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Enhanced Home Health Program
Cedars-Sinai Health System
April 23, 2015
Los Angeles market for Home Health Agencies
2
There are over 700 Home Health Agencies that
operate within Cedars-Sinai’s Primary Service
Area.
Root Causes for Home Health Readmissions
3
• Patients & families often turn away Home Health agencies after hospital discharge
• Inconsistency in frequency of home visits post-discharge
• 45% of readmissions occurred on a Saturday or Sunday
• Patient/Family not communicating Red Flags to Home Health agency
• Medication Management/Reconciliation
• Physicians not responsive when Home Health Agencies have questions/concerns
A chart review of 45 Home Health patients revealed recurring factors that likely contributed to preventable readmission within 30 days.
The Problem
4
Home with Home Health
Cedars-Sinai 15.8%
All UHC Hospitals(Average) 16.2%
All-Cause 30-Day Readmission RateMarch 2013 – March 2014
The Cedars-Sinai 30-day all-cause readmissions rate for Home Health patients was about even as the average for all UHC hospitals.
The Enhanced Home Health Program
5
Focus Home Health Patients
Metric30-day all-cause
readmissions to CSMC
Target 10% readmission rate
By When March 2015
6
Agency Selection Process
125• Agencies submitted RFPs
25
• Selected based on Home Health Compare Data
• Complete self-assessment
13• Interviewed in person
5• Selected to participate in Enhanced Home
Health
The Enhanced Home Health Program
7
7 Touch Points
On-site Liaison
MD Interface
CS-Link access
24/7 On-Call Clinical Support
Building Awareness
Data Collection & Documentation
EHH is a collaboration with 5 home health agencies to ensure high quality patient-
centered care transitions from hospital to home.
Enhanced Home Health Protocol Touch points to occur within the first two weeks of discharge
24 – 48 Hours prior
to dischargeDay after
discharge
1st weekend patient
is at home
Pre-Discharge
Hospital Visit
with Home
Health Liaison
Home visit• Med rec
• Safety check
• Assessment &
education
• Identify other
disciplines that
may be needed
Home visit (2-3 in first week)
• Med
compliance
• Vitals
assessment
• Schedule next
home visit
Tuck-in Phone
call • Identify red flags
• Schedule next
home visit
• MD Follow up
appointment?
2nd weekend that
patient is at home
1st Friday patient is
at home
Home visit• Med compliance
• Vitals
• Well-being
assessment
Monday-Thursday
Minimum of 1 home
visit
Home visit• Med compliance
• Vitals
• Well-being
assessment
Tuck-in Phone
call• Address questions
• Schedule next home
visit
Week 1
Week 2-4
2nd Friday patient is
at home
Tuck-in Phone
call• Address questions
• Schedule next home
visit
Weekly 15-30 days
post discharge
Intro Phone
Call• Identify red flags
• Address
questions/anxiet
y
Evening of
Discharge
8
9
On-Site Liaison
How can your Agency benefit from having an On-Site Liaison?
Increase your agency acceptance rate
Gain in Medical Staff engagement and buy-in
No surprises for you or your patient
Ability to pull all necessary patient information prior to discharge
Ensure that the patient has all the necessary equipment
Inpatient RN is present to answer any additional questions
10
Proposed Pre-discharge visit: Home Health Liaison
Home Health Liaison complete the following on site, prior to discharge:
• Patient contact information
• Caregiver contact information
• MRN and ACCT ID Number
Verify the following in CS-Link
• EHH fact sheet
• When to call 9-11
Review Cedars-Branded Patient Education Materials with patient and family
• Preferred language
• Preferred time of day
• Presence of a caregiver (if applicable)
Identify patient preferences
• Speak with Attending Physician and identify the MD who will be following the patient in the post-discharge setting
• Call identified MD and ensure they are on board with post-discharge plan
Identify post-discharge MD follow-up
• Survey Monkey Tool
• CS-Link (long-term)
Documentation and Data Collection
11
EHH Patient Flow
Notification of new patient referral to one of the “Enhanced Home Health” (EHH) Agencies.
Visit patient prior to discharge to inform patient about HH agency and EHH program
Track all EHH discharges and referring agency to facilitate communication with the HH agencies and track all patients
Communicate regularly with the HH agencies to confirm all discharges to the agencies and track EHH touch-points
Follow-up with patients to ensure that the Home Health agencies are providing Enhanced Home Health
EHH Data
The EHH Population
13
Medicine35%
Surgery65%
Type of Hospital Encounter
2.8
2.4
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
EHH Non-EHH
EHH vs. Non-EHHCMI
March 2014-January 2015
EHH
Non-EHH
*Data Source: ROM, CMI and Hospital Encounter for patients discharged to EHH agencies, Date Range: March-14 to Jan-15
EHH vs. Non-EHH Readmission
14
17%
14.7%
11.4%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Baseline - All HomeHealth
Non-EHH EHH
Re
adm
issi
on
Rat
e
Patient Home Health Discharges
Baseline - AllHome Health
Non-EHH
EHH
April 2013 – February 2014 March 2014 – January 2015
*Data Source: ROM, Readmission rate for patients discharged to EHH agencies, Date Range: April-13 to Jan-15
EHH Process Improvements
Continued Performance and Process Improvements
16
CS-Link (Epic EMR) Access
Agency liaisons in the ED
Home health agency and Attending Physician communications
Alignment of patient education materials
Real time feedback using patient interviews
Agency clinical huddles
Agency check-in meetings
Organizational engagement through Grand Rounds
Epic Home Health build
Empathy Interviews
Patient’s trigger point
• Pain
• Afraid
Key findings
• Strong patient/nurse relationship
• Compassionate care
Opportunities
• Accessibility to contacts
• Consistent patient education
17
Looking Forward
18
• Year One Celebration and Raising Awareness • Grand Rounds on the EHH test of change
• Learning opportunity for physicians • Main target: Hospitalists
• Year Two Forecast• Potential partnership with vendor to pilot wearable technology that
could improve patient care• CS-Link Integration (home health module)• Continue empathy interviews and other performance improvement
initiatives
Thank you!
Any Questions?
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