Transcript Integrated Marketing & Communications Plan

Hallmark Health System
October 11, 2011
Founded as a system in 1997, Hallmark Health is a local, not
for profit, community based healthcare system serving
Boston’s northern suburbs. The two hospitals that comprise
Hallmark Health System are the Lawrence Memorial Hospital
and the Melrose-Wakefield Hospital.
STAAR Hallmark Health System
Maureen Pierog MS, RN
Vice President
Quality Improvement
Barbara Marullo RN,BSN
Program Manager
Quality Improvement
Focus on CHF
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High volume
Problematic
Public data through June 2009 showed Hallmark as
worse than expected
Future financial implications
Readmission Profile
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Elderly (>75)
10 or more medications
Independent (refusing increased
support at discharge)
Did not use discharge information
Multiple diagnoses for
readmissions
2010 Initiatives in Place
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In House pharmacy consults in place for
high risk CHF patients expected to go
home.
( 75 or older and or on > 10 meds)
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Case Management assesses every CHF
patient with a risk for readmission tool.
This is communicated throughout the
continuum of care.
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Case Management is making follow up
appointments for all CHF patients before
discharge from the hospital.
FOCUS on SNF Returns
Key Changes
Provide Real – Time Handover
Communication
Provide customized, real time
critical information to the next
clinical care providers
Goal : Prevention of Readmission from Courtyard
Nursing Facility to Lawrence Memorial Hospital
Starting Point
Initial discussions centered around the following:
1. Discharge Information and Communication
2. The true capabilities and limits of the care available at the SNF
3. Role of the ED physician; automatic admission vs treat and return
4. How time of day and medical availability affects decisions
5. What role could physician to physician contact play?
6. What role could nurse to nurse contact play?
Baseline Data
LMH / Courtyard Nursing Care Center
November / December 2010
# admitted from Courtyard = 48
# admitted from all SNFs = 188
26% of patients from SNF came from
Courtyard
# of readmissions = 13
# of admissions from Courtyard = 48
27% readmission rate
OBSERVATIONS
1. No direct Nurse to Nurse communication
during the transfer process.
2. No Physician to Physician communication
during the transfer process.
3. The traditional 3-page discharge referral was incomplete.
After reviewing all the data, the Readmission Committee decided
that just concentrating on CHF was too limiting. We expanded this
to include ‘all cause’ transfers to the emergency department.
Changes Tested
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Courtyard Nursing Care Center utilizes
the INTERACT tool for clear
communication with any patient sent to
LMH ED
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Initiation of Geriatrician to ED
Physician telephone communication
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LMH nurse to nurse phone call with
any patient discharged to Courtyard
Nursing Care Center
Failed Tests
For all discharges from LMH to CNCC we
set a goal to use the state proposed
expanded transfer tool. (CMS Universal
Transfer Form)
We tried to produce a prepopulated
electronic pull in meditech during the
discharge process.
PROJECT AIM
By October 2011
Reduce Hallmark Health System 30 – day readmission rate for patients
with heart failure by 15 %
Traditional Medicare from 23.5 % to 20 %
All Payer from 21.64 % to 18.4 %
Hallmark Health System
Principal Diagnosis:CHF & All Payers
40%
35%
% 30 Day Readmit
30%
25%
20%
15%
10%
5%
0%
Jan
Feb
Mar
Apr
May
Jun
2010
Jul
Aug
2011
Sep
Oct
Nov
Dec
Hallmark Health System
30 Day Readmission
01/01/2010- 05/30/2011
16.00
% 30 Day Readmit
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Jan
Feb
Mar
Apr
2010
May
Jun
Jul
Aug
2011
Sep
Oct
Nov
Dec