Transcript Hunterdon Medical Center - National Readmission Prevention

Readmissions Experience
Hunterdon Medical Center
CMO Roundtable
October 2014
Background
• Hunterdon Medical Center is a 176 bed hospital
in west-central New Jersey
• It is part of Hunterdon Healthcare, which also
includes Hunterdon Regional Community Health
(home care, visiting nurse, and hospice) and
Mid-Jersey (for profit arm)
• Hunterdon Healthcare partnered with the
Hunterdon Physician Practice Association, an
IPA, to form Hunterdon HealthCare Partners
Background
• Readmissions Committee work began in
2011 in anticipation of CMS penalties to
begin in fiscal 2012
• Focused on CHF first as we had the
highest rate out of the three
• First looked at patient education
AMI
CHF
Pneumonia
Patient Education
• Created forms for nursing to document
education during the inpatient stay
• Used a “stop light” system for patient selfassessment after discharge
• Tried to institute a discharge “test” for
teach-back
Why Are Patients Readmitted
• We had our patient care managers
complete a short questionnaire with
readmitted patients
• Did the questionnaire with 50 patients
• Did not see any real trends
Our goal at Hunterdon Medical Center is to improve the status of your health. One of our
goals is to avoid readmission to the hospital. We would like to ask you a few questions as
to why you think you were brought back to the hospital so soon.
Information obtained from:
____Patient
_____ Family Member
Discharge Diagnosis from first admission:_____________________
1. Were you advised to stop any medications?
_____ Yes
_____No.
2. Were you prescribed new medications when you were discharged from the hospital?
_____ Yes
_____No.
If yes, go to Q3, if no, go to Q5
3. Did you get the prescription filled within 24 hours?
_____ Yes
_____No
If yes, go to Q5, if no, go to Q 4.
4. Why were you unable to fill the prescription?
_____ Financial
_____Transportation
_____Other___________________
5. Did you receive and understand your discharge instructions?
_____ Yes
_____No.
6. Did you have appointments with your physicians following your last hospitalizations?
_____ Yes
_____No.
How many appointments?_____
7. Were the appointments made for you_____, or did you need to call_____?
8. Were you able to keep the appointments?
_____ Yes
_____No
_____Some of them
9. If you were unable to keep your appointments, why was that?
_____ Financial
_____Transportation
_____Back in hospital
_____Other___________________
10. Are there any other issues that you feel contributed to your re-hospitalization?
________________________________________________________________________
________________________________________________________________________
CHF Study
• Conclusions
– 37% of these patients left HMC without an
appointment to see their doctor on the first admission
– 16% of these patients left HMC without an
appointment to see their doctor on the second
admission
– 60% of these patients were 81 years of age or older
– 64% of these patients were discharged to home
Partnering with Post-Acute
Providers
• Post Acute Providers were added to the
Committee
• INTERACT II (Interventions to Reduce
Acute Care Transfers) Program introduced
at one nursing home
– Program to identify early changes in resident
status that could lead to hospitalization
– Tools available through http://interact2.net/
Expansion of the Committee
Role
• In September 2012, the Committee
decided to look globally at readmissions
and to look at processes around
readmissions including:
– Discharge checklists
– Transfer of Information
– Medication Reconciliation
Risk Stratification
• We beta tested a program called Crimson
RealTime from the Advisory Board
Company
• Using historical billing data, the software
was designed to:
– Identify patients at high risk via a proprietary
algorithm
– Identify CHF, Pneumonia, MI patients
Care Co-ordination Across the
Continuum
• Set up a meeting with our inpatient Patient
Care Managers and our Care
Coordinators in the primary care offices
• Had them exchange phone numbers
• The Care Coordinators are informed when
a high risk patient is admitted and when
they are discharged
Exchange of Information
• At discharge, the unit coordinator will fax
(don’t judge me) the discharge medication
reconciliation and the discharge
instructions to the PCP office (we are
looking into a scan/e-mail system)
• It is an expectation that discharge
summaries are dictated at the time of
discharge—our hospitalists have this built
into their bonus calculation
Follow-up
• Through our IDS, we created an
expectation that high risk patients have a
follow up appointment within 3 business
days and moderate risk patients within one
week
• We have not been universally successful
in getting f/u appointments made prior to
the patient leaving the building
Follow-up
• Our Clinical Nurse Leaders make phone
calls 1-2 days after discharge and ask
whether patients have their post-acute
appointments made and whether they
have filled their discharge prescriptions
• Care Coordinators will also reach out in a
similar manner
Other Factors
• Our Home Health Company has invested
in 20 telehealth monitors for CHF patients
• We have had our word processing
department “push” discharge summaries
out to the PCP of record
Next Steps
• Getting our inpatient EHR (Quadramed QCPR) to talk to
our outpatient system (NextGen), especially regarding
medications, and medical documentation
• Continue to improve our patient education functions
• Continue to improve communication between Hospitalist
and PCP
• Filling discharge prescriptions in outpatient pharmacy
• Greater acceptance of Palliative Care and Hospice
services by both physicians and families
Readmits—Medicare AMI
2012 thru 2014
Readmits—Medicare CHF
2012 thru 2014
Readmits—Medicare
Pneumonia 2012 thru 2014
Readmits—Medicare
2012 thru 2014
Readmits—All Payers
2012 thru 2014