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AHA/HRET HEN: Data and Coaching Webinar: Reducing Readmissions Data Review June 4, 2012 1:00 2:00 PM, CDT Slide 2 Welcome and Overview Welcome, thank you for joining us today! Housekeeping: This webinar is being recorded and will be archived. You will receive a PDF of todays presentation, later this week, as well as a link to fill-out the evaluation, a summary of Q&A and a link for the recording. For questions: please reach out to your state lead or email us: HEN@aha.org.HEN@aha.org Agenda: Readmission Measures Content Review Hospital Story Teach Back 2 Slide 3 Polling Questions (#1 and #2) How Many of You are Joining Us From: Hospital type? A. General Medical / Surgical B. Teaching C. Rural D. Childrens E. Long-term Care F. Psychiatric Hospital size? A. CAH B. Not CHA, 2 passes Adequate literacy364519 Marginal literacy226216 Inadequate literacy116227 US born374617 Born outside US156"> Characteristic% 1 pass% 2 passes% >2 passes Adequate literacy364519 Marginal literacy226216 Inadequate literacy116227 US born374617 Born outside US156125 The number of passes required through consent process to obtain informed consent, by participant characteristics Sudore, Schillinger 2006 JGIM Slide 60 Provider-Patient Concordance in Medication Regimen 60 Patients with atrial fibrillation at high risk of stroke Treatment with warfarin (blood-thinner) reduces risk of stroke by 70% Requires close monitoring and frequent dose adjustments Miscommunication/ inappropriate dosing can lead to poor outcomes (stroke or bleeding) Studies have shown miscommunication rates (discordance) as high as 50% Slide 61 Literacy, Discordance and Safety 61 Anticoagulant regimen concordance lower for patients with inadequate vs adequate literacy (42 % vs 64 %, OR = 0.41, P Polling Question (#1) Are your clinicians actively using the teach- back method with patients to communicate medication changes during the hospital stay? Who is currently reviewing readmission data on a monthly basis? A. Yes all the time (100%) B. Yes most of the time (> 50% to < 100%) C. Yes sometimes (< 50%) D. No or rarely 69 Slide 70 Polling Question (#2) Are your clinicians actively using the teach- back method with patients to communicate discharge instructions? A. Yes all the time (100%) B. Yes most of the time (> 50% to < 100%) C. Yes sometimes (< 50%) D. No or rarely 70 Slide 71 Connecting the Dots Hospital to Home Joan Carroll, RN, BA, CDMS, CCM Lee Memorial Health System, FL Slide 72 72 CTI Program Design Care Transitions Intervention (CTI) is a 4 week program to help patients transition from hospital to home, while learning how to manage their chronic condition Eric Coleman has been a leader in establishing an evidence based model called Care Transitions and this is the model we have chosen to adopt Slide 73 73 Lee Memorial Health System 4 acute care hospitals in SW Florida Regional trauma Center, regional childrens hospital, inpatient rehab hospital and a full post acute service network # of residents over 65 is 23.5% or nearly double the national average of 13% CHF readmission rate has been 24% Care Transitions readmission rate is 6.9% Slide 74 74 CTI Program Design Care Transition coach sees the patient in the hospital and completes the first Patient Activation Assessment (PAA). Follow up meeting within 3 days of discharge in the patients home to identify medication discrepancies, teach Medication Management, the use of a Personal Health Record, Red Flags and how to manage them, diet and fluid balance, and physician communications. This visit allows us the opportunity to evaluate psych-social needs and connect people to community services. Weekly phone calls for 3 weeks to determine if the patient has seen their PCP and all their questions have been adequately answered. The 2 nd PAA gives us assurance that the patient can self manage their condition. Slide 75 CTI Lessons Patient Findings 70% of our patients said no one went over discharge instructions Patients may not be honest about their understanding Patients may not be realistic about their abilities Patients do not know anything about sodium Actions Began monthly meetings with discharge nurses/ added highlighters to DI/ shared stories Teach back is mandatory, cognition problems Observe their follow through with scales, meds We worked with the VP of nursing to change DI to include the word salt. Slide 76 CTI Lessons Patient Findings: Patients do not understand Activity as tolerated and often do not know their diagnosis Many patients are not assessed adequately for home going assistance Example, PT, balance programs for frequent fallers /ADLs not IADLs, financial or transportation needs Actions: Quarterly meetings with Hospitalists and asked to change that instruction on DI/ share stories to demonstrate pt confusion Continual meetings with case managers to share stories and increase post acute referrals appropriately Slide 77 CTI Findings Medication Discrepancies Brand/generic names Pt has given inaccurate list of meds on admission Dosage change not clearly explained New meds not highlighted and described Prescriptions missing Actions Work with pharmacy and have them available to review with patient Have both names on DI and on the bottles Met with nursing. They are working on improved listing of meds on admission. EMR will help with many of these issues Slide 78 78 Suggestions for CTI Success Form a committee with VP of nursing, CAO, Medical Director, Post Acute administration, Case Management, Process Improvement leaders, Hospitalists, Cardiologist Pharmacy and Home Health Directors. Meet monthly to discuss data collected and share stories. Meet with the nursing staffs and the discharge nurses regularly. Slide 79 79 Caution Encourage the CTI coaches to share stories so they can be part of the solution rather than the problem. Be careful with the risk assessments. They are only as good as the person doing the questioning. Most patients are not non- compliant. There are real reasons they did not do as they were instructed. You have to ask the right questions. Slide 80 80 Polling Question (#3) Do you use a formal assessment instrument or tool to evaluate readmission risk? -A. Yes all patients -B. Yes only high risk patients -C. Sometimes to rarely, use is inconsistent -D. Not yet Slide 81 81 Questions? 81 ? Slide 82 Wrap Up and Next Steps Next TOC Reminder: Visit the HRET HEN website: http://www.hret-hen.org/http://www.hret-hen.org/ for information, resources and events, such as the additional topic-specific Data and Coaching webinars throughout June and July. Thank you for joining us! 82