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Reducing Readmissions

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  1. Reducing Readmissions Catholic Medical Center July 27, 2012

  2. Highlights • Data • Lean Six Sigma Improvement Initiative • QIO Improvement Initiative • AMI, HF, Pneumonia Readmission Strategies • Key Strategies • Catholic Medical Center

  3. CMC-US Readmission Rates 2007-2010 CMS Hospital Compare

  4. CMC AMI, HF, Pneumonia2011 Readmission Rates

  5. LSS Initiative Key Findings • CMC and highest referral SNF LSS project • SNF nurses more alert to change in condition as evidenced in labs, etc. • SNF Medical Director talks with ED Physician • Return to SNF if possible after ED visit • Continued meetings between CMC and SNF to refine communications and care process

  6. QIO Community Initiative • Northeast Health Care Quality Foundation (CMS QIO) led initiative on Transitions of Care • Two hospitals, five SNFs, four home health agencies and three ambulance services • Meetings, flow charts, collected data • Improved communications between agencies • Discharge hand off checklist • Transfer report between agencies • SBAR report form for complete communication

  7. AMI Strategies • Discharge education with on-site interpreters • Post-discharge cardiac rehabilitation and continuing education • New England Heart Institute post-acute follow up

  8. Heart Failure Strategies • New England Heart Institute Cardiomyopathy Clinic was started 2003 • 2900 heart failure patients • Physician/APRN ongoing evaluations • Clinical outcomes, quality of life, education • Hospital discharge education with scales, pill boxes

  9. Pneumonia Strategies • Discharge education • Transitions of care to SNF, HH, PCP • Comprehensive communication • SNF Medical Director and ED physician communication with return to SNF if possible • Follow up calls following discharge from acute care or SNF • PCP follow up within two weeks

  10. Key Strategies • Discharge education • On-site interpreters • Transitions of Care • Discharge hand off checklist • Transfer report • Post-Acute Communication • Physician to physician calls for returns to ED

  11. Catholic Medical Center • Located in Manchester, NH, largest city in New Hampshire with a population of 110,000 • 330-bed, full-service health care facility with 25 subspecialties represented • New England Heart Institute (NEHI) offering comprehensive cardiac services with 20 board-certified cardiologists and mid-level providers • HealthGrades America’s 100 Best Hospitals, Cardiac Care and Coronary Intervention