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All Hands On Deck. Impacting Patient Readmissions. Sherry Sweek, RHIA, CPHQ, CPMSM, Director, Quality Improvement Southeast Georgia Health System [email protected] , 912.466.3265 October 2, 20013. Southeast Georgia Health System. Two hospitals: Brunswick-316 beds, Camden-40 beds - PowerPoint PPT Presentation
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All Hands On Deck. Impacting Patient Readmissions
Sherry Sweek, RHIA, CPHQ, CPMSM, Director, Quality Improvement
Southeast Georgia Health [email protected], 912.466.3265
October 2, 20013
Southeast Georgia Health System
• Two hospitals: Brunswick-316 beds, Camden-40 beds
• Two Nursing Homes: Brunswick-232 beds, St. Marys-78 beds
• Three Immediate Care Centers• Physician Practices: over 90 physicians in
primary care and specialty care practices• 2,300 team members
• Focus today is experience at Brunswick facility
Session Learning Objectives
1. Discuss initiatives to impact readmissions.
2. Outline the steps to implement a successful engagement with Area Agency on Aging (AAA).
3. Identify the outcomes impacted by our local AAA interventions.
P D C A (Plan, Do, Check, Act)Quality Improvement Model
• PLAN–What is driving readmissions, which patient populations are problematic?
• DO-Implementation the action steps identified in the planning phase.
• CHECK-Measure process and outcome indicators. Test.
• ACT-Did we achieve results we expected? What other steps are needed?
Plan
Check
Act
Do
Plan the Improvement• No organized plan to address readmissions
– Case Management looking at 7 day readmissions, SNF bounce backs
– Patient Education looking at readmissions for all patients for any reason
– Quality focused on Heart Failure & Pneumonia• Utilize existing Quality Committee and structure meeting
as working sessions for GHA HEN initiatives• Determine how to work with Area Agency of Aging to
impact specific high-risk patient populations• Identify internal changes to complement work from AAA
Do the Improvement• Patient Education Coordinator interviewed readmitted patients
over three months: 25% did not understand medications or have follow-up appointment. Implemented Patient Education folder and training for bedside nurse.
• Renal patients accounted for 60% of Heart Failure readmissions, highest at risk group. Target with AAA.
• SNF readmissions: 18% (60% of those from our system SNFs-Pneumonia). Work with
• Post-Discharge Call program with Beryl Health• Schedule meeting with AAA to understand Bridge Program. Pilot
on one unit, then expanded to two additional units with focus on Renal and Pneumonia patients
Area Agency on Aging Impact: Readmission Prevented
2
3
2
4
3
5
4
0
2
4
6
8
10
13-Jan
Feb Mar Apr May Jun Jul
Check: Heart Failure Readmissions
Heart Failure Medicare 30-Day Readmissions
9.1% 6.7%4.8%11.8%8.7%
3.6%0.0%0.0%
10.0%
20.0%
30.0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
US Rate: 24.70%
Heart Failure 30-Day All-Payer Readmissions
24.7%11.4%
4.4%12.2%10.3%
5.7%0.0%14.0%
0.0%
20.0%
40.0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
US Rate HF Readmit %
30-Day Readmissions-Brunswick
10/07-06/10
10/08-06/11
07/09-06/12
US National
Rate
Heart Attack 19.6% 18.4% 15.2% 17.9%
Heart Failure 21.6% 22.0% 19.2% 22.9%
Pneumonia 16.2% 17.3% 16.6% 17.6%
Medicare patients only, readmit for any reason,
readmit to any hospital in US as Inpatient status
• All readmits: no different than US rate (no penalties) for 2nd year in a row
Red 0-25th percentile
Yellow 26th-50th percentile
Green 51st-75th percentile
Blue 76th-100th percentile
Check: HCAHPS Top Box Score
August-low volume
Post-Discharge Calls: HCAHPS
BWK - Top Box Scores (With and Without Followup Calls)
74%
85%
67%
87%
70%
77%
67%
90%
52%
73%
50%
80%
59%
71%
58%
80%
39%
48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rate Hospital0-10
Comm withNurses
Resonse ofHospital Staff
Comm withDoctors
HospitalEnvironment
PainManagement
Comm aboutMeds
DischargeInformation
CareTransitions
Received Followup Call No Followup Call
Act on Results • Monthly meeting with AAA to discuss patient cases• Post-Discharge Calls moved to clinical calls in July 2013 • Patient Education folders expanded to Maternity in May
2013• Nursing Leadership tracking communication with nurses
and communication on medications as 2013 PI Project
• Interaction with AAA has been great and the impact they have made in invaluable. We love having them on our team!!
