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Transforming Healthcare. Nancy M. Strassel Senior Vice President Greater Cincinnati Health Council. Where Are the Connections?. 270,000 discharges 1 in 5 patients readmitted We can do better. Laser Focus. 18 hospital learning collaborative Reduce heart failure readmissions

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transforming healthcare
Transforming Healthcare

Nancy M. Strassel

Senior Vice President

Greater Cincinnati Health Council

where are the connections
Where Are the Connections?
  • 270,000 discharges
  • 1 in 5 patients readmitted
  • We can do better
laser focus
Laser Focus
  • 18 hospital learning collaborative
  • Reduce heart failure readmissions
  • Improve transitions of care
  • Know who our patients are – equity in care
readmission reduction and care transitions standards t5

These 5 areas are targeted for high risk CHF patients in support of the ACT Hospitals.

Readmission Reduction and Care Transitions Standards (T5)
  • Upon admission implement a risk assessment tool with a focus on Heart Failure to identify patients who are at high risk of readmission considering social factors
    • Include a comprehensive assessment of the post hospital needs
  • Use the teach-back method during the hospital stay from admission to discharge during key clinical interventions.
  • Provide real-time handover communications (IHI, 2011)
    • Provide patient and primary care givers a patient-friendly post-hospital care plan which includes a clear medication list
    • Provide customized, real-time critical information to the next clinical care provider(s)
    • For high risk patients, have a clinician call the individual(s) listed as the patient’s emergency contact to discuss the patient’s status and plan of care as applicable
  • Address timely physician follow-up (appt to occur within 5-7 days of discharge)
    • Either schedule follow up physician appointment for the patient, provide scheduling info to the patient or sit with the patient while they make the appointment prior to discharge – appointment should be tailored to the care giver’s schedule (include primary care specialist and therapy appointments if possible)
  • Follow up with the patient or primary care giver (or emergency contact) within 48-72 hours of discharge via telephone or home visit.

Adopted by the ACT Leadership on 10/12/11 from a variety of sources including Project BOOST, STAAR and IHI.

chart reviews and patient interviews
Chart Reviews and Patient Interviews
  • 36% had a follow-up appointment scheduled prior to discharge (6/7/12 sample)
  • 52% did not call a health professional for guidance before being readmitted (10/18/12 sample)
  • 39% made and/or kept appointment within 7 days (4/11/13 sample)
care transitions new approaches
Care Transitions – New Approaches
  • 5 hospitals, Health Council, COA
  • Christ, Mercy FF, Jewish, University, Clinton
  • Patient coaching and empowerment model
  • Two-year contract with CMS
  • RESULTS: Baseline of 25% to a current readmission rate of 15.2% (coached patients)
equity in care
Equity in Care
  • Standardized categories and methodology for the collection of patient race, ethnicity and language data
  • Data integrity standards
  • Spread to primary care practices
  • 56% collecting all three fields (REL) to 100%
  • LEP improvement project underway
what did we learn
What Did We Learn?
  • One model doesn’t fit all
  • Focus on entire continuum of care
  • This is not linear work
  • IT has to integrate into the work processes
  • Leadership and grassroots group needed to drive change
  • Power of patient interviews; test staff perceptions
  • Measure!
  • Pull in physicians to be part of the dialogue
  • Build on common ground with post-acute providers
  • Data delays can be a challenge

Thank You……….

Nancy Strassel, SVP