Strategies for Readmission Reduction in Transitional Care: A Three (3) Part Process.

Telehealth Alliance of Oregon ConferenceApril 11 & 12, 2013

Jean McCormick, RN, MSN, Clinical Nurse Educator

Objectives• To discuss and demonstrate the effects of the new form

of handoff between OHSU providers and collaborating Skilled Nursing Facilities (SNFs).

 • To examine the impact of the video technology

surrounding the patient – alleviation of patient and family anxiety;– patient empowerment;– and most importantly, patient satisfaction.

 • To demonstrate the cost benefit for both facilities with the

emerging changes in health care.

OHSU Telehealth Activities – Across the Continuum

*Other uses: Language interpretations

Ambulatory Care*

ED, Nursery,

Acute CareInpatient*

Transitions (SNF’s, LTACH,

etc)

In Home Monitoring

Continuum of Care

The OHSU Telemedicine Network

• 15 sites covered

• 6 different services (stroke, pediatrics, neonatal, genetics, trauma and neurosurgery)

ED, Nursery, Acute Care Consults by Month

Since May 2010:• 421 emergent consults• 262 Transfers to OHSU• 159 remained in community (38%)• Averted transport savings: >$2,202,440

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5

10

15

20

25

30

SNF – OHSU Telemedicine Collaboration

Goals– Reduce Readmissions– Reducing the per Capita costs of Care for

Populations; – Improving the Health of Populations; and – Improve the Individual Experience of Care

The Three Part Process…

• Nurse to Nurse “Warm” Handoff

• Brown Bag Educational Sessions

• Coming Soon: MD Video Connections

Nurse to Nurse Video Handoff

Nurse to Nurse “Warm” Handoff

• What is a “warm” handoff? • EMR Documentation• Workflows• Benefits and Challenges• Goals

EMR Documentation

Workflows are Key..

Benefits

• Quality Review• Creating a Visual Care Plan• Builds rapport between providers at

collaborating facilities• Patients

– Alleviates anxiety for patient/family – Empowers patients in their own care– “15 minutes of fame”

• Technology• Buy – In• Constant Work in Progress (changes in

dynamics, teaching, workflow, and turnover)

Quality Review – the good, the bad, and the ugly.

SNF Educational Brown Bag Series

• Education – the 2nd Part of the Process• Monthly topics chosen based on identified needs• Enabled through our health system video bridge• Up to 40 endpoints can connect

SNF Educational Sessions—Lessons Learned

• Quality Reviews• Teaching on the Bridge…• Technology Challenges• Presentations (Evidence based practice,

simulation, and collaboration)• Outcome of 1st Quarterly PICC/ID Series • Goals and Future (CMEs, more simulation and

real time interaction, and more sites)

Continuous Work towards Lowering Readmissions – SNF Consults…

• Third & maybe not Final Part of Process..• Review of Skilled Nursing Facility Patient Re-

Admissions Reasons• Hospital Department/Physicians/Medical

Directors at SNF Buy-In• No Credentialing• Possible Challenges Ahead

SNF Consult

Conclusion & Summary

• Tying it all together… the 3 part process• Electronic medical records • Know your institution Process Flow (from billing,

credentialing, activation, documentation, to having a contingency plan)

• Buy-In- Workflows- Education & Handouts- CNO, Nurse Managers, Nurse Units- Staff Meetings

• Technology is your friend!

Presentation Takeaways• Understand the effect of utilizing video technology to

communicate a discharge report (e.g., pros, cons, problems, benefits, and future projects).

• Recognition that telemedicine can be a valuable tool for all care transitions, including discharge from the hospital to a skilled nursing facility, in line with the Triple Aim.

• Recognition that telemedicine is an effective tool to empower patients and to establish rapport between health care providers.

Acknowledgement and Thank You!!!

• Miles Ellenby, MD, Medical Director of Telehealth Services

• Mark Lovgen, Director of Telehealth Services

• Danielle Willard, Project Coordinator

• Kristoffer Kelly-Campanale, IT Engineer

• Nancy Trumbo, Director of Care Management and OHSU’s Care Management team

• Floor Nurses and partnered SNFs

Questions?