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Readmission Race: Checkpoint Call Improving the Discharge Planning Process. October 22, 2012 12:00 to 12:45 pm CST. Welcome and Overview. Welcome, thank you for joining us today! Housekeeping This webinar is being recorded and will be archived.

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readmission race checkpoint call improving the discharge planning process

Readmission Race: Checkpoint CallImproving the Discharge Planning Process

October 22, 2012

12:00 to 12:45 pm CST

welcome and overview
Welcome and Overview
  • Welcome, thank you for joining us today!
  • Housekeeping
    • This webinar is being recorded and will be archived.
    • You will receive a PDF of today’s presentation, as well as a link to fill-out the evaluation and a summary of Q&A.
    • For questions: please reach out to your state lead or email us:
  • Agenda
    • Improving the Discharge Planning Process
    • Hospital Sharing and Coaching
    • Q&A
  • Tasha Gill, MPH, HRET
  • Denise Remus, PhD, RN, Cynosure Health
  • Amy E. Boutwell, MD, MPP, Collaborative Healthcare Strategies
  • Misti Wedding, RN, Medical/Surgical/ICU Nurse Manager, Harrison Memorial Hospital
readmissions race improve the discharge planning process

Readmissions Race: Improve the Discharge Planning Process

Amy E. Boutwell, MD, MPP

Collaborative Healthcare Strategies

terminology matters
Terminology Matters
  • Discharge planning process….
    • Implies we in the hospital make the plans
    • Discharge is rather unilateral in nature
  • Transition to the next setting of care….
    • Reminds us there is a next setting with needs
    • Transition is more bilateral in nature
improving transition process matters
Improving Transition Process Matters
  • A lot of focus on NEW work and NEW tools
    • Transitional care coaches
    • Transitional care Nurse Practitioners
    • Disease-specific clinics
    • Medical home care managers
    • Tele-monitoring
  • We have a lot of opportunity to improve our DAILY work:
    • 81% of patients requiring assistance with basic functional needs failed to have a home-care referral
    • 64% said no one at the hospital talked to them about managing their care at home

Clark PA. Patient Satisfaction and the Discharge Process: Evidence-Based Best Practices. Marblehead, MA: HCPro, Inc.; 2006.


42 million family caregivers

  • 46% perform nursing tasks
  • 75% of them manage medicines
  • 33% of them do wound care
  • 66% of the patients had no VNA

Available at:


“We ask caregivers to do things that would make even

nursing students tremble…….

As hospitals discharge patients quicker and sicker…..

family caregivers are responsible for medical and nursing care including medication management and wound care.”

~ Susan Reinhard

SVP & Director, AARP Public Policy Institute


“Despite frequent encounters with the acute care system, family caregivers were not prepared for the medical and nursing tasks they were expected to provide at home…

“We asked family caregivers how they learned to manage their family members’ medications and 61 percent said, ‘I learned on my own.’ Clearly, professionals need to do a better job of training family caregivers.”

~ Carol Levine

Director of Families and Health Care Project

United Hospital Fund

step 1 study your existing process
Step 1: Study your existing process
  • * WARNING: Do not get stuck in process mapping quicksand!
  • This does not need to take months
    • I have seen hospitals take over 18 months
    • Aim for basic blueprint in 2-3 meetings
  • This does not need to be done perfectly with complete review and consensus prior to starting improvements
    • Many teams do not start on clear tests for too long
    • Aim for first test of change “by Tuesday”
step 1 study your existing process1
Step 1: Study your existing process

Describe the existing steps and tasks involved in the discharge planning process currently

  • Involve multiple stakeholders input
    • Admitting RN
    • Floor RN
    • Floor CM/discharge planner
    • Floor Nurse Manager
    • Resident MD (they do most “teaching” discharges)
    • NP/PA if part of floor team (they do most discharges)
    • Attending MD (especially those that discharge “non-teaching” patients)
    • PT/OT/SLP/RT/nutrition/SW/clergy
  • Don’t forget the “receivers” on your cross-continuum team!
    • Patients/families/caregivers
    • Home health, hospice
    • SNF/LTAC
    • Outpatient providers, when available (don’t always need MD; practice manager/RN)
step 2 compare to best practice
Step 2: Compare to Best Practice
  • Role Definition, Responsibility & Standardization
    • Discharge Advocate
    • Checklist or “bundle”
  • Enhanced Assessment of Risk
    • Patient/caregiver/provider interview for readmitted patients
    • Expanded view of risk, and assessment techniques
  • Enhanced Teaching & Learning
    • Teach-back/ personal health record
    • Identify the appropriate learner/ engage caregiver
  • Timely Communication
    • Communication with PCP at admission and d/c; same-day summary
    • Warm handoffs to clinicians for complex/high risk
  • Timely Follow-Up
    • 24-48h contact for complex/high risk ; availability for contact
    • Follow up 3-5 days
step 3 implement tests of change
Step 3: Implement Tests of Change

Examples of tests you could implement today:

  • Enhanced assessment
    • Use your data systems: daily readmission reports; high utilizer reports
    • Risk screens include: BOOST 8P or STAAR readmission interview
  • Identify Learner
    • As the patient/family “who will help you with your care/medications…?
    • It is NOT always the visitor at the bedside, NOT always the spouse
  • Use Teach-Back
    • Use the entirety of the hospital stay to engage in education
    • Ask the patient/learner to describe medications, care plan, follow up when & why
  • Timely communication
    • Warm handoffs with SNFs
    • Clinical synopsis sent to receiving MD at time of discharge (real-time)
  • Follow-up
    • Make follow up appointment(s) for the patient prior to discharge
    • Coordinate follow up phone call <72h to review medications, plan, questions
snf circle back
“SNF Circle Back”
  • Multi-hospital system in North Carolina
  • Pilot in one hospital; commitment to spread system-wide if effective
  • Problem: early readmissions from SNF
  • Test:
    • warm handoffs to SNF
    • Call back to SNF 3-24 hours after transfer to answer questions
  • Details:
    • RCA revealed SNF-readmission patters
    • Hospital readmission champion met with SNFs to discuss shared goals
    • Hospital (with some leadership effort) asked SNF to participate in this communication
    • RN calls nurse at SNF
    • SW or care coordinator calls for follow up clarification 3-24 hours after transfer
    • Daily workflow (with some modifications for weekends, done next business day)
    • Follow up calls are scripted and documented in Allscripts system
    • Pilot on paper with 1 RN and 1 SW
    • Pilot expanded to RN call report to SNF
    • Pilot expanded to add follow up calls
    • Pilot expanded to build questions into Allscripts
    • Expand to all; new standard of practice

Source: Emily Skinner, Carolinas Healthcare System

snf circle back 2
SNF Circle Back -2

SNF Circle Back Questions

  • Did the patient arrive safely?
  • Did you find admission packet in order?
  • Were the medication orders correct?
  • Does the patient’s presentation reflect the information you received?
  • Is patient and/or family satisfied with the transition from the hospital to your facility?
  • Have we provided you everything you need to provide excellent care to the patient?


    • Transitions are a PROCESS (forms are useful, but only a tool to achieve intent)

Source: Emily Skinner, Carolinas Healthcare System

transition to snf medication safety
Transition to SNF Medication Safety
  • 2007, medication events, patient complaints re: d/c process
  • Evaluated medication orders
  • Found that only 8% of their patients had NO errors

Medication reconciliation was complete >90% of the time!

  • Common medication errors:
    • Formulation errors
    • Duplicates
    • Incorrect dose
    • Missing medications
    • Insulin dosing errors

Source: Bruce Thompson, AHRQ Innovations Exchange

transition to snf medication safety 2
Transition to SNF Medication Safety-2
  • New Process: Enhanced medication review

MD orders Pharm D and CCSNF

  • Identify patients being d/c to SNF
  • When bed available, MD, Pharm D and CC paged
  • MD has 4 h to enter d/c orders
  • CC scans orders hourly; paged Pharm D when entered
  • Pharm D & CC have 2 hours to review; clarify with MD
  • When errors are noted, resident AND attending are paged
  • Outcomes: enhanced review group had 5.7% readmissions v. 10.2%
  • High patient satisfaction, high physician satisfaction

Source: Bruce Thompson, AHRQ Innovations Exchange


Thank you!

Amy Boutwell, MD, MPP

President, Collaborative Healthcare Strategies

Faculty, HRET HEN Readmissions Race

Co-PI, AHRQ Reducing Medicaid Readmissions Project

Physician Consultant, CMS QIO Care Transitions Theme

617 710 5785

readmission race checkpoint call improving the discharge planning process1

Readmission Race: Checkpoint CallImproving the Discharge Planning Process

Misti Wedding, RN, Medical/Surgical/ICU Nurse Manager, Harrison Memorial Hospital

harrison memorial hospital who we are
Harrison Memorial Hospital Who We Are…
  • Speaking; Misti Wedding, RN, Harrison Memorial Hospital Medical/Surgical/ICU Nurse Manager
  • Cynthiana, Kentucky, 61 beds, private not-for-profit hospital
  • A full-service regional medical center meeting the needs of residents of seven
  • central Kentucky counties
  • HMH and its employees are accredited members of the following organizations, showing that we meet or exceed strict guidelines for healthcare quality:
    • The Joint Commission
    • College of American Pathologists
    • American College of Radiology for– CT,
    • Mammography, Nuclear Medicine, MRI
    • Fifty-eight percent of hospital staff are
    • clinical staff members who have multiple
    • certifications and licensures
reducing readmissions
Reducing Readmissions
  • Our readmission rate for Congestive Heart Failure (CHF) is higher than the state and the nation.
    • Medicare Readmission Rate ( 10/1/08-6/30/10)
      • HMH rate for CHF – 26.2 %
      • KY rate for CHF – 25.3%
      • U.S. rate for CHF – 24.8%
  • Goal: Reduce CHF Readmissions by 20% by December 2013
reducing readmissions1
Reducing Readmissions
  • Improve discharge process
    • Multidisciplinary team participation
    • Community Collaborative against readmissions
    • Improve patient compliance
    • Standardize discharge process
    • Provide CHF patients with the Heart Healthy Handbook
    • Increase patient safety and improve patient outcomes


improving the discharge planning process
Improving the Discharge Planning Process
  • Multidisciplinary team approach
    • CEO
    • Nurses
    • Physicians
    • Pharmacists
    • Information Technologists
    • Dieticians
    • Case Managers
    • Everyone contributes to the discharge process


improving the discharge planning process1
Improving the Discharge Planning Process
  • Community Collaborative
    • Quarterly meeting with Nursing Homes, Hospice, Home Health, Physicians, Nurse Practitioners, and our readmission team members.
    • Improve communication.
    • Standardize discharge process decreasing preventable readmissions.


improving the discharge planning process2
Improving the Discharge Planning Process
  • Discharge teaching and planning begins on admission
    • Utilize the teach-back method
  • Follow-up phone calls to patients and nursing homes after discharge. Bedside nurse verifies phone number with patient at discharge.
  • Ensuring patients have the means to be compliant
    • Can they afford the prescribed medications?
    • Do they have a scale to weigh on daily?
    • Are they able to obtain transportation to their follow-up appointments?
improving the discharge planning process3
Improving the Discharge Planning Process
  • Heart Healthy Handbook
    • CHF discharge instructions
    • Low sodium diet with sample menu
    • Medication list (Pharmacist review)
    • Calendar of appointments
    • After hospital care plan
    • Weight log
    • Scale provided if unable to obtain one
    • CHF magnet with heart healthy reminders
    • Teach-back method utilized
    • Checklist for discharging nurse to complete


improving the discharge planning process4
Improving the Discharge Planning Process
  • CHF discharge process changes effective October 1st
  • CHF patients are contacted after discharge by a nurse
    • Can they verbalize the instructions they were given?
    • Example: Mrs. Jones can you tell me when your appointment is with Dr. Besson?
lessons learned
Lessons Learned
  • Hard to receive and maintain physician participation
  • Interim team meetings are beneficial to keeping the interest and process flowing
  • Team approach requires the division of labor and the relinquishing of control thereby encouraging ownership and buy-in.
  • Meister, C., 2012. “Re-engineered discharge” A conversation about Barriers & Opportunities. K-HEN Kickoff Conference. Retrieved from
coming up
Coming Up….
  • Upcoming Readmissions Race Events
  • Thank you for joining us!