Risk Assessment- What are we Learning?

Stephanie Mudd RN MSM CCMSupervisor, Care Management TG/AH/MBCH

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Presented by Washington State Hospital Association Safe Table, 7/10/13

Pierce County Community – Readmission Reduction pilot project (August 2012)

Research for Readmission Risk Tools Adapted a tool from Mary Naylor’s readmission risk

tool Started using it in April, 2013 Goal

Risk assessment on 100% of patients Implement Care Management Strategies related to

risk

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Background

Presented by Washington State Hospital Association Safe Table, 7/10/13

Tool

Check the following that are true. PointsAge 80 or older 1No funding source 1More than 4 Chronic Conditions 1Active Behavioral / psychiatric health issue 1Six or more prescribed medications 1Two or more hospitalizations within the past 6 months 1Readmitted within 30 days 1Inadaquate support system 1Low health literacy 1Documented history of non adhearence to the therapeutic regimen 1Require assistance with ADL's 1Substance / ETOH abuse 1CM / MSW / Physician determination 6Take the sum of the points and enter the total

ScoreLow 0 to 2Medium 2 to 4High 5 to 6Intensive above 6

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Presented by Washington State Hospital Association Safe Table, 7/10/13

Process

•Care Management assessment within 48 hours of admission•Readmission Risk Score Completed and Documented in Epic•Risk Score listed on hospital censes•Case Manager prioritizes patients according to scores

•Care Conference arranged•Referrals Made•Discharge Report sent to PCP including Readmission Risk Score• PCP offices prioritizing their patients follow up phone calls based on readmission risk score

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Presented by Washington State Hospital Association Safe Table, 7/10/13

Intensive Readmission Risk• Care Conference• Evaluate Skilled Nursing Facility versus Home Health• Referrals• Palliative• Social Work• Pharmacy Medication Reconciliation• Community Referrals

• Follow up appointment made for patient to be seen by PCP within 2 days

• Care Management Discharge Summary Completed

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Presented by Washington State Hospital Association Safe Table, 7/10/13

High Risk Readmission Risk• Care Conference Recommended• Evaluate Skilled Nursing Facility versus Home Health• Referrals to Consider• Social Work• Palliative• Community Referrals

• Follow up appointment made for patient to be seen within 2 to 4 days

• Care Management Discharge Summary Completed

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Presented by Washington State Hospital Association Safe Table, 7/10/13

Medium Readmission Risk• Evaluate Skilled Nursing versus Home Health• Community Referrals• Out patient palliative care consult for goal setting• For CHF assess for Heart Failure Clinic follow up• PCP appointment for follow up within 5-7 days• (Unless patient is cognitively impaired, patient would arrange

their own follow up appointment. CM to confirm that appointment is made)

• Care Management Discharge Summary Suggested

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Presented by Washington State Hospital Association Safe Table, 7/10/13

Low Risk Readmission Risk

• Skilled Nursing versus Home Health• Community Referrals• For CHF assess for Heart Failure Clinic follow up• PCP follow up within 7-10 days• (patient to make unless cognitively impaired)

• PCP to determine if Palliative Consult needed• Care Management Discharge Summary not required

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Presented by Washington State Hospital Association Safe Table, 7/10/13

Lessons Learned

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We had to add the ability for MD, Social Worker, Case Manager to score higher at their discretion (Example Trauma patients)

Adjust the scores as they overlapped

Presented by Washington State Hospital Association Safe Table, 7/10/13

Validation

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Review readmitted cases weekly and do chart review toValidate the effectiveness of the tool Identify education and training

opportunities

Presented by Washington State Hospital Association Safe Table, 7/10/13

Next Steps

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Continue to monitor validity of the tool

Maintain risk assessment completed on 100% of admission

Revise the tool as necessary per the findings

Presented by Washington State Hospital Association Safe Table, 7/10/13