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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

Transitions in CareakaReducing Readmissions

Shawnee Mission Medical Center

Kim Fuller, MSW, MBA, CCE

Janet Ahlstrom, MSN, ACNS-BC

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

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