Transcript Safe Transitions

Safe Transitions
North Memorial
Using Society of Hospital
Medicine’s BOOST Toolkit To
Improve Patient & Family
Engagement
2010 NMR Data
 Readmits
w/in 30 days = 3,452
 Unique Patients Readmitted = 2,249
 Readmits w/in 72 hours = 654
 ED visits w/in 30 days = 2, 273
 ALOS 1st visit = 4.13
 ALOS 2nd Visit = 4.23
Digging A little Deeper - CHF
 474
CHF patients
 574 Hospitalizations
 22% Home Health Referrals
 7% Seen by Cardiologists Within 7 days
 12% Seen by NM Primary Care Clinics
Within 7 days
Who Are Our Patients At Risk For
Readmission?
A6 Daily Report
PTA Meds 2 = At Risk
(See Footer)
2
Living
Situation
0
Prior
Hospitalizatio
ns in Last 3
Months
Primary Prob
Gi Bleed (Principal Prob)
2
MRN
579099
Patient
Testpatient A (73 y.o. M)
Unit Room
A6
A680
2127710
Testpatient B (54 y.o. M)
A6
A681
2
5
1
2950
1595169
592956
72095
Testpatient, C (74 y.o. M)
Testpatient, D (69 y.o. M)
Testpatient, E (75 y.o. M)
Testpatient, F (90 y.o. M)
A6
A6
A6
A6
A683
A684
A685
A687
2
2
2
2
0
0
0
0
0
0
0
0
598609
Testpatient, G (93 y.o. F)
A6
A688
2
5
0
295097
Testpatient, H (62 y.o. F)
A6
A689
2
0
1
259096
296795
Testpatient, I (69 y.o. F)
Testpatient, J (67 y.o. F)
A6
A6
A690
A693
2
2
0
1
0
1
250608
Testpatient, K (88 y.o. F)
A6
A697
2
2 [senior apt]
1
#PTA Meds: 0 = Less than 3, 1 = 3 - 5, 2 = More than 5
Living Situation: 4 = Lives Alone, 5 = Nursing Home/Residential Care, 10 = Caregiver for Spouse or Family
Seizure (More)
Sepsis Secondary To Lll Pneumonia
(Principal Prob)
Atrial Fibrillation Or Flutter (More)
Htn (Hypertension) (More)
Atrial Fibrillation (More)
Chest Pain, Unspecified (Principal
Prob)
Nstemi (Non-st Elevated Myocardial
Infarction) (Principal Prob)
Phone #
Primary Care Provider
763-555-1234 PREBONICH, M (763-520-2980)
HENNEPIN FACULTY ASSOC,
952-555-1234 (612-347-6449)
763-555-2345
763-555-3456
763-555-4567
763-555-5678
KRIEGER, D (763-587-7900)
LAGER, R (763-520-2980)
FRANE, G (763-504-6400)
NOONAN, D (763-420-1900)
651-555-1234 UNKNOWN, M
763-555-6789 SORENSEN, P (612-302-8200)
Syncope And Collapse (Principal Prob) 763-555-7890 VINCENT, P (763-504-6500)
Lobar Pneumonia (Principal Prob)
763-555-8901 SHEFFELS, A (763-420-1900)
Ckd (Chronic Kidney Disease) Stage
3, Gfr 30-59 Ml/min (More)
763-555-9012 SICORA, J (763-425-1888)
Patient and Family Engagement

White Boards



Serve as a
communication tool.
Used by all disciplines
and patient/family.
Helps care team and
patient/family focus on
goals.
Patient and Family Engagement

Patient/Family
Centered Rounds


Identification of high
risk patients
Rounding script used
to develop plan for
hospitalization and
safe transition to
home.
Patient and Family Engagement

Follow-Up
Appointments
 Teach Back & Patient
Education Materials
 Medication
Reconciliation

Home Health Phone
Call 24-48 hours post
discharge
 Palliative Care
Optimization
 Family Care
Conferences
Teach Back & Patient Education
 Patient




Education At Bedside
RN conducting education rather than nurse
educator
Teach Back added as methodology for patient
educational assessment
Teach Back regarding medications &
discharge instructions
CHF Binder used during Teach Back and to
build redundancy between hospital and clinic
Did Someone On Hospital Staff Explain The
Purpose Of The Medicines You Were To
Take At Home In Ways You Could Understand?
90%
80%
70%
60%
A-6
A-5
Hospice
50%
40%
30%
20%
10%
0%
1st Q
2nd Q
3rd Q
Did The Hospital Staff Include Your Family Or
Someone Close To You In
Discussions About Your Care?
48%
46%
44%
42%
A-6
A-5
Hospice
40%
38%
36%
34%
1st Q
2nd Q
3rd Q
Key Learnings

Follow up appointment compliance in 7 days tripled
by assisting in coordinating appointments
 Need the same tool for risk stratification across
system
 Need system staffing model to support care
coordination across enterprise
 Need community to help in preventing
hospitalizations
 Need to "un-teach" how to conduct Teach Back
 Need learning environment to help support change
effort
Questions??
 John

Degelau, MD
[email protected]
 Sonne

Rivers, BSN, MA
[email protected]
 Society

of Hospital Medicine
http://www.hospitalmedicine.org