Post on 17-Jan-2016
Hallmark Health SystemOctober 11, 2011
Founded as a system in 1997, Hallmark Health is a local, notfor profit, community based healthcare system servingBoston’s northern suburbs. The two hospitals that compriseHallmark Health System are the Lawrence Memorial Hospitaland the Melrose-Wakefield Hospital.
Hallmark Health System
Maureen Pierog MS, RNVice President
Quality Improvement
Barbara Marullo RN,BSN Program Manager
Quality Improvement
STAAR
Focus on CHF
High volume Problematic Public data through June 2009 showed Hallmark as
worse than expected Future financial implications
Readmission Profile
Elderly (>75) 10 or more medications Independent (refusing increased
support at discharge) Did not use discharge information Multiple diagnoses for readmissions
In House pharmacy consults in place for high risk CHF patients expected to go home. ( 75 or older and or on > 10 meds)
Case Management assesses every CHF patient with a risk for readmission tool.This is communicated throughout the continuum of care.
Case Management is making follow up appointments for all CHF patients before discharge from the hospital.
2010 Initiatives in Place
FOCUS on SNF ReturnsKey Changes
Provide Real – Time Handover Communication
Provide customized, real time
critical information to the next
clinical care providers
Goal : Prevention of Readmission from Courtyard Nursing Facility to Lawrence Memorial Hospital
Starting Point
Initial discussions centered around the following:
1. Discharge Information and Communication 2. The true capabilities and limits of the care available at the SNF3. Role of the ED physician; automatic admission vs treat and return4. How time of day and medical availability affects decisions5. What role could physician to physician contact play?6. What role could nurse to nurse contact play?
LMH / Courtyard Nursing Care CenterNovember / December 2010
# admitted from Courtyard = 48# admitted from all SNFs = 18826% of patients from SNF came from Courtyard
# of readmissions = 13# of admissions from Courtyard = 4827% readmission rate
Baseline Data
OBSERVATIONS
1. No direct Nurse to Nurse communication during the transfer process.
2. No Physician to Physician communication during the transfer process.
3. The traditional 3-page discharge referral was incomplete.
After reviewing all the data, the Readmission Committee decidedthat just concentrating on CHF was too limiting. We expanded this to include ‘all cause’ transfers to the emergency department.
Changes Tested
Courtyard Nursing Care Center utilizes the INTERACT tool for clear communication with any patient sent to LMH ED
Initiation of Geriatrician to ED Physician telephone communication
LMH nurse to nurse phone call with any patient discharged to Courtyard Nursing Care Center
Failed Tests
For all discharges from LMH to CNCC we set a goal to use the state proposed expanded transfer tool. (CMS Universal Transfer Form)
We tried to produce a prepopulated electronic pull in meditech during the discharge process.
PROJECT AIM
By October 2011
Reduce Hallmark Health System 30 – day readmission rate for patients with heart failure by 15 %
Traditional Medicare from 23.5 % to 20 %
All Payer from 21.64 % to 18.4 %
Hallmark Health System Principal Diagnosis:CHF & All Payers
0%
5%
10%
15%
20%
25%
30%
35%
40%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
% 3
0 D
ay R
ead
mit
2010 2011
Hallmark Health System 30 Day Readmission01/01/2010- 05/30/2011
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
% 3
0 D
ay R
ead
mit
2010 2011