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Presentation on Teamwork for Avoiding Potentially Avoidable Readmissions in Value-based Care
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KEY QUESTIONS
What are the barriers to seamless care transitions for your
patients?
In a perfect world what intervention, if implemented, would be
most effective for your patients?
What intervention can you realistically implement?
What can you contribute to the work of this coalition in
decreasing avoidable readmissions in our community?
Fragmentation of data
Inappropriate end of life care
Medication issues
At-risk patients not properly identified at discharge
Lack of post-discharge follow-up
Lack of disease-specific protocols
Lack of Patient Self Management
Lack of community awareness
DRIVERS OF RE-HOSPITALIZATION
IMPLEMENTATION: GETTING TO WORK
Invite a patient(s) / family(ies) to participate
Design metrics and evaluation strategy
Engage in staff education/outreach
Develop protocols, policies, forms, tools, etc., from intervention
model
Redesign care processes as needs identified
INTERVENTION SELECTION- ROOT CAUSE
ANALYSIS (RCA)
Identify patient population with highest percentage of
readmission
Identify Drivers of Readmission in this patient population
Identify potential interventions to address the identified drivers of
readmission
Evaluate Evidence-Based Intervention Models to determine the
best fit for your unique drivers
1. Better Outcomes for Older Adults through Safe Transitions (BOOST) – Society
of Hospital Medicine
2. STate Action on Avoidable Re-hospitalizations (STAAR) – Institute for
Healthcare Improvement (MI, WA, MA, OH)
3. Re-Engineered Discharge (Project RED) – Boston University
4. Geriatric Resources for Assessment and Care of Elders (GRACE Team Care
Model) – Indiana University (Steven Counsell MD Medical Home Model)
INTERVENTION MODELS
5. Transitional Care Model – Mary Naylor (Home Health patient coaching)
6. Best Practices Intervention Package for Transitional Care Coordination
(Home Health QI Initiative)
7. Interventions to Reduce Acute Care Transfers (INTERACT) – Florida Atlantic
University (Nursing Facility)
8. Care Transitions Intervention (CTI) – Dr. Eric Coleman (Physician Office)
INTERVENTION MODELS
SELECTING INTERVENTIONS
What are your primary drivers of readmission?
What driver(s) does this intervention address?
What is your goal for the intervention?
How does the selected intervention improve the quality and safety
of patient care, transitions of care, and post-acute-care follow-up?
Driver
1. Fragmented Documentation
2. Inappropriate End-of-Life Care
3. Medication Errors
4. High-Risk Patients Poorly
Identified
5. Lack of Post-Discharge
Follow up
6. Lack of Disease-Specific Protocols
7. Poor Patient Self-Management
8. Lack of Community Awareness
Intervention
1. Standardized Transfer Forms
2. Discharge Risk Assessment Tool
3. Personal Health Record
4. Discharge Risk Assessment Tool
5. Coaching, Follow-up Scheduling
6. Protocol Improvement Project
7. Personal Health Record,
Coaching
8. Community outreach campaign
DESIGNING INTERVENTIONS TO ADDRESS DRIVERS
MONITORING THE WORK
Intervention Phase
Monitor interventions
Measure progress
Reassess and evaluate processes
Keep stakeholders informed
Think about where you will get data
Financial operations
Patient profiles/medical record/Information Services
Process information
Patient satisfaction
Patient interviews
Staff interviews
CALIBRATING TOO MUCH DATA WITH TOO LITTLE TIME
Think about where you will get data:
Length of Stay
Readmission rates
Payer mix
Cost-per-case and admission
Occupancy rate
Readmission by diagnosis
Denial rates for discharge readiness
Patient Satisfaction Surveys (H-CAHPS)
FINANCIAL OPERATIONS
Think about knowing when and from where patients
are readmitted
Medical record
Admission source
Patient interview
Discharge disposition
Discharge risk assessments
PATIENT PROFILES
Think about processes that impact and are impacted by readmission
Holding in ER, ICU, recovery
Denied days for delay in discharge
ER diversion rates
Discharge planning process
Bed turnover measures
Patient education
Referrals
PROCESS INFORMATION
PATIENT SATISFACTION
Think about how a patient’s perception impacts readmission (H-CAHPS)
Medication management
• Question # 16
• Question # 17
Discharge Planning
• Question # 19
• Question # 20
Think about how staff can give you their perspective on
processes that impact their work and readmissions
Discharge process
Discharge risk factors
Patient education
Tools
Opportunities
Solutions
STAFF INTERVIEWS
Think about questions you can ask the patient that
will help you understand readmission
Reason for readmission
Discharge process
Discharge risk factors
Patient efficacy – response to education
Solutions
PATIENT INTERVIEWS
Index Admission: The initial inpatient admission within a given 30-day period.
Readmission: A patient readmitted to an inpatient bed within 30 days of
discharge from the previous inpatient hospitalization (index admission).
Outcome: An expected change that results from an intervention, reflecting an
effect on root cause.
Improvement: Meeting a benchmark set at intervention implementation or
achievement of statistical significance over a defined time period.
DEFINITIONS
SURVEYING THE WORK
Surveillance Phase
Analyze data
Adjust interventions
Report data to stakeholders
Monitor – Improve – Report activities
”…the secret of the care of the patient is in caring
for the patient.”
Francis W. Peabody, MD (1881-1927)
REMEMBER
Definition: Patient Experience
The sum of all interactions, shaped by an
organization’s culture, that impact patient
perceptions across the continuum of care
TEAMWORK IN VALUE-BASED CARE
Patients are starting to discover that
their healthcare is not nearly as good as
it should be.
TEAMWORK IN VALUE-BASED CARE
Patients are starting to discover that their
healthcare is not nearly as good as it should
be.
Value-based care is the right thing to do,
and it’s not that hard.
TEAMWORK IN VALUE-BASED CARE
• Patients are starting to discover that their healthcare is not
nearly as good as it should be.
• Value-based care is the right thing to do, and it’s not that
hard.
• Value-based care will make any healthcare provider stand
out from the crowd.
TEAMWORK IN VALUE-BASED CARE CARE
1. Providers and patients know each others’ names.
2. Patients’ opinions are actively sought, listened to and
honored where possible (a suggestion box, patient
satisfaction survey or mission statement doesn’t
constitute being value-based — if you think they are then
you aren’t value-based).
3. Patients tell you that their doctors and other team
members really listened to what they had to say (again, if
you think satisfaction surveys qualify, you aren’t there yet).
TEAMWORK IN VALUE-BASED CARE
1. Patients are treated as the most important
member of the healthcare team and taught how
they can best contribute to the team’s success.
2. Providers feel that their patients are actively
involved in their own care.
3. You see a significant improvement in patient
health status, health literacy / adherence/ self-
management, engagement, level of utilization
and patient/provider experience.
TEAMWORK IN VALUE-BASED CARE
CALL TO ACTION
Reduction in preventable readmissions cannot be
accomplished by individuals or providers working in
isolation.
Determine which post-acute care providers readmit
patients to your facility most often and why.