Readmission Reduction: Patient Interviews. KHA Quality Conference March, 2018

Transcription

1 Readmission Reduction: Patient Interviews KHA Quality Conference March, 2018

2 Initial Driver Diagram Use Data and Root Cause Analysis to drive Continuous Improvement Analyze data to inform targeting approach Understand root cause of readmissions; elicit the patient, caregiver and provider perspectives Periodically update approach based on findings; articulate your readmission reduction strategies Develop performance measurement dashboard to use Implementation data to drive continuous of improvement change ideas Reduce all-cause, all-payer readmissions within 30 days from 13.8% to 13.5% by April 30, 2018 Improve Standard Hospital-based transitional care processes Deliver enhanced services based on need Engage patients and their caregiver to identify the Learner, understand care preferences and assess readmission risk factors Facilitate interdisciplinary collaboration on readmission risks and mitigation strategies Develop a customized care transitions plan, taking into account patient preferences & addressing readmission risk factors and post-hospital contact names and numbers Use teach-back to validate patient understanding; use low health literacy techniques and/or professional translation services to optimize understanding and teach-back Make timely post-discharge follow up phone calls to follow up on symptoms and review care transitions plan Palliative Care Condition Specific Programs Pharmacy Intervention ED pause Collaborate with providers and agencies across the continuum Identify clinical, behavioral, social and community based supports that share the care of high risk patients Convene a cross-continuum team of providers and agencies that share the care of high risk patient populations Improve referral processes to make linking to behavioral, social and community based services more effective and efficient

3 Why were you hospitalized earlier this month? Prompt for patient/caregiver understanding of the reason for hospitalization. When you left the hospital: How did you feel? Where did you go? Did you have any questions or concerns? If so, what were they? Were you able to get your medications? Did you need help taking care of yourself? If you needed help, did you have help? If so, who? Tell me about the time between the day you left the hospital and the day you returned: When did you start not feeling well? Did you call anyone (doctor, nurse, other)? Did you try to see or did you see a doctor or nurse or other provider before you came? Did you try to manage symptoms yourself? Prompt for patient/caregiver self-management techniques used. In our efforts to provide the best possible care to you and others like you, can you think of anything that we or anyone could have done to help you after you left the hospital the first time so that you might not have needed to return so soon?

4 Reason- Please check all that apply Medication Management Unable to afford medication Lack of Understand medication Unable to obatain Medication Provider follow up No appointment Readmitted before scheduled appointment Provider instructed Patient to go to the ER Did not call Prvider/went directly to ER Discharge Instructions Needs additional education Did not review AVS provided Cardiopulmonary Rehab Eligible Cardiopulmonary Rehab Eligiblility not addressed Four or More Admissions Four Or more Admissions within one year Non-Adherence Diet Medication Management Provider appointments/therapies Psychosocial/family dynamics Behavioral Health Lack of family support Lack of self-care Limited Health Literacy Care Coordination Resources not arranged Resources non existent No Gaps Identified No Gaps Identified Transportation Dependent on Others

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7 Project Driver Diagram Approximately 40 Readmissions Need to be Prevented in Order to meet FY18 Goal (0.3% Reduction * 12,634 FY17 Discharges) FY18 Total Anticipated Readmits Avoided: 95

8 16.00% 15.00% All Cause, All Payer Readmissions- Rates Reported on Strategic Goal July 2017-Launch of Reducing Readmission Primary Driver Teams Readmission Interview Tool completed w ith all identified readmissions September 2017-Deep Dive Review s Aggregated Root Causes of Readmissions Implemented teaching points (CHF&COPD) 14.00% 13.00% 12.00% 11.00% 10.00% 9.00% May Implementation of HRET HIIN Change Package August 2017-SNF Readmission Review Tool October 2017-Lace+Score Visibility Longitudinal POC implemented Primary Learner Identification Post D/C phone calls November Banners and symbols flagging 8.00% May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Cumulative: 12.59% % readmitted Median Goal

9 Next Steps? Promote process reliability Sustainment Continuous Improvement Sepsis Challenging Populations Non-Adherence Behavioral Health Substance Abuse Kentucky Hospital Association Resources: K-HIIN HRET The issues are difficult or they would have been solved already; so it will take us all to find solutions. Charlie Kendell, MPH