ten strategies to reduce acute care re-hospitalization rates

1. Ten Strategies to Reduce Acute Care Re-Hospitalization Rates Carin Croker RN, MSN, CCM Director of Patient Services Aspirus VNA Home Health & Comfort Care Hospice Services

3. Appropriate Level of Care Critical Assessments Telephonic/Intake Discharge Planners/Case Managers Home Health Care Short Term Skilled Care Safety Support Optimal Treatment Outcomes

4. Appropriate Care Treatments Wound Care Wound Clinic Support Cardiac Monitoring Telemonitoring Medication Management Current Medications/Education Therapy Outpatient

5. On-Site Assessments Homecare Assessment Specialists Skilled Nursing Facilities Assisted Living Facilities Hospitals Home Visits

6. Telemonitoring/Telehealth Daily Telemonitoring: 31 days CHF COPD Diabetes Pneumonia

7. Front-Loading Visits Cardiac Diagnosis Daily Visits (3-5 days) Wound Care Daily Visits (2-3 days) Focus on Teaching Patient/Family Telephonic Monitoring Specific Patients/Education

8. Establish Pathways Hospital Based Pathways Transitional Consistency Between Levels of Care Wound Care Cardiac Diabetes COPD CHF

9. Teaching Focus Assess Teaching Before Admission Screen for Ability Assess for Support Communication Upon Admission

10. Physician/Provider Collaboration Wound Clinic Pain Clinic Hospitalists Surgeons

11. Support Services Family/friends Private pay custodial services Transportation Laundry Shopping Maintenance Services House Cleaning

12. PPS Reimbursement Focus on Short Term Skilled Care Focus on Assuring Appropriate: Care Treatments Level of Care Family/Patient Involvement Utilization of Services/Amount Interdisciplinary Approach/Communication

13. Hospital MS/DRG Collaboration with Hospitals LOS Appropriate Discharges Transitional Level of Care Utilization of Resources MEDICARE THE BIGGEST HMO

14. Home Health Compare Home Health Compare 2005 Acute Care Re-Hospitalization & Emergent Care Rates 20% 18% Home Health Compare 2008 Acute Care Re-Hospitalization & Emergent Care Rates 8% 12%

15. Questions