
readmission
Patient and family education via providers ,
educators, ( e.g. diabetes) literature, and other
modalities
Baseline
performance is
12.5% as per QIP
Engage patients and families to identify root
causes for readmissions via use of IHI
diagnostic tool
Leverage Medical Quality of Care plan to improve
utilization of discharge medication reconciliation
process
Analysis of local data to identify high risk populations
Mental Health ( ACTT, ReLinC,)
Consumer portal
Pilot and deploy LACE Index to identify high
risk patients in real time
Multiple policies and procedures (falls prevention, least
restraints, early mobilization, Silver Spoon etc)
Communication to
community based
providers
Post discharge
follow up
Patient self
management
Discharge planning
Pain management
Preserve cognition
and function
Minimize
complications
Chronic disease
management
Selected CMG’s
Cardiac (CAD,
Arrhythmias)
CHF
Stroke (Ischemic
and Hemorrhagic
COPD
Pneumonia
Diabetes
GI (all med/surg/
onc CMGs)
DRIVERS
Palliative Care Initiative
QIP
Change
Idea
QIP
Change
Idea
QIP
Change
Idea
QIP
Change
Idea
Collaborative Care by Design (CCbD)
Hospital Elder Life Program ( HELP)
Lean ALC initiative
Nurse Practitioner based follow up within local long
term care facilities ( NP-STAT)
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Targeted Change Ideas
Reduced 30-Day
Readmission Rate
Right Care in Hospital
Identify patients at-risk for
readmission
Effective transitions to community
Chronic Disease Management
Change ideas focus on
detecting at-risk patients
and transitioning
them effectively back
into the community
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LACE Implementation
Piloted on 3 wards March 1-10
Respirology/medicine and 2 cardiology
wards (enriched population)
Clinical leaders trained
Paper-based scoring tool (St Mike’s)
Calculated on day of discharge
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LACE – Results
50 patients
LACE 10
75% of cardiology patients
60% of respirology/medicine patients
Readmissions: 13 patients (26%)
11 patients (85%) had LACE 10
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Lessons Learned
Increased staff awareness
Avoidable hospitalization = quality issue
Empowering: prevent ‘frequent flyers’
Comorbidities difficult to find – patient
interview often required
2-5 minutes per patient
Could be perceived as added work
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Frontline Staff Recommendations
Use prior to date of discharge
Do not identify risk for its own sake
Must have resourced intervention to
deploy for at-risk patients
Many (all?) LACE variables in EPR
Can LACE be automated within EPR?
Link to visual management
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Visual Management
30
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Actions To Achieve QIP Goal
1. Broader engagement
Validate / prioritize driver diagram change ideas
Assess resource implications
2. Automate LACE
3. Develop a Transitions Team
Defined population (seniors)
At-risk by LACE
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Questions or Comments?