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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