Readmission Reduction Chino Valley Medical Center Chino, CA November, 2014 AIM Statement Run Chart Reduce all-cause Medicare Fee for Service readmission rate by 20% from 2011 baseline of 23.4% to 18.4% by December 2014. • Update the “dialog” for both the Discharge Office and the Call back process. Include the floor nursing and unit managers in the call back process to better connect the staff to their patients post discharge. Interventions • Assess and improve the pharmacy’s role in the discharge process and medication reconciliation. Test (T), Interventions (I), Spread (S) • Standardized discharge instructions; available in several languages; distributed to patient/care taker. (T, I, S) • Improve and expand the risk screening tool to include bedside nursing. • Discharge instructions are being built into the electronic record. (T) • Develop an “enhanced home health” program. • Initiated “discharge envelope” (with hospital logo and contact information) to consolidate discharge paperwork in one area so patient has hospital staff to contact when questions arise post discharge. (T, I, S) • Implemented teach back methodology to ensure patient comprehension (T, I, S). Additional staff training of teach back based on identified need. (S) • Created ‘Discharge Office’ for patient stop during actual discharge to ensure patient has discharge instructions and follow-up appointment. (T, I) • Developed script for ‘Discharge Office’ (T, I). Script revised in 2014 to elicit more meaningful responses and understand issues that still need to be resolved. • Expanded ‘Discharge Office’ stop to 7 days per week. (I) • Adapted EMR to include documentation of patient comprehension of education/preparation and Incorporate all required elements of discharge summary. (T, I) • Engaged CMO in concurrent and retrospective review of readmissions. (I) • Coordinated with IT for electronic trigger of patients readmitted within 30 days including in ER. (T, I, S) • Follow-up appointments carefully monitored and a post discharge process has been implemented for patients who discharge without an appointment in place. (T, I, S) • Reviewed core measure patients to ensure all elements of Evidence Based Practice are implemented. (T, I, S) Next Steps • Develop a partnership with local residential programs to improve the hand-off process. Data Source: Comprehensive Data System-HRET as of 09-09-2014 Lessons Learned • Processes needs to be assessed on an ongoing basis. • Focus group needed expansion to include key community members i.e, Home Health and residential/assisted living programs. Team Members • Case Management/Champion: Sue Montoya-Bell, LCSW • PI Director: Donna Young, RN • MST Director: Angelica Silva, RN • ICU Director: Sandra Moreno, RN Resources • ED Director: Cheryl Gilliatt, RN • Clinical specialist with IT: Jean Arriaga, RN • Director of HIM: Nancy Dukes • HQI Readmission Elimination Toolkit is available on the HQI website at hqinstitute.org < Tools and Resources. • Pharmacy Director: Dr. Joseph Catalano, RN, PharmD • Questions: Contact Mahsa Farahani, Project Manager, HQI at 916-552-7521, email [email protected]. • Chief Medical Officer: Dr. James Lally, MD