A Rehospitalization Reduction Program on a Geriatric Skilled

Nursing Unit

Randi Berkowitz, MD

Hebrew SeniorLife

Why decrease readmissions?

I. Excellence in care– Decrease errors

– patient satisfaction

– staff satisfaction

II. Financial– Increased referrals

– subacute beds long-term care

– census

– reimbursement/patient

How?

1. Admission2. Stay on unit3. Discharge

Admissionassessment

TIPSConference

Re-engineereddischarge

Rehab - SNF

Unplanned discharge

Sharing lessons learnedIHI

Lear

n fro

m

avoi

dable

disc

harg

es

Reducing AVOIDABLE hospital transfers

Bucket #1: Problems on Admission

• Ineffective communication of prognosis / options

• PCP out of loop• Inadequate care plans for

recurrent symptoms

Reduce AVOIDABLE hospital transfers

Approach to the Problem: Admission

• MD standardized discussions

• Communication family and PCP

• High risk patients– Automatic Palliative Care consult– Flag for entire team

Bucket #2: Stay on Unit:Problems With Team Operation

• Disciplines operating in silos

• Failure to identify problems early

• Failure to learn from mistakes

Reduce AVOIDABLE hospital transfers

Approach to the Problem: Stay on the Unit

• Team Improvement for the Patient and Safety (TIPS) conference

• Call to hospital

• Root cause analysis

Bucket #3: Problems With Home Discharge

• Poor hand off to next team

• No teach back with patient/HCP

• No standardized discharge summary/ nursing process

Reduce AVOIDABLE hospital transfers

Approach to the Problem: Home Discharge

• Project RED– Written home care plan from electronic medical

record– Making specific for geriatric use

• E.g. advance directives, diet, VNA, assistive devices

• Standardized discharge summaries

Target Population

• All admissions to the RSU subacute unit

• 1000 admissions a year

• 3NP/3MD- geriatric and palliative care certified

Process and Outcome Measures

• Admission– 90% patients have discussion with MD

• prognosis

• rehospitalizations past 6 months

• Communication family and PCP

– Patient/ family satisfaction survey

Process and Outcome Measures

• Middle- Stay on the unit– Unplanned discharge rates – benchmarked staff safety survey for staff

Process and Outcome Measures

Discharge Home

• 30 day readmission rates after discharge from SNF

• Satisfaction survey of discharge preparedness

Perceived Facilitators/Barriers

• Pt acceptance of less aggressive approaches• Increased liability • Increase cost keeping sicker patients• Difficulty obtaining information from hospital• Time needed to engage primary care • Lack of practitioner access to computer systems in

key referral sites• Limited IT resources for Project RED

Preliminary Data Unplanned Transfers

• January 2008- June 2009 compared with post TIPS July 2009-November 2009

• Massachusetts 30 day 22-28%Pre-intervention 16.9%Post-intervention 12.7%Rate Reduction -24.7%

Staff feel safe reporting their mistakes

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Stronglydisagree

Disagree Neitheragree nordisagree

Agree Stronglyagree

Does notapply or

don't know

Stronglydisagree

Disagree Neitheragree nordisagree

Agree Stronglyagree

Does notapply or

don't know

Series1

Series2

Questions

Flag risk to entire teamAvoidable-unavoidable dischargesRED

call everyone 30 days- use OASISCall those LTC

Aides to TIPS conferencesSurvey admission process

high risk vs everyonetool