FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge. July 24, 2018

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1 FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge July 24, 2018

2 Welcome & Overview How are we doing on Reducing Readmissions? Peer Sharing Presentation: Improving the Discharge Process Leslie Pollart, Director of Nursing for Memorial Regional Hospital Q&A / Group Discussion Next Meeting Today s Agenda

3 FHA Mission To Care Hospital Improvement Innovative Network (HIIN)

4 The Largest Quality Improvement Initiative in the WORLD!

5 Who is in the HRET HIIN? FHA Mission To Care: 93 Hospitals 5

6

7

8 Readmissions Regional Discussion Forums Opportunity to share challenges and explore strategies Themes Focus on Readmissions within 7 days Follow up appointments Patient engagement Challenging diagnoses Medication safety Discharge delays Hospital-SNF-Hospital transitions Palliative Care referrals

9 Readmissions 30 Day All Cause Rate per BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 FL Rate HRET HIIN Rate # FL Rptg # HRET HIIN Rptg. 1,461 1,493 1,492 1,526 1,508 1,504 1,525 1,489 1,487 1,502 1,475 1,475 1,496 1,464 1,451 1,453 1,413 1,389 1,205 Effective date: July 20, 2018

10 Readmissions Medicare Baseline = Rate per O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 FL Rate # FL Rptg Effective date: July 20, 2018

11 Readmissions Medicare Rate per BL O-16 N-16 D-16 J-17 F-17 M-17 A-17 M-17 J-17 J-17 A-17 S-17 O-17 N-17 D-17 J-18 F-18 M-18 FL Rate HRET HIIN Rate # FL Rptg # HRET HIIN Rptg. 1,165 1,340 1,338 1,367 1,361 1,358 1,374 1,339 1,337 1,354 1,328 1,325 1,340 1,316 1,287 1,295 1,260 1,224 1,048 Effective date: July 20, 2018

12 IMPROVING THE DC PROCESS Leslie Pollart, Director of Nursing Volume LOS Timeliness

13 History Opened in 1953 with 100 beds Three campuses, one license, 1,057 total beds: Memorial Regional Hospital (553 beds) Joe DiMaggio Children s Hospital (224 beds) Memorial Regional Hospital South (280 beds) Regional Tertiary and Quaternary Care Hospital One of only 7 state-approved Level 1 trauma centers (adults and pediatrics) Largest provider of emergency services in Broward County 1 Largest provider of acute care inpatient services in Broward County 1 Comprehensive Stroke Center Adult Heart Transplants 1 Source: Broward Regional Health Planning Council, One Year Ending December 2014

14 Services

15 DISCHARGE VOLUME: DAILY/HOURLY ANALYSIS

16 ADMISSION ORDERS BY TIME OF DAY

17 Discharge Timeliness: MD order time to Endpoint Goal is 120 minutes!

18 DISCHARGE BY DISPOSITION Against Medical Advice ALF Placement 14.21% Another Health Care Institution Not Defined Skilled Nursing Facility Expired 72.20% Home or Self Care Home-Health Care Svc Hospice/Home Psychiatric Hospital

19 MISSION STATEMENT Vacate the Bed

20 COURTESY LOUNGE

21 DC ORDER TO ENDPOINT ALL DISCHARGES Average Time 158 min

22 DISCHARGE ORDER TO END POINT (FROM DCL) Average Time 105 min

23 DC ORDER TO END POINT: 4 TH QUARTER 2016 OBSERVATION UNIT Average Time 93 min

24 DISCHARGE LOUNGE VOLUME DCL Closed for Reno Volume Jan April May June July Aug Sept Oct Nov Dec Feb Mar April May June July Aug Sept Oct Nov Dec '17 Volume

25 COURTESY LOUNGE UTILIZATION : HOME AND HOME HEALTH D/C JULY 2016 TO DECEMBER

26 Average Time in DCL: April 2014 thru May

27 Discharge Timeliness: Observation Unit

28 DISCHARGE LOUNGE STATISTICS Median Order to DCL Median DCL to End April May June July Aug Sept Oct Nov Dec

29 DC Lounge Utilization & Frequency of Purple Alerts Month Total Purple Alerts

30 Discharge Courtesy Lounge Hours of Operation: Monday through Sunday 09am-2130 RN & PCA open lounge; then RN is added at 11am

31 TRANSITIONS OF CARE TEAM

32 TRANSITIONS OF CARE: DEFINITION Definition of Terms Transition of Care The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. Reference: CMS.gov

33 FOCUS Medication- Pharmacy review of medications while in hospital, post-discharge and access to medications. Increased utilization of concierge pharmacy. Disease education- Clinical support team available to assist patient in better understanding of disease process and treatment plan. Follow- up care- Case Management team instrumental in identifying at risk group upon admission and assisting in providing additional support to patient both during and after hospitalization.

34 CALL BACK SCHEDULE Day of Call Case Management Pharmacy Nursing 2 x 7 x 14 x 21 x 28 x

35 CONTACT CARDS

36 TOC TRACKER Call backs: Days 2, 5, 7, 10, 14, 21, & 28 Indicates DC to DC clinic

37 CALL BACK SCRIPTS BY TIME INTERVAL

38 EPIC CALL BACK DOCUMENTATION

39

40 ACUTE MYOCARDIAL INFARCTION

41 CHRONIC OBSTRUCTIVE PULMONARY DISEASE

42 HEART FAILURE

43 PNEUMONIA

44 TOTAL HIP/KNEE ARTHROPLASTY

45 AVERAGE TIME TO READMISSION (DAYS) Days Highest Risk for Readmit AMI COPD HF Pneumonia Hip/Knee Avg Time to Readmit (Days)

46 CALL BACK ATTEMPTS OCTOBER-DECEMBER % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Day 7 Day 14 Day 28 Oct 100% 84% 93% Nov 100% 95% 98% Dec 100% 90% 87% Oct Nov Dec

47 CALL BACK CONTACTS OCTOBER-DECEMBER % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Day 7 Day 14 Day 28 Oct 69% 50% 79% Nov 77% 60% 71% Dec 84% 55% 49% Oct Nov Dec

48 QUESTIONS?

49 Improving the Flow of Information - EDie ED as an Island ED as a Bridge PCP Post-Acute In-Patient ED is focused primarily on efficiency and is only concerned with acute care episode ED and hospital at large view as separate from the larger care continuum ED is intrinsically connected to entire healthcare enterprise and is focused on items beyond efficiency ED collaborates to help prevent readmissions, avoid preventable admissions, and promote care coordination

50

51 Upcoming Events EDie Lunch & Learn Meeting (July 26 in Hollywood, FL) Register: Readmissions Sepsis Fishbowl Webinar Series: Part 5 (Aug. 12-1pm ET) Register: FHA Readmissions Stakeholder Virtual Meeting #4 (Oct. 12-1pm ET) Register: HIIN@fha.org to request a topic for discussion

52 Contact Us We are here to help!

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