Transcript Ste. Genevieve County Memorial Hospital

MHA Immersion Pilot Project
Reducing All Cause Readmissions at
Ste. Genevieve County Memorial Hospital
Hospital Information/Team
Members
• 25 Bed CAH
• Smallest
clinical cancer
research in the
USA
• Over 100
providers
available in our
small
community
Brandie-Social Services
Missy-QI Director
Laura-Pharmacy
Sheila-IS
Julie-Clinic RN
Kim-Case Manager
Hirschel-Med/Surg
Director
Dr. Noguera-Hospitalist
Wanda-Home Health
Laura-ER Director
Carrie-RT Director
Chrissy-RT
Janice-Dietician
Project Focus/Problem Statement
 Our project goal is to reduce all-cause
Readmissions within our 25 bed critical access
hospital:
 To evaluate the cause of reoccurring patients
who have failed the discharge plan
 To address concerns from primary care
physicians post discharge
 Improve patient safety and coordination of
care
What initial barriers were identified
to project implementation?
Patient and family engagement
EMR limitations (Meditech 6.0)
Multi-disciplinary team awareness
External stake holder involvement
Communication issues-across all levels of care
Processes initiated without
sustainability/accountability
 Staff buy-in
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Percent of Project Quarterly Tasks
Completed
 List first quarter task completion 100%
 List second quarter task completion 100%
 List third quarter task completion 100%
Key Solutions Implemented
 Developed a process improvement team
 Initiated a High Risk Screening tool in our EMR to identify those who
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are at high risk for readmission and posted on the status board
Created consistent chronic disease education across all levels of care
Implemented a daily multidisciplinary patient care team huddle
Focused on Pharmacy education for all high risk and readmit patients
Re-launching of staff education on Teach-back
Accurate and accessible discharge medication lists and medication
safety focus at all levels
Coordinated accurate medication reconciliation at admission, at any
change in the level of care and at discharge
Implemented post discharge phone calls within 2 days and follow up
appointments within 3-5 days of discharge
Developed a new discharge process i.e. Smart Discharge
Readmission Concurrent Reviews (RAT team)-discuss patients
concurrently
Key Lessons Learned
 Engage your discharge partners (including nursing
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homes) from the beginning
Verify administration support and involvement to
endorse change. Engage your front line leaders.
Effective change requires a team!
The need for ongoing re-education was necessary to
sustain progress.
There are limitations to EMR adaptability and
reporting
Conflicting priorities are a challenge and impacting
initial buy-in, clinical staff’s availability and
scheduling, and the overall engagement of our team
Results
Return on Investment
 Identified that education was an issue; therefore
we are investing in our patients through
education across the spectrum. i.e. CHF,
Medication, Joint replacement
 Saving education materials through consistent
education.
 Utilizing our care team partners for education
i.e. Cardiac Rehab educating CHF; Ortho
educating Joint replacement; Pharmacy
education for Medications
Team Accomplishments
 Implementation of High Risk Screening tool
 Foster good communication between the Intra
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disciplinary team
Medication Reconciliation
Pharmacist educating poly-pharmacy and high
risk patients
Teachback
Follow up phone calls
Sustainability and Spread Plan
 Focus on standardizing additional education on
other chronic diseases i.e COPD, Diabetes,
Pneumonia
 Audit follow up phone calls, teachback, follow up
appointments and discharge summaries sent to
out of town PCP.
 Spread Intra-disciplinary huddle to other
departments
Next Steps/Future Plans
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Patient engagement
Initiating Transitional Care support
Sustainability
Additional relationship development with our
external stakeholders