MI STAAR: Transitions of Care

1. MI STAAR: Transitions of Care Mercy Memorial Hospital System Success at MMHS • Mercy Memorial Hospital System • Monroe Michigan • 238 Licensed Beds • ECF, Home Care, Hospice and Home Respiratory • Located Southeast Michigan close proximity to Ohio border • Discharge planning • Often crosses state lines • Demographics • Mixed : Middle/Low-income

2. Statement Disclosure I do not have any relevant financial relationships with any commercial interests.

3. Goal: Improve Patient Outcomes What gets measured, gets done! We need a cross-functional team Leadership support Physician involvement Community involvement

4. Objectives: Decreasing Readmissions • Leadership Rounds/Care Coordination Rounds. • What do they look like? • Who does the rounding? • What are potential outcomes? • Physician Involvement. • Examine strategies to improve outcomes. • Partnership to drive best practices. • Community Involvement • Collaboration between agencies and partnerships

5. Leadership Rounding(Process – Measure - Execute) • Process • Every Bed: Monday – Friday • AIDET • Keep it simple - scripting (very good care) • Ensure we are meeting the needs of our patients • Focus on the patient experience • Measure • Document Concerns • Detailed summary sent to the nurse manager • Execute • Summarize on rounding logs • Follow up on actions to improve patient care

6. Care Coordination Rounds(Process – Measure – Execute) Cross Functional Teams • Process • Implemented Care Coordination Rounds in August 2012 • Bedside Nurse, Physicians, Case Manager, Social Worker, Dietician, Pharmacist, PT/OT • Monday – Friday - 30 minutes or less • Measure • Identify any tests/procedure delays • Focus on patient progression for discharge • Identify barriers to ineffective care transition • Execute • Detailed summary provided to Nursing • Follow up on actions to improve patient care.

7. Care Rounds-Patient Focus Multidisciplinary Communication, Collaboration and Coordination • Identifying all 30 day readmissions on day one. • Identify who is the caregiver –start education from day one. • Care team begins discharge planning at admission and continues through patient’s hospital stay. • Completion of a discharge risk/assessment during the hospital stay. • Standardized transition plans, procedures and forms.

8. HCAHPS

9. HCAHPS

10. Physician Involvement Involve the physician to improve patient outcomes. Partner with physician champions/hospitalists. Engaged five physician champions - receive their approval for implementing orders. • Visiting nurse for patients discharge to home • PT/OT to evaluate for home vs. rehab • Pharmacy consult on heart failure patients • Dietary consults for education of the HF patients • Follow-up doctor appointments

11. Physician Order Form

12. Physician Partnership • Physician involvement and shared accountability during all points of transition. • Home care visits authorized. • Medication scripts to ECF to prevent any delay in treatment. • Timely follow-up, support and appointment within 3-5 days for any patient going home. • Office staff allotting appointment times for follow up care. • More frequent rounds in nursing homes by the physicians.

13. Zone Education Mercy Memorial Hosppital Mercy Memorial Hospital

14. Readmission Rate

15. Community Involvement Partnership for our Patients ▪ Health Department ▪ Home Healthcare Agencies, ▪ Physician Clinics ▪ Skilled Nursing Facilities ▪ Free Clinics ▪ Low Cost Healthcare in the Community

16. Community ECFs Monroe Skilled Nursing Facilities • Monthly meetings and collaboration • Shared data - readmissions and outcomes • Use SBAR for SNF and Zones teaching • Electronic transfer of information • HF/COPD patient discharge binder

17. Community Involvement Moving from the Inpatient Setting to the Outpatient Arena Teachback - community agencies Physician offices - educated on Heart Failure and COPD Zones Mercy’s Angels - Hospital implemented a program in the community to educate on free and low cost health clinics: • Flu shots- seasonal • Glucometer checks - monthly • B/P checks - monthly • Free clinics in community • Dental care – Monroe County Health Department

18. Lessons Learned Outcomes • Scripting of rounds to identify problems real-time. • Patient telling us what is going well/not so well. Look for opportunities to improve patient care. • Fix the problem while the patient is still in the hospital. • Moving from inpatient to outpatient. Successful partnerships with physicians and Healthcare Professionals. • Partnership with outside agencies and office practices to succeed in reducing readmissions.

19. References • Bell, B. Thornton, The Need for Better Improved Care Coordination, From Promise to Reality: Achieving the Value of an E.H.R, Healthcare Financial Management, 65(2) p.51-56. • Coleman, Eric, MD, MPH, Division of Health Care Policy and Research, University of Colorado Health Science Center, Development and Testing of a Measure Designed to Assess the Quality of Care Transitions, International Journal of Integrated Care, Vol. 2, June, 2002. ISSN 1568-4156. Pages 1-9. • Institute for Healthcare Improvement, Heart Failure Zone Flyer, Knowledge Center of IHI, Tools.http://ihi.org. • Weireter, Erin, NQF Endorses Care Coordination Measures, http://www.qualityforum.org • Quality Net Reports User’s Guide, Hospital Readmissions Reduction Program, http://www.qualitynet.org • Quality Net ,CAHPS Hospital Survey (HCAHPS), http://cms.hhs.gov • Reddish, Lorrie RN, Director of Case Management, Jennie Edmondson Hospital . Council Bluffs, IA. Keep your Team Focused During Care Coordination Rounds, Case Management Monthly, April 1, 2011. www.hcpro.com/CAS-262795.

20. Questions