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Safe Transitions North Memorial

Utilizing Society of Hospital Medicine’s BOOST Toolkit to enhance patient and family engagement, reducing readmissions and improving care transitions. Analyzing CHF data for insights and implementing strategies for improved care coordination.

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Safe Transitions North Memorial

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  1. Safe Transitions North Memorial Using Society of Hospital Medicine’s BOOST Toolkit To Improve Patient & Family Engagement

  2. 2010 NMR Data • Readmits w/in 30 days = 3,452 • Unique Patients Readmitted = 2,249 • Readmits w/in 72 hours = 654 • ED visits w/in 30 days = 2, 273 • ALOS 1st visit = 4.13 • ALOS 2nd Visit = 4.23

  3. Digging A little Deeper - CHF • 474 CHF patients • 574 Hospitalizations • 22% Home Health Referrals • 7% Seen by Cardiologists Within 7 days • 12% Seen by NM Primary Care Clinics Within 7 days

  4. Who Are Our Patients At Risk For Readmission? A6 Daily Report

  5. Patient and Family Engagement • White Boards • Serve as a communication tool. • Used by all disciplines and patient/family. • Helps care team and patient/family focus on goals.

  6. Patient and Family Engagement • Patient/Family Centered Rounds • Identification of high risk patients • Rounding script used to develop plan for hospitalization and safe transition to home.

  7. Follow-Up Appointments Teach Back & Patient Education Materials Medication Reconciliation Home Health Phone Call 24-48 hours post discharge Palliative Care Optimization Family Care Conferences Patient and Family Engagement

  8. Teach Back & Patient Education • Patient Education At Bedside • RN conducting education rather than nurse educator • Teach Back added as methodology for patient educational assessment • Teach Back regarding medications & discharge instructions • CHF Binder used during Teach Back and to build redundancy between hospital and clinic

  9. Key Learnings • Follow up appointment compliance in 7 days tripled by assisting in coordinating appointments • Need the same tool for risk stratification across system • Need system staffing model to support care coordination across enterprise • Need community to help in preventing hospitalizations • Need to "un-teach" how to conduct Teach Back • Need learning environment to help support change effort

  10. Questions?? • John Degelau, MD • John.Degelau@northmemorial.com • Sonne Rivers, BSN, MA • Sonja.Rivers@northmemorial.com • Society of Hospital Medicine • http://www.hospitalmedicine.org

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