Transcript Day 1_115-230_BIDMC

Reducing Avoidable
Readmissions
A Cross-Continuum Approach
BIDMC’s Strategy for Readmission Reduction
Risk Factors
System
Level
Condition
Specific
Medication
Mgmt
Patient
Activation
Mitigation Strategies
Care
Coordination
Disease
Specific
Pathways
(Inpt & Outpt)
Pharmacist
Med Rec &
Consolation
Care Transition
Coaching
Effective Teaching & Learning Based on Health Literacy Level
Family / Social Support & Community Services
Health Care Associates (HCA) Pilot
Target Population=
HCA Medicare Patients with Discharge Diagnosis of Heart
Failure, Pneumonia or Heart Attack (AMI)
Hospitalization
Hospital Care Team
30-Days Post Discharge
ECF/VNA
Pharmacists
Specialists
Primary Care Team
Nurse Care Transition Specialist (CTS)
Patient & Family
Care Transitions Coach
ASAP Network Social /Community Support Services
HCA Pilot: Teaching & Learning Component
Key Learning:
Patients retain very little of the teaching that
occurs at discharge
Hospitalization
CTS performs bedside
assessment to identify
patient’s health literacy
level and knowledge of
condition.
30-Days Post Discharge
CTS meets patient
after post-discharge
visit to answer
questions and discuss
the plan.
When patient returns
home CTS calls to
review the discharge
instructions and
condition based
teaching, using Teach
Back techniques.
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 Continuum
Heart Failure Patient A– Medication Knowledge & Adherence
Bedside Visit
Patient 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 VNA
Received 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 Management
VNA 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-Up
F/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.