Thinking Differently about Hospital Readmissions LaNita Knoke RN, BS, CMCN Healthcare Strategist
Senior Care Continuum Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Four Areas of Focus Nutrition Medication Management Doctor Appointments Warning Signs Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Personal Side of Care Knowledge Compliance Communication Communication Knowledge BASIC NEEDS Meeting Basic Need Compliance
Home Instead Readmissions Studies 2 Livonia, MI 1 Richmond, VA Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Desired Outcome Both Studies were designed to determine if patient compliance with discharge instructions along with monitoring of key quality outcome indicators in the home, correlated to reduced unnecessary hospital readmissions 2 1
1 Study May 1, 2012 April 1, 2013 Large for profit hospital system 55 patient pilot study Primary diagnosis: CHF (Heart Failure) 30 Day Plan of Care GOAL: Reduce hospital readmissions of 16% by 1% Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
2 Study July 2012 to November 2012 2 non- profit hospitals 30 patient pilot study Primary diagnosis: CHF (Heart Failure)/ COPD 30 Day Plan of Care GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Discharge Model 1 2 3 4 Discharge Planners completed risk assessments on each patient Home Instead Senior Care completed care consultations to determine patient specific home needs prior to discharge Example With the Discharge Planner, and based on these assessments, we determined the necessary level of care, which drove the required hours of care Prior to discharge we worked together to created individualized care plans that involved the patients own goals
Home Management with Patient Care Plan focused on patient-centered goals with action plans Functional goals: drive, grocery shop, wedding, garden Home Instead Senior Care was present at discharge Helped to build trust, clarify discharge instructions, and understand the program Use of the Teach Back Method instead of a complete care approach Week 1: one hour of service for five visits Week 2: one hour of service for four visits Week 3: one hour of service for three visits Week 4: one hour of service for one or two visits
Patients only remember and understand <50% of what clinicians explain to them in a hospital setting. The discharge plans must shift from Patient Education to Patient Engagement
Critical Components for Success Medication management Reconciliation from discharge Appointment with Primary Care Physician First week home Diet and nutrition Low salt Monitoring vital signs Blood pressure, weight, fluid intake Warning signs Red flags red, yellow, green zones Organization of medical records in the home
Outcomes Study 1 23.5% 97% Reduction in readmission rate. Initial goal was to drop it 1% Improvement upon national readmission estimates for Medicare patients with CHF Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Outcomes Study 2 93% Of patients were discharged to their own homes 93% Of patients remained out of the hospital 60 days post discharge 96% Of patients remained out of the hospital 30 days post discharge 90% Of patients remained out of the hospital 90 day post discharge Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Outcomes In both studies we were able to fill the discharge gap in education and compliance. Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Care Management with Patient Nutrition Management Follow-Up Physician Visit Assistance Warning Signs Monitoring and Notification Medication Self Management Each Home Instead Senior Care franchise office is independently owned and operated. Home Instead, Inc. 2015. 2013. Home Instead Senior Care franchises provide only non-medical services. For medical advice, please consult your physician.
Best Practice Results Disciplined, consistent discharge process Successful hospital to home transition Ensuring nutritious groceries are in the home, reviewing the hospital diet instructions and providing mealtime socialization Physician appointment within 7 days post discharge, testing and therapy follow up completed when scheduled by providing transportation and assistance
Results (Cont.) Teaching patients to care for themselves instead of doing the care for them Focus should be on initial admission prevention Developing the Returning Home Program Medication Management needs resulted in launching Simple Meds by Home Instead
Person-centered solutions to reduce hospital readmissions
5 Ways to Prevent Senior Hospitalization Guide Returning Home Guide
Non-Medical Home Care: A Proven Resource to Reduce Hospital Readmissions