Transcript RARE presentation for Texas Hosp Assoc

Reducing Readmissions by
Engaging Patients and Families
Kim McCoy, Stratis Health
Teri Beyer, Rice Memorial Hospital
September 11, 2012
RARE Campaign: Maintaining
patient health after
a hospital stay…
…So We All
Sleep More
Peacefully.
The RARE Campaign
• A campaign across the continuum of care to
reduce avoidable hospital readmissions across
Minnesota
• Focused on hospitals with support of providers,
health plans, other key stakeholders
• Designed to improve coordination of care and
reduce fragmentation of the health care system
Statewide Triple Aim Goals
• Population health
Reduce overall readmissions rate by 20% from 2009
baseline by December 30, 2012
• Care experience
Enable patients to spend 16,000 more nights in their own
beds instead of in the hospital
• Affordability of care
Save an estimated $30 million for commercially insured
patients; additional savings for Medicare patients
RARE Campaign Implementation Overview 2011-2012
Broad Community Support
• Operating Partners
• Institute for Clinical Systems Improvement (ICSI)
• Minnesota Hospital Association (MHA)
• Stratis Health (MN QIO)
• Supporting Partners
• Community Partners
Geographic Representation
Support for Hospitals
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RARE Resource Consultant
Learning collaborative options
Best practice toolkits
Face-to-face sessions
Webinars and conference calls
Data reporting
Five Key Areas
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Comprehensive discharge planning
Medication management
Transition care support
Transition communications
Patient and family engagement
Recommended Actions Report - http://rarereadmissions.org/documents/RARE_Recommended_Actions_Care_Transitions.pdf
Patient and Family Engagement
• Typical Transition Failures
• Best Practices/Improvement
Strategies
• Proposed Measures
• Gap Analysis
• Tools and Resources
Patient and Family Engagement
• Use teach back to assess
patient’s understanding of
any instructions
• Ensure caregivers are
engaged in developing the
plan of care
• Use health literacy
standards
RARE Results to Date
• 81 hospitals
• 75 Community
Partners across the
care continuum
• 2,607 readmissions
prevented (13%
reduction)
• 10,000 more nights of
sleep in their own
beds
http://www.rarereadmissions.org/
For more information…
Kim McCoy, MPH, MS
Program Manager
Stratis Health
[email protected]
952-853-8563
Rice – Reducing Readmissions
Rice Memorial Hospital
• City Owned Hospital
• 100 bed Hospital (average daily census
60)
• West Central MN – Willmar, MN (pop
20,000)
• Service area 14 counties
Key Players
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Rice Memorial Hospital
Family Practice Medical Center
Affiliated Community Medical Center
Willmar Area Skilled Nursing Facilities
– Rice Care Center
– Bethesda Pleasantview & Bethesda Heritage
– Willmar Care Center
Hospital Team
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Administration
Care Manager & Adult Health Care Director
Discharge Planner/Social Work
Care Manager
Adult Health Care Nurse
Respiratory Therapy
Pharmacy
Hospitalist
Clinical Information Systems
Finance
Focus Areas
• After Hospital Care Plan
– Medication Management
– Patient & Family Discharge Preparation
• Discharge Advocate
– Comprehensive Discharge Plan
– Essential Transition Communication Elements
• Follow –Up Support
– After Discharge Follow Up
– Community Partnerships
After Hospital Care
Medication Management - Home Medication List Accuracy
• Trial of Pharmacist involvement in verifying the
accuracy of the Home Medication List within 24
hours of Admission
– Clinical Pharmacist completed an Admission
Medication Review on 42 Family Practice Medical
Center Patients
– Interviewed Patient & Family as to what they were
“actually taking”
– Verified with Local Pharmacies
– Checked Clinic List
Medication List Accuracy – Pharmacy Review
FINDINGS
66% had at least one
discrepancy
50% had 2+ discrepancies
Average of 1.9 per patient
After Hospital Care
Patient & Family Discharge Preparation
• Patient & Family Learning
• Daily Weights
Patient & Family Learning - Healthcare Literacy
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14% of all adults in the USA function below or at the 3rd grade level, 29% at
a 6th grade level, 44% at 8-10th grade level, 13% > 10th grade level
Patients who are older, racial/ethnic minorities, non native English speakers,
low income levels and compromised health status have lower Literacy rates.
Those with lower literacy rates have 4 times the healthcare costs than those
with higher literacy skills.
Patient adherence to Discharge Instructions affects hospital readmission
rates.
If patients do not understand the implications of their diagnosis and the
importance of prevention and treatment plans, there is the potential for
errors, adverse events, or unnecessary re-hospitalizations.
WHAT and HOW we teach becomes even more important!
Patient & Family Learning - Focus
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Reason for hospitalization
Tests, treatments & interventions
New medications
When to contact healthcare providers
Follow-up appointments
Patient & Family Learning “Teach Back”
• Screen Pt/Family for Healthcare Literacy Level
and Readiness to Learn
• A scheduled time is arranged with patient and
family
• A Patient Teaching Method where the “learner
teaches the teacher back” what they just
learned.
– Creates greater retention and recall
– Allows for verification of learning
Patient & Family Learning - Discharge Folders
Pt/Family Discharge Preparation - Daily Weights
• Daily weights to monitor for increasing
weight while hospitalized
– Often a sign of fluid overload
– Can happens with IV Hydration, Medication
Infusions or Blood Infusions
– A reason for readmission – accumulation of
fluid in the body in the lungs, lower extremities
makes the work of the heart and breathing
harder.
Discharge Advocacy
• Comprehensive Discharge Plan
• Essential Transition Communication
Elements
Comprehensive Discharge Plan
• Starts on Admission for Every Patient
– High Risk Care Management Screening
• Lives alone, over age 80, chemical dependency,
frequent ESD or hospital readmissions, mental
health concerns, inadequate support at home for
care needs, receiving other services at home…….
• Focused Discharge Planning and Care Coordination
based on patient and caregiver needs to create a Safe
Discharge Plan
• Discharge Advocate Roles
– Staff Nurse, Social Worker & Care Manager
Essential Communication Elements - Discharge Summary Availability
• Created a system to provide Primary Care
Providers at the clinic with the Discharge
Summary for the patient follow up visit
– Hospitalists created a template to “tell the
story” of the hospitalization including key
components essential for follow-up care.
– Faxed to clinics and scanned into clinic EMR’s
Essential Communication Elements – Skilled Nursing Facilities
• Participated in the Minnesota Hospital
Association “Safe Transitions Pilot Project”
• Included the Essential Elements of
Communication in “Interagency Transfer
Form”
– Pressure Ulcer/Risk, Precautions, Pending
Labs
• “Hard Stop” Discharge Nurse to Admission
Nurse Report & Order Review
Follow-Up Support
• After Discharge Follow Up
• Community Partnerships
After Discharge Follow Up - Follow Up Visits
• Ward Secretaries meet with patient/family
when scheduling follow-up appointments
for them prior to leaving hospital
– Clinic Post Hospitalization within 5-7 days
• Previously up to 3 weeks (21 days)
– Post ESD Visit within 3 days
• Previously up to 2 weeks (14 days)
After Discharge Follow Up - Post Discharge Phone Call
Hospital Care Managers
•Call based on risk
Clinic Nurse
•Call all patients within 72 hrs
post discharge
Community Partnerships
• Cultivating Community Partnerships are
Vital!
• It takes a community focus and
accountability to create the safety net for
our patients.
Readmissions/Safe Transitions In Care
– MHA Statewide Goal – 20% less potentially
avoidable readmissions from baseline in 2009 (Actual
Rate/Expected Rate Ratio of 0.80)
RMH Potentially Avoidable Readmission
– RMH:
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2009 Rate = 0.96
2010 Rate = 0.87
2011 Rate = 0.77
2012 Rate = 0.49
(1st Qtr data)
Actual/Expected Rate Ratio
0.96 0.8
0.87 0.8
0.81
0.8
0.8
0.78
0.8
0.75
0.8
0.8
0.73
0.49
2009
2010
Q1 2011
Q2 2011
Q3 2011
RMH Actual/Expected Ratio
Q4 2011
State Goal
Q1 2012
Questions