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Transforming Healthcare. Nancy M. Strassel Senior Vice President Greater Cincinnati Health Council. Where Are the Connections?. 270,000 discharges 1 in 5 patients readmitted We can do better. Laser Focus. 18 hospital learning collaborative Reduce heart failure readmissions

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Transforming healthcare
Transforming Healthcare

Nancy M. Strassel

Senior Vice President

Greater Cincinnati Health Council

Where are the connections
Where Are the Connections?

  • 270,000 discharges

  • 1 in 5 patients readmitted

  • We can do better

Laser focus
Laser Focus

  • 18 hospital learning collaborative

  • Reduce heart failure readmissions

  • Improve transitions of care

  • Know who our patients are – equity in care

Readmission reduction and care transitions standards t5

These 5 areas are targeted for high risk CHF patients in support of the ACT Hospitals.

Readmission Reduction and Care Transitions Standards (T5)

  • Upon admission implement a risk assessment tool with a focus on Heart Failure to identify patients who are at high risk of readmission considering social factors

    • Include a comprehensive assessment of the post hospital needs

  • Use the teach-back method during the hospital stay from admission to discharge during key clinical interventions.

  • Provide real-time handover communications (IHI, 2011)

    • Provide patient and primary care givers a patient-friendly post-hospital care plan which includes a clear medication list

    • Provide customized, real-time critical information to the next clinical care provider(s)

    • For high risk patients, have a clinician call the individual(s) listed as the patient’s emergency contact to discuss the patient’s status and plan of care as applicable

  • Address timely physician follow-up (appt to occur within 5-7 days of discharge)

    • Either schedule follow up physician appointment for the patient, provide scheduling info to the patient or sit with the patient while they make the appointment prior to discharge – appointment should be tailored to the care giver’s schedule (include primary care specialist and therapy appointments if possible)

  • Follow up with the patient or primary care giver (or emergency contact) within 48-72 hours of discharge via telephone or home visit.

Adopted by the ACT Leadership on 10/12/11 from a variety of sources including Project BOOST, STAAR and IHI.

Chart reviews and patient interviews
Chart Reviews and Patient Interviews support of the ACT Hospitals.

  • 36% had a follow-up appointment scheduled prior to discharge (6/7/12 sample)

  • 52% did not call a health professional for guidance before being readmitted (10/18/12 sample)

  • 39% made and/or kept appointment within 7 days (4/11/13 sample)

Care transitions new approaches
Care Transitions – New Approaches support of the ACT Hospitals.

  • 5 hospitals, Health Council, COA

  • Christ, Mercy FF, Jewish, University, Clinton

  • Patient coaching and empowerment model

  • Two-year contract with CMS

  • RESULTS: Baseline of 25% to a current readmission rate of 15.2% (coached patients)

Equity in care
Equity in Care support of the ACT Hospitals.

  • Standardized categories and methodology for the collection of patient race, ethnicity and language data

  • Data integrity standards

  • Spread to primary care practices

  • 56% collecting all three fields (REL) to 100%

  • LEP improvement project underway

What did we learn
What Did We Learn? support of the ACT Hospitals.

  • One model doesn’t fit all

  • Focus on entire continuum of care

  • This is not linear work

  • IT has to integrate into the work processes

  • Leadership and grassroots group needed to drive change

  • Power of patient interviews; test staff perceptions

  • Measure!

  • Pull in physicians to be part of the dialogue

  • Build on common ground with post-acute providers

  • Data delays can be a challenge

Questions support of the ACT Hospitals.

Thank You……….

Nancy Strassel, SVP

[email protected]