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Breakout A : Ensuring Post-Hospital Care Follow-up. Saint Anne’s Hospital. A Catholic Community Hospital – Saint Anne’s Hospital. 160 beds including 16-bed geriatric psychiatry unit with medical, surgical, oncology and pediatric units No maternity unit Multiple satellite outpatient services.

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Breakout a ensuring post hospital care follow up

Breakout A: Ensuring Post-Hospital Care Follow-up

Saint Anne’s Hospital

A catholic community hospital saint anne s hospital
A Catholic Community Hospital – Saint Anne’s Hospital

  • 160 beds including 16-bed geriatric psychiatry unit with medical, surgical, oncology and pediatric units

  • No maternity unit

  • Multiple satellite outpatient services

Founded in 1906 by the

Dominican Sisters of the Presentation

Service area
Service Area


Primary Service Area

Secondary Service Area

Extended Service Area

Community health status greater fall river area
Community Health StatusGreater Fall River Area

  • Highest incidence rate for cardiac disease in the state

    of Massachusetts

    • 24% higher incidence rate for coronary heart disease

  • Highest prevalence for diabetes in the state

    • 42.26 per 1000 persons

    • USA average is 34.1 per 1000

    • Diabetes incidence has risen 49% since 1990.

Community health status greater fall river area1
Community Health StatusGreater Fall River Area

As compared to state average:

  • Higher concentration of area residents with risk factors for developing heart disease, cancer, and diabetes including:

    • 30% higher rates for smoking

    • Higher obesity rates: 28.0% vs. 25.8 % state

    • Higher cholesterol: 36.8% vs. 28.3% state

    • High blood pressure: 29.2% vs. 21.6% state

Community demographics
Community Demographics

  • Median household income for Fall River

    • $33,124 vs. $64,081state (2009)

  • Nearly 1 in 5 families with children live below the

    official poverty level in Fall River.

  • Only 25% of Fall River residents have obtained a

    high school diploma.

  • Higher than state avg. of residents over age 65

  • 13.2% Unemployment in Fall River (Sept. 2011) MASS state unemployment average 7.4%

Community demographics city of fall river
Community DemographicsCity of Fall River

  • Fall River has been an economically disadvantaged city for many years after mass closings of the it’s textile mills.

  • It is a federally designated medically underserved area.

  • Violent crime has been on the rise accompanied by increasing drug use, notably heroin.

  • Largest Portuguese American population in the US between 43-49% depending on data source.

  • Hispanic American: 7.5% in 2010, up from 4.0% 2009

  • African American: 4.0% in 2010, up from 2.5% 2009

  • Asian American: 2.5%, in 2010, up from 2.2% 2009

World-class community health care where you live

Cross continuum team members
Cross-Continuum Team Members

  • Ann Archibald RN CRNI, Director Clinical Operations & NE Infusion Resource Nurse, Genesis Healthcare

  • Carole Billington MSN, RN, NEA-BC Vice President Patient Care Services, Chief Nursing Officer, SAH

  • Debbie Costello RN, BSN, MSM, Vice President Quality & Safety, Steward Home Care

  • Mary N. Dana MSW, LICSW, Supervisor Case Management, SAH

  • Nicole Decoffe, Clinical Liaison, Kindred Healthcare

  • Lisa DeMello MSN, RN, ACNS-BC, Clinical Educator/Stroke Coordinator, SAH

  • Andrew Dousa RPh, Pharmacy Director, SAH

  • Erika Sundrud MA, System Director of Performance Improvement, Steward Health Care

  • Katherine Librera, Clinical Admission Director, Genesis Healthcare

  • Robin Lynch MS, RN, CAGS, CPHQ, Director of Quality and Patient Safety, SAH

  • Erin McGough RN, CCM, Director of Case Management, SAH

  • Theresa Moss MSN RN, Clinical Leader, Telemetry, SAH

  • John Arcuri,MD, Medical Director and Chief, Department of Emergency Medicine, SAH

  • Saira Nisar MD, Hospitalist, SAH

  • Robin Pelletier BSN, RN, CHPN, Director, Hospice and Palliative Care, Steward Home Care

  • Donna Rebello BSN, RN, OCN, Director St. Mary’s and St. Dominic's, SAH

  • Lisa Shea MSN, RN, Patient Care Director, SAH

  • Andrea Hodge, BSN, RN, ED Case Manager, SAH

Cross continuum team members continued

Gina Gough, Supervisor, Rehab Department, SAH

Jennifer Davis, Catholic Memorial

Linda Perry RN, Nursing Informatics Manager, SAH

Nancy Cooper RN, Nurse Liasion Steward HomeCare

Susan Jamieson, VP of Integrated Services

Susan Oldrid VP, Mission of Community Relations, SAH

Terence McGovern, Pulmonologist

Teresa Ferriera NP, Steward

Christine G. Leeman MS, RN, CCM, Patient Care Coordinator, PrimaCARE

Tina Whitney BSN, RN, CCM, Director of Case Management, Steward Network Services

Lisa Souza, Wellness Director, Landmark Assisted Living

Barbara Wales RN, Health Service Manager, Bristol Elder Care

Maureen Bannan, VP of Clinical Service Steward

Michael Spearin, Kindred Health Care

Sheila Duval, Southpoint Skilled Nursing and Rehab

Stephanie Weir RN, Steward Physician Group

Tracy Faris, Kindred Health Care

Cynthia A. Anderson BSN, RN, Director, ICU and Telemetry, SAH

Lena Gomes RN, CMSRN, Clinical Leader, St. Mary’s, SAH

Edwina Cummings, Patient representative

Shannon Hebda, Director of Community Supports, People Incorporated, Patient and Family Advisory Committee Member

Cross-Continuum Team Members (Continued)

Identified opportunities from our starting point
Identified Opportunities from Our Starting Point

  • Accuracy of Home Medication List

  • Under utilization of Telehealth Resource

  • Lack of person to person hand off transition to Home Care

  • Availability/Capacity for follow-up appointments

  • Home Care Psychiatric Nurse

  • Family (care giver) education

  • End of life discussions with patients and families

  • Social Disparities (transportation, poverty, housing, education level, substance abuse etc.)

  • Knowledge Gap – related to Community Resources

Year of the family
Year of the Family

  • Identify Partner in Care at time of admission

  • Include Partner in care in discharge planning, instructions/education, pharmacist visit, follow up phone call

  • Color coded one page Zone Discharge Instruction sheets

Follow up appointments
Follow up Appointments

  • Attempts made to schedule follow up appointments prior to discharge on all 30-day readmits

  • Patients decline staff scheduling of appointments related to transportation issues and family members work schedules

  • Verification of follow up appointments made by patients independently done at time of discharge

  • Staff report greater success scheduling timely appointments when made prior to discharge

  • Barriers include late and weekend discharges. During initiation, attempts were made to make all appointments for all discharges. These efforts were unsuccessful related to volume and time required.

Discharge phone calls
Discharge Phone Calls

  • All patients are called within 72 hours of discharge

  • If unable to reach on first attempt a second attempt is made the following day

  • Family present during the discharge call are encouraged to ask questions

  • Topics reviewed include: discharge medications, diet, follow up appointments, reportable signs and symptoms and any questions patient has

  • All calls are made by a Registered Nurse

Handover communication
Handover Communication

  • Implemented communication template to promote standardized approach (SBAR)

  • Nurse to nurse verbal report for all patients discharged to SNF

  • Nurse to nurse verbal report for all patients discharged to Steward Home Care

Financial counseling
Financial Counseling

  • All self pay and underinsured are assessed by a financial counselor the day of admission or following business day

  • Patients are assessed for all public programs and eligibility for private insurance

  • Patients are assisted in navigating the process through to determination

  • Patient Advocate is available to all community members to screen for eligibility and assist with navigating the process

Inpatient pharmacist visit medication consult
Inpatient Pharmacist Visit/ Medication Consult


  • Provide medication education to patients considered high-risk for re-admission within 30 days of discharge, in an attempt to prevent re-admission due to lack of understanding of medication instructions once discharged.


  • Once a high-risk has been identified, the case manager assesses the patient and determines if patient needs, or is interested in, a medication consultation.

  • Eligible patient names are sent to pharmacy, who visits patient in their room and provides education to them and preferably a family member or caregiver as well.

  • The consultation is geared towards determining if the patient understands their medications, how to take them, and also compares meds upon last discharge to current admission. Discrepancies, if thought to be unintentional, are brought to the attention of the physician.

  • All consultations are documented in the progress notes, with recommendations for that particular patient’s discharge instructions to help them better understand them.

  • You’d be surprised what a patient tells a pharmacist, and not their physician!

Steward healthy transitions
Steward Healthy Transitions

A 30-day program post-discharge for high risk Medicare patients with a diagnosis of Heart Failure, Myocardial Infarction and Pneumonia

Service provides

  • A thorough medication review and optimization with a Clinical Pharmacist in the patients home within 2 days of discharge, and ongoing telephonic support for 30 days

  • Patient and caregiver disease state/medication education

  • Special attention to adherence issues and medication organization

  • Ensure patients are prepared for and attend their physician follow up visit

  • Patient and caregiver health coaching on self management of chronic illnesses.

  • Evaluation of falls risk and home safety risks for readmission.

Steward home care palliative care
Steward Home Care & Palliative Care

  • Palliative Care Team

  • COPD & HF team

  • Telehealth

  • Home Care Psychiatric Nurse

  • Teach Back

Post acute collaborative team pact
Post Acute Collaborative Team (PACT)

  • What is PACT?

  • Compliment to Cross Continuum Team

  • Objectives

  • Members

  • How PACT has improved communication, care transitions and reduction in re-admissions

  • Case reviews indentify causes for readmission

Resource manual for ed
Resource Manual for ED

  • Clinical capabilities provided by area skilled nursing facilities.

  • Three resource books provided to ED listing clinical capabilities for each facility. Resource books are kept in physician and nurse areas for ease of access.

  • Overview of site capabilities and new medication turn around time provided

Saint anne s hospital 30 day readmissions all cause
Saint Anne's Hospital30 Day Readmissions (All Cause)

Saint anne s hospital 30 day readmissions all cause heart failure
Saint Anne's Hospital 30 Day Readmissions (All Cause)Heart Failure

Saint anne s hospital 30 day readmissions all cause pneumonia
Saint Anne's Hospital30 Day Readmissions (All Cause)Pneumonia

Saint anne s hospital 30 day readmissions all cause acute myocardial infarction
Saint Anne's Hospital30 Day Readmissions (All Cause)Acute Myocardial Infarction

Breakout a ensuring post hospital care follow up
Saint Anne's Hospital30 Day Readmissions (All Cause)Chronic Obstructive Pulmonary DisorderMS DRG 190,191,192

Next steps
Next Steps

Spiritual Care

Parish Nurses

High Risk identification algorithm

Spread beyond Pilot Unit and population

Address barriers to follow-up appointment

Electronic integration of enhanced admission assessment

Hospitalist ↔ PCP Communication

Community Health Volunteers