Transcript Presentation

All Hands On Deck.
Impacting Patient Readmissions
Sherry Sweek, RHIA, CPHQ, CPMSM,
Director, Quality Improvement
Southeast Georgia Health System
[email protected], 912.466.3265
October 2, 20013
Southeast Georgia Health System
• Two hospitals: Brunswick-316 beds, Camden40 beds
• Two Nursing Homes: Brunswick-232 beds, St.
Marys-78 beds
• Three Immediate Care Centers
• Physician Practices: over 90 physicians in
primary care and specialty care practices
• 2,300 team members
• Focus today is experience at Brunswick facility
Session Learning Objectives
1. Discuss initiatives to impact readmissions.
2. Outline the steps to implement a successful
engagement with Area Agency on Aging (AAA).
3. Identify the outcomes impacted by our local AAA
interventions.
P D C A (Plan, Do, Check, Act)
Quality Improvement Model
Act
Plan
Check
Do
• PLAN–What is driving
readmissions, which
patient populations are
problematic?
• DO-Implementation the
action steps identified in
the planning phase.
• CHECK-Measure
process and outcome
indicators. Test.
• ACT-Did we achieve
results we expected?
What other steps are
needed?
Plan the Improvement
•
•
•
•
No organized plan to address readmissions
– Case Management looking at 7 day readmissions, SNF
bounce backs
– Patient Education looking at readmissions for all
patients for any reason
– Quality focused on Heart Failure & Pneumonia
Utilize existing Quality Committee and structure meeting
as working sessions for GHA HEN initiatives
Determine how to work with Area Agency of Aging to
impact specific high-risk patient populations
Identify internal changes to complement work from AAA
Do the Improvement
•
•
•
•
•
Patient Education Coordinator interviewed readmitted patients
over three months: 25% did not understand medications or have
follow-up appointment. Implemented Patient Education folder and
training for bedside nurse.
Renal patients accounted for 60% of Heart Failure readmissions,
highest at risk group. Target with AAA.
SNF readmissions: 18% (60% of those from our system SNFsPneumonia). Work with
Post-Discharge Call program with Beryl Health
Schedule meeting with AAA to understand Bridge Program. Pilot
on one unit, then expanded to two additional units with focus on
Renal and Pneumonia patients
Area Agency on Aging Impact:
Readmission Prevented
10
8
6
5
4
4
3
2
4
3
2
2
0
13Jan
Feb
Mar
Apr
May
Jun
Jul
Check: Heart Failure Readmissions
Heart Failure 30-Day All-Payer Readmissions
US Rate
HF Readmit %
40.0%
20.0%
14.0%
0.0%
5.7%
Feb
Mar
10.3%
24.7%
12.2%
4.4%
11.4%
0.0%
Jan
Apr
May
Jun
Jul
Aug
10.0%
0.0%
9.1%
Jan
8.7%
0.0%
Feb
Apr
Nov
Dec
Nov
Dec
11.8%
3.6%
Mar
Oct
US Rate: 24.70%
Heart Failure Medicare 30-Day Readmissions
30.0%
20.0%
Sep
May
4.8%
6.7%
Jun
Jul
Aug
Sep
Oct
30-Day Readmissions-Brunswick
Medicare patients only, readmit for any reason,
readmit to any hospital in US as Inpatient status
10/0706/10
10/0806/11
07/0906/12
US
National
Rate
Heart Attack
19.6% 18.4%
15.2%
17.9%
Heart Failure
21.6% 22.0%
19.2%
22.9%
Pneumonia
16.2% 17.3%
16.6%
17.6%
• All readmits: no different than US rate
(no penalties) for 2nd year in a row
Red
0-25th percentile
Yellow 26th-50th percentile
Green
Blue
51st-75th percentile
76th-100th percentile
Check: HCAHPS Top Box Score
August
-low
volume
Post-Discharge Calls: HCAHPS
BWK - Top Box Scores (With and Without Followup Calls)
Received Followup Call
No Followup Call
100%
90%
90%
87%
85%
80%
80%
74%
73%
70%
59%
60%
50%
71%
70%
67%
48%
80%
77%
67%
58%
52%
50%
39%
40%
30%
20%
10%
0%
Rate Hospital Comm with Resonse of Comm with
0-10
Nurses
Hospital Staff
Doctors
Hospital
Pain
Comm about Discharge
Environment Management
Meds
Information
Care
Transitions
Act on Results
•
•
•
•
•
Monthly meeting with AAA to discuss patient cases
Post-Discharge Calls moved to clinical calls in July 2013
Patient Education folders expanded to Maternity in May
2013
Nursing Leadership tracking communication with nurses
and communication on medications as 2013 PI Project
Interaction with AAA has been great and the impact they
have made in invaluable. We love having them on our
team!!