Improving Patient Outcomes through Quality Transitions
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1 Improving Patient Outcomes through Quality Transitions
2
3 Founded in 1892, Union Hospital began as a 20 bed facility and has grown into a 380 bed not-for-profit hospital Union Hospital is a Regional Referral Center serving patients in west-central Indiana and east-central Illinois The Union Health System also includes Union Hospital Clinton and several facilities dedicated to specific service offerings, patient groups, and physician groups Union Health Systems is the largest provider of health care services between Indianapolis, IN and St. Louis, MO, providing quality care to all, regardless of ability to pay.
4 Pam Alexander Lennie Blythe Dr. John Bolinger Myrna Dienhart Shad Goodman Terri Hill Lori Horrall Sherri Kannmacher Dawn Jolliff Dr. Steven McDonald Amy McHenry Annette Smith Jana Smith Rhonda Smith Andrea Spendal Jeanette Spradlin Stacy Street Debbie Stuck Kristi Williams Kerry Wilson Marina Wolfe
5 Readmission Numbers Above National Average All Cause Medicare Readmission Rates to Union Hospital % % Medicare CHF Readmission Rates to Union Hospital % % *CHF Readmissions Identified as First Priority*
6 Pilot began October 1, 2012 A Registered Nurse used in Coaching Role Identification of CHF Patient on Admit and Initiation of CHF Education Began Teach Back Method of Education was Utilized Assist with Discharge Planning Coordination with Next Level of Care More Timely Follow-up with PCP Increase Communication with PCP Office
7 Developed as Monthly Meeting Coordination and Communication Includes: Long term care facilities Home health Care Hospices Area Agencies Durable medical equipment companies Purpose Enhance quality of care Define gaps in care Improve communication and coordination to next level of care
8 Universal Heart Failure Color Zone Soarian Report Built to Identify CHF Patients Heart Failure Education Packet Developed 30 Day Readmission Report Built CHF Calendar Revised to Include Monthly Tips SBAR Tool Education Collaboration with Area 7 Counsel for Aging Increased Referrals to Support Agencies
9 Root Cause Identification of Patient Diagnosis was Inadequate December, 2012, 37 of 54 CHF Patients Were Identified During Admission Identified Problems 1) Computer Systems Do Not Interface 2) Data Fields Free Text Rather than Discrete Fields 3) Duplication of Efforts Identifying Patients
10 1) Consistent Process to Identify Primary Diagnosis Upon Admission Quality of Care Improvement Appropriate Patient Education Effective Discharge Planning 2) Establish Method Where ALL Departments Use Same Process 3) Aid in the Process of Concurrent Chart Review for CMS Measures
11 Streamlined and Standardized the Report Generation Process All Disciplines Receive Same Report from the Same Source
12 Delayed End of Life Discussions Teaching Versus Motivational Interviewing Physician Buy-In Culture Difficulty in Diagnosis Recognition
13 Building Good Community Relationships (Partnership with Area 7) Value of Coordinated Care Ensuring Timely Inpatient Intervention as Well as Post Hospital Follow-up Need for Open/Honest End of Life Discussion
14 Formation of Palliative Care Team Community Support Group for CHF Patients and Caregivers Continued Community Care Transitions -Work on Gaps in Care- Integration with ACO Care Management Collaboration with ER Case Management Incorporation of Physician Advisor
15 40% UNION HOSPITAL CHF Readmission Rates All CHF 35% Pilot Program 30% 25% *National Average CHF Readmit % 15% 10% 5% 0% Oct Nov Dec Jan 2013 Feb Mar Apr May
16 19.5% Medicare 30 day Readmissions All Diagnosis/All Cause 19.2% 19.0% 18.9% 18.5% 18.0% 17.5% 17.0% 16.9% 16.5% 16.0% 15.5% FY 2011 FY 2012 FY 2013
17 19.0% Medicare 30 Day Readmissions AMI 18.5% 18.0% 18.2% 18.4% 17.5% 17.0% 16.5% 16.0% 15.8% 15.5% 15.0% 14.5% 14.0% FY 2011 FY 2012 FY 2013
18 45.0% Medicare 30 Day Readmissions CHF FY % 36.6% 38.5% 35.0% 32.5% 30.0% 25.0% 23.5% 25.6% 20.0% 20.0% 19.4% 18.8% 15.0% 13.3% 10.0% 5.0% 0.0% Sep Oct Nov Dec Jan Feb Mar Apr May
19 30.0% Medicare 30 Day Readmissions COPD 26.1% 26.0% 25.0% 20.0% 19.4% 15.0% 10.0% 5.0% 0.0% FY 2011 FY 2012 FY 2013
20 22.0% Medicare 30 Day Readmissions Pneumonia 21.8% 21.5% 21.0% 20.6% 20.5% 20.0% 19.9% 19.5% 19.0% FY 2011 FY 2012 FY 2013
21 o Raised Awareness Hospital Staff Physicians Community o Increased Communication Hospital Staff Physicians Community o Coordination Hospital Staff Physicians Community
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