UPMC St. Margaret Project RED Initiative

UPMC St. Margaret Project RED Initiative

Facts Related to Hospital Readmissions Preventable readmissions are receiving more attention because they present important opportunities to improve patient care and reduce costs. The Medicare Payment Advisory Commission has estimated that potentially preventable readmissions might account for as much as $12 billion per year in medical costs nationally. Patients with heart failure had the highest total number of readmissions in the state of Pennsylvania, resulting in a readmission rate of 24.3 percent. 13.5 percent of adults end up back in the hospital within a month of their first admission. 2

Common Reasons for Readmissions Lack of timely post hospital follow up with a physician Patient has no primary care physician Patient lacks transportation Poor medication reconciliation Patient did not receive homecare services

What is Project RED? Re- Engineering Discharge

Re-Engineering Discharge To improve the discharge process at UPMC St. Margaret Project RED : Patient centered Prepares patients to care for themselves at home Decreases readmissions and visits to Emergency Department

11 Reinforcing Components of Project RED 1. Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Follow up Appointments 4. Outstanding tests 5. Post discharge services 6. Written discharge plan 7. What to do if problems arise 8. Patient education 9. Assess patient education 10.Discharge summary sent to PCP 11. Telephone reinforcement

St. Margaret Comparison Baseline Readmission Rate at SMH = 12.4% Readmission rate per Diagnosis: CHF = 19.2% COPD = 16.5% PNA = 14.2% Average LOS at SMH = 4.89 days

Targeted Population of Project RED Pilot Patients admitted on 5A & 5B who are: Diagnosed with: CHF COPD PNA Readmitted within 30 days of discharge» Excludes UPMC Health Plan participants

Discharge Planning Patient Admission H & P Rx Plan Discharge Order Written Discharge Process Discharge Event PATIENT EDUCATION DISCHARGE INSTRUCTIONS Post-D/C Follow-up

Staff Member Roles Patient s physicians and medical team Nursing staff Care Management staff 10

Role of the Nursing Staff Provide nursing care Educate patient and family Communicate with each other Communicate with members of the multi-disciplinary team Including the Discharge Advocate (D/A) Ensure patient and family understanding of final discharge instructions 11.

Role of the Care Management Staff Coordinate an enhanced discharge plan Ensure accurate medication reconciliation Identify educational needs and opportunities Provide patient education related to: Diagnosis, Medication, signs & symptoms Schedule follow up appointments Follow up phone call 24-48 hours post discharge

Discharge Advocate (D/A) Role for Project RED Will be performed by Care Management staff Prepare patients for hospital discharge Assist patients to safely transition from hospital to home Develop care plan for patient use after d/c Medication reconciliation Coordinate all d/c activities within patient population

Discharge Advocate (D/A) Role for Project RED Ensure patient/family understands information and encourage compliance with the instructions (assess literacy level) Provide patient education related to: Diagnosis, Medication, Signs & Symptoms Discuss best days of the week and times for appointments Schedules follow up appointment with physician within 5 days of discharge Schedules any necessary follow up tests or procedures Documents follow up appointments in Depart to reflect on discharge instructions Identifies any transportation needs

Process Change Care Management duties on 5A and 5B units will be reformed Utilization review will be performed separately by one Care Manager for 5A and 5B **this role will rotate monthly or as needed** Discharge planning will be performed by the Discharge Advocate (D/A) on all patients, not just those patients in the Project RED Pilot

Documentation Discharge Advocate (D/A) documentation will be reflected in the electronic health record Clinical Notes Notes D/C Plan

Click on the date and it will show you the discharge plan documented by Care Management staff.

Summary Project RED Pilot will begin in the first quarter of 2013 Focus on patients with CHF, COPD, Pneumonia, and patients who are readmitted within 30 days of discharge Physicians, Nurses and Care Management staff will be the primary contributors to the pilot Project RED is UPMC St. Margaret s pilot approach to reduce avoidable hospital readmissions 18

References http://www.phc4.org/reports/readmissions/10/nr042612.htm\ Retrieved August 3, 2012. Pennsylvania Patient Safety Authority. Retrieved August 3, 2012, from https://psapasskey.org/collab/collab8/collab8_1/default.aspx 19