Reducing Avoidable Readmissions

A Cross-Continuum Approach

BIDMC’s Strategy for Readmission Reduction

Risk Factors

System Level

Condition Specific

Medication Mgmt

Patient Activation

CareCoordination

Mitigation Strategies

DiseaseSpecific

Pathways (Inpt & Outpt)

PharmacistMed Rec & Consolation

Care TransitionCoaching

Effective Teaching & Learning Based on Health Literacy Level

Family / Social Support & Community Services

Health Care Associates (HCA) Pilot

Hospitalization 30-Days Post Discharge

Nurse Care Transition Specialist (CTS)

Patient & Family

Care Transitions Coach

Primary Care TeamHospital Care Team ECF/VNA Pharmacists Specialists

ASAP Network Social /Community Support Services

Target Population= HCA Medicare Patients with Discharge Diagnosis of Heart Failure, Pneumonia or Heart Attack (AMI)

HCA Pilot: Teaching & Learning Component

Key Learning: Patients retain very little of the teaching that occurs at discharge

Hospitalization 30-Days Post Discharge

CTS performs bedside assessment to identify

patient’s health literacy level and

knowledge of condition.

When patient returns home CTS calls to

review the discharge instructions and condition based

teaching, using Teach Back techniques.

CTS meets patient after post-discharge

visit to answer questions and discuss

the plan.

Weekly calls from the CTS focused on

condition management education, based on the patient’s learning

needs.

Example of Alignment on Teaching & Learning Across the ContinuumHeart Failure Patient A– Medication Knowledge & AdherenceBedside VisitPatient is able to name her medications and state why she takes them. She also checks her blood sugar 4x/day and is independent with administering her insulin.

Progress Note from VNAReceived update from pt's visiting nurse, after her home visit with the patient today. Reports that she visited pt around noon. Pt had not yet taken medications. Skilled nurse performed medication teaching with patient. Instructed her on how to take TID meds. Enforced that she needs to take am meds in the morning to be on schedule.

Decompensation ManagementVNA called, patient cont with some dizziness with ambulation but did not feel like she was going to pass out. Pt denies any CP. I spoke with Dr who would like to decrease pt's dose of Torsemide to 40mg. I have explained this to pt who seems to understand current dosing of meds & new change. Follow-UpF/U call made to pt's home to check in & see how she was feeling. Pt states her dizziness has resolved & is feeling much better. She cont with 40mg Torsemide daily.

Progress to Date & Next Steps

• After two months, reliably implementing all elements of the intervention

• Next Step: At three months, evaluate outcome measures, including impact on readmission rates.

• Teaching and learning is most effective when reinforced consistently from multiple care providers

• Opportunity: Standard teaching tools across care settings (hospital, ECF, VNA, transition coaches, primary care)

• Opportunity: Identify way to track patient’s level of understanding and communicate teaching/learning needs across the continuum.