A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association

NYSPFP Preventable Readmissions Pilot ProjectHospital Storyboard Companion Guide

August 2014

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Instructionso This storyboard will be used to tell other hospitals about your team’s

experience with one or more of the pilot phases **: Phase 1 – On Admission, Phase 2 – During the Hospital Stay, or Phase 3 – Discharge Day and Beyond, of the NYSPFP Readmissions Pilot.

** Please note: hospitals are welcome to do more than one storyboard.

o Please highlight your team’s experience with planning and implementing one or more of the pilot phases: (i.e., Phase 1, Phase 2, or Phase 3), including:o Successful strategies and tipso Challenges faced by your teamo Data and outcomeso Key lessons learned (good, bad and “pearls”)o Next Steps for spread and hardwiring

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Hospital and Team Information

o Hospital Name and Demographics:o Location; number of beds; services; notable community

characteristics especially as related to preventing readmissions

o Describe Your Hospital Readmission Team:o Come up with a creative team name - List of team

participants (name, title, discipline)o Insert a team picture on the page provided

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Indicate the Pilot Phase Being Summarized

Address your summary in the context of the Phase Objectives:oPhase 1 – Admission

o Identify patients on admission who are at risk for readmission using an “any risk” assessment approach.

o Assemble a multidisciplinary team to address interventions that will mitigate risks for readmission.

oPhase 2 – Hospital Stayo Prepare patient and caregiver for discharge, beginning at admission.o Conduct ongoing patient reassessment to identify new or changing risk factors.o Ensure systems for multidisciplinary communication, coordination, planning, and

evaluation. o Utilize teach-back or other patient educational approach.

oPhase 3 - Dischargeo Ensure patient and family/caregiver are fully prepared for post hospital care.o Provide timely and thorough communication to post hospital providers.

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Highlight Your Successful Strategies & Tips for the Phase

o Phase 1 (for example)o Successes with team assembly and established role

responsibility o Integration of the “any risk” assessment approacho Tips for early identification and mitigation of risk

o Phase 2 (for example)o Strategies for strong and fluid team communicationso Tips for patient/family inclusion as part of the teamo Successful patient/family education validation practice

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Highlight Your Successful Strategies & Tips for the Phase (continued)

o Phase 3 (for example)o Final verification of patient/family preparation for

dischargeo Timely, and thorough communication to the post-

discharge provider(s)o Thorough medication reconciliation with all discrepancies

addressedo Post-discharge follow-up PCP and/or specialty

appointment arranged pre-dischargeo Post-discharge patient/family calls with 48-72 hours

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Describe Challenges (for example)

o What were challenges and barriers encountered:o Staff education and engagement o Referral timeframes not met o Inconsistent follow-through and lack of feedbacko Communication vehicles not used o No formal steps to reassess patient’s risk

o Describe steps to overcome challenges and barriers:o Held a team focus groupo Changed communications vehicle o Multi-disciplinary daily rounding, daily goal sheets, etc.

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Key Lessons Learned

o Describe some new understandings that resulted from your participation in the pilot phase work. For example:o Nursing admission assessment could be adapted to

include an “any risk” approach.o The disciplines were able to establish risk mitigation

plans earlier in the stay due to the timely on admission risk identification process.

o Specific members of the team must be responsible for medication reconciliation at every transition to ensure it is completed.

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Steps to Spread and Hardwire

o Share plans to continue your readmission prevention efforts hospital-wide. For example:o What areas still need to be “rapid” tests of change?o How will you expand process improvements from one

unit to the next?o How will you formalize the new processes?o What steps will be taken to monitor new processes put in

place?o What two-way feedback mechanism will be in place for

the team, patient and families for continued process improvement?

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Outcomes and Data

o Insert data here, demonstrating outcomes from pilot phase. For example:o Unit readmission rate trends before and after pilot phase

implementationo Pilot unit readmission rate as compared to hospital

overall rateo Readmission reasons before and after pilot phase

implementationo Percent of post-discharge follow-up appointment made

prior to dischargeo Percent of post-discharge follow-up phone calls made

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Data Aggregate Tool & Available Reports

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Available Reports

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Next Steps

o Choose a Team Name (optional)

o Contact your NYSPFP Project Manager for assistance

o Storyboard Due Date: September 22, 2014o Please send completed Storyboard to your NYSPFP

Project Manager.

o Register and attend regional in-person educational conference

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