TRANSFORMING HEALTH CARE THROUGH RESEARCH AND EDUCATION © 2

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Maulik S. Joshi, Dr.P.H. President, Health Research & Educational Trust

Senior Vice President, Research, American Hospital Association

Email: mjoshi@aha.org Office Phone: 312-422-2622

Reducing Readmissions: What Will it Take?

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• Some movement and improvement

• Questions about full program solutions or individual interventions

• Challenged by definitions of avoidable

• Challenged by reliable data

• Social factors are significant

National Perspective

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• Delayed physician follow-up after discharge

• Inadequate hospital communication with primary care physicians

• Inadequate education of patient, especially about drug therapy and how to manage post-acute care needs

• Lack of personal follow-up with the patient to reinforce care plan, identify emerging problems

Common Discharge Process Breakdowns Associated with Readmissions

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Pre-discharge Interventions— • Patient education • Medication reconciliation • Discharge planning • Schedule Post-D/C physician appointment

Post-discharge Interventions— • Follow-up telephone calls to the patient • Patient-activated hotlines • Timely communication with ambulatory physicians • Timely ambulatory physician follow-up • Post-discharge home visits

Bridging Interventions— • Transition coaches • Physician continuity across inpatient to outpatient care • Patient-centered discharge instruction

A Taxonomy of Twelve Care Transitions Interventions (Source: Annals of Int Med, Oct 18, 2011)

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RED has eleven mutually reinforcing components: 1) Medication reconciliation 2) Patient education 3) Follow-up appointments 4) Outstanding tests 5) Post-discharge services 6) Reconcile discharge plan with national guidelines 7) What to do if problem arises 8) Written discharge plan 9) Assess patient understanding 10)Discharge summary sent to PCP 11)Telephone reinforcement

Project RED 11-point Checklist

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HRET Leadership Guide

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To effectively implement the strategies identified in the three tables, hospitals may need to involve key stakeholders in the care delivery process: patients, physicians, pharmacists, social services, nutritionists, physical therapists, and the community.

Strategies to Implement Along Care Continuum

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Strategies to Implement During Hospitalization

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Strategies to Implement at Discharge

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Strategies to Implement Post-Discharge

11 www.hret-hen.org

Key Drivers to Reducing Readmissions

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Examine your hospital’s current rate of readmissions.

Assess and prioritize your improvement opportunities.

Develop an action plan of strategies to implement.

Monitor your hospital’s progress.

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Four Steps for Hospital Leaders

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The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.

Plan-Do-Study-Act (PDSA)

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Model for Improvement

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Repeated Use of the Cycle

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1. Risk screen upon admission for high risk rehospitalization – consider clinical and social factors.

2. Use teach back during discharge. 3. Customized, understandable discharge

plan – checklist, patient centered. 4. Schedule follow-up physician

appointment. 5. Telephone follow-up within 48 to 72

hours.

First Interventions to Consider?

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1. Learn your causes early – WHY? 2. Assess the Key Drivers, Change

Packages and put together an Aim Statement – IMPROVE WHAT by WHEN?

3. Identify tests of changes, key change concepts – HOW?

4. DO; DO Again; DO Again; Do Again;…. 5. Speed, Implementation, Multiple

Interventions, Test and Learn

Your Leadership in Reducing Readmissions