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Transitions in Care aka Reducing Readmissions. Shawnee Mission Medical Center Kim Fuller, MSW, MBA, CCE Janet Ahlstrom, MSN, ACNS-BC. Shawnee Mission Medical Center. Preventing Re-hospitalization within 30 days. Selected populations : Congestive Heart Failure Pneumonia

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Transitions in Care aka Reducing Readmissions

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Transitions in care aka reducing readmissions

Transitions in CareakaReducing Readmissions

Shawnee Mission Medical Center

Kim Fuller, MSW, MBA, CCE

Janet Ahlstrom, MSN, ACNS-BC

Shawnee mission medical center

Shawnee Mission Medical Center

Preventing re hospitalization within 30 days

Preventing Re-hospitalization within 30 days

Selected populations:

Congestive Heart Failure


Acute Myocardial Infarction (AMI)

Our journey

Our Journey

  • IHI Collaborative on Reducing Readmissions in 2009/2010.

  • Developed multidisciplinary internal team to participate in the Collaborative and to begin designing program.

  • Did chart reviews of readmissions to assess patterns, failure points, potential interventions and conducted tests of change.

  • Discovered many readmissions coming back from SNF’s, so invited key partners to join Collaborative.

Journey continued

Journey continued….

  • Split internal team and external community partner group into separate meetings.

  • Justified initial addition of an FTE by quantifying potential cost to the bottom line following implementation of CMS penalties.

  • Hired .5 MSW and .5RN and Transition Coach role fully implemented in August, 2011.

Smmc program 4 main focus areas

SMMC Program4 main focus areas

  • Enhanced Admission Assessment for Post Hospital Needs

  • Effective Teaching and Enhanced Learning

  • Real – time Patient and Family Centered Handoff Communication

  • Post-Hospital Care Follow Up

Internal team

Internal Team

  • Membership includes:

    • Nursing representation from cohort areas for CHF, AMI and Pneumonia.

    • Pharmacy

    • Social Work/Utilization Review

    • Ask a Nurse Call Center

    • SMMC Home Health

    • Cardio-Vascular Services

    • Nursing Education

External team

External Team

  • Membership includes

    • Home health

    • Skilled nursing facilities

    • Assisted Living Facilities

    • Hospice

    • Private Duty

    • LTAC

    • Emergency Medical Response

External team focus

External team focus

  • Case studies of readmissions from various facilities, identifying breakdowns and creating new processes.

  • Education re: disease specific protocols provided to SNF’s. i.e. importance of daily weights and use of the zone chart for CHF patients.

  • Development of common hand off tool that meets needs of hospital and external agencies.

  • Strategies to increase involvement of palliative care and hospice when appropriate.

External team focus1

External team focus

  • Education about national movement toward use of Transportable Physician orders for End of Life treatment wishes.

  • Development of special interest sub-committees to concentrate and problem solve issues that are unique to different settings.

  • Trend readmission data specific to various agencies/facilities to use in forming stronger community partners with those that have lower readmission rates.

Transitions in care

Transitions In Care

Shawnee Mission Medical Center

Melanie Davis-Hale, LMSW

Cathy Lauridsen, RN, BSN

Transition coach

Transition Coach

  • 0.5 Social Worker/ 0.5 RN

  • Identify high risk patients in hospital

  • Initiate individualized program

  • Follow for 30 – 45 days regardless of setting

  • Facilitate smooth TRANSITIONS

  • Early intervention with any readmissions

  • Meet weekly with physician champions at SMMC

  • Provide education for patients and healthcare team partners

Identifying high risk patients

Identifying High Risk Patients

  • Currently utilizing the Better Outcomes for Older adults through Safe Transitions (BOOST) Tool

  • Collaborative Care Team (CCT) process at SMMC

  • Chart review of Electronic Medical Record

Boost tool

Boost Tool

8P screening tool:

  • Problem Medications –(anticoag, insulin, aspirin, digoxin)

  • Punk (depression) - screen positive or diagnosis

  • Principle diagnosis – COPD, cancer, stroke, DM, heart failure

  • Polypharmacy - >5 or more routine meds

  • Poor health literacy - inability to do teachback

  • Patient Support – support for d/c and home care

  • Prior Hospitalization - non-elective in last 6 months

  • Palliative Care – pt has an advanced or progressive serious illness

Pre and post hospital care and follow up

Pre and Post Hospital Care and Follow Up

  • Initial contact with patients/family during the hospitalization.

  • Schedule follow-up PCP/Specialist appointment prior to hospital discharge.

  • Follow patient across all levels of care for up to 45 days post discharge.

  • Phone/in person home visits.

  • Continually assess patient needs post discharge.

Four patient centered elements for teachback

Four patient centered elements for Teachback

  • Medication management

  • Follow up with PCP/Specialist

  • Patient centered record

  • Knowledge of Red flags and how to respond

Strategies for success

Strategies for Success

  • Develop a relationship with patient and/or family prior to hospital discharge

  • Identifying patients’ healthcare goals

  • Matching patients to Social Worker or RN based on patient needs

    • Social Worker

      • Financial needs

      • Psycho-Social needs

      • Community resources

    • RN

      • Patient/Family/Caregiver Education

      • Facility/Service Provider Education

      • Symptom management

Strategies for success1

Strategies for success

  • Interventions to prevent readmission based on patients’ discharge plan

    • Patient Discharges to SNF/LTAC/Acute Rehab

      • Visit/phone call to patient, patient’s nurse, social worker, PT/OT, Medical Director.

        • Ensure patient has seen Medical Director within 72 hours

        • Identify medication issues/concerns/changes and other areas of symptom management.

        • Awareness of patient discharge plan from facility

      • Maintain communication with patient’s PCP/specialist

      • Prepare patient for transition to lower level of care/home

Strategies for success2

Strategies for Success

  • Patient Discharges to Home with Home Health

    • Collaborate with Home Health Agency/Case Manager to develop care plan to prevent readmission

    • Ensure patient attends follow-up PCP/specialist appointment

  • Patient Discharged to Home

    • Continue post-discharge education to patient/family/caregiver

    • Identify medications issues/concerns

    • Identify and referred to needed services

    • Encourage self-management when possible



  • Identifying patients that will code out as CHF, Pneumonia, AMI

  • Continually educating service providers on role of transition coach

  • End of life issues

Program results

Program Results

Program results1

Program Results

Program results2

Program results

Program results3

Program results

Program results4

Program Results

Program results5

Program Results

Contact information

Contact Information

  • Kim Fuller

    • 913-676-2293


  • Janet Ahlstrom

    • 913-676-2032


  • Cathy Lauridsen

    • 913-676-8611


  • Melanie Davis-Hale

    • 913-676-2168


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