Hospital Story

Donna Collins, RN,MS/ CPHQ, Quality Manager, Weeks

Medical Center, NH

About Us

• Weeks Medical Center, 25 bed CAH• Single entity w/ full service hospital, OP oncology, 4

office practices, home health, hospice• Catchment area – primarily older population w/

multiple co-morbid conditions• Lowest per capital income in State of NH• Long standing history - high re-admission rate

What Did We Test?

•Follow-up appointments scheduled within 4 days of discharge; appointment phone line established for weekend discharges •Earlier referral to Home Care/Hospice/Palliative Care services•Post discharge patient phone calls by outpatient case manager/nurses•Transition of care summaries ( H&P, discharge summary, discharge medications, instructions) sent to PCP; EMR preparation prior to follow-up visit

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What Have We Learned So Far?

• Aligning the readmission reduction goal throughout the organization elevates the goal to a priority status- CEO driven

• Hospital, office and home health team leaders and representatives are essential ( CMO, CNO, Office Practice Director)

• A new communication/coordination infrastructure is required- change in employee roles/functions in all care settings

• Patient and family involvement with follow-up care gets you far but not 100%

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What Barriers Did We Encounter?

• Hospital, office and home care information systems are not integrated

• Medication Reconciliation is still a burden; most patients are discharged on >9 medications

• Patients and families are optimistic for cure; often prefer acute hospital care late in disease process – delayed referrals to Hospice

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How Did We Overcome These Barriers?

• Expanded roles and responsibilities of admitting/communication, case management and clinic nurses to build transition bridge

• Continuing development of Medical Home model• Continuing development of Palliative care program• Involvement of Home care and hospice staff in

design • Patient education regarding palliative care options

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How Are We Doing Now?

Year Quarter Num. Den. % Goal = 6.7%

20102010201020102011

12341

19611159

207164157176166

9.1%4.9%7.0%8.5%5.4%

2011 2 16 158 10.1%2011 3 6 125 4.8%2011 4 9 129 6.9%2012 1 11 139 7.9%

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Readmissions within 30 days

Weeks Medical Center Acute Care Readmission

What Can Others Learn From Our Journey?

• Share team activities/ updates with medical staff- they are concerned about re-admissions and will offer valuable improvement suggestions

• Conduct case reviews using a standardized tool; helpful in identifying subtle quality issues and barriers

• Refer cases into QA peer review process if indicated• Re-visit basic processes to check all are functioning

well- consistency in patient activity orders; PT/OT evaluations

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Do Not Try This At Home (Suggestions for What Not to Do…)

• Attempt to implement major changes without MD input and involvement

• Assume that one or two strategies will fix the problem ( we know it can’t)

• Implement new work processes without adequate staff education and training