Hallmark Health System

1. Hallmark Health System October 11, 2011 Founded as a system in 1997, Hallmark Health is a local, not for profit, community based healthcare system serving Boston’s northern suburbs. The two hospitals that comprise Hallmark Health System are the Lawrence Memorial Hospital and the Melrose-Wakefield Hospital.

2. STAAR Hallmark Health System Maureen Pierog MS, RNVice President Quality Improvement Barbara Marullo RN,BSN Program Manager Quality Improvement

3. Focus on CHF • High volume • Problematic • Public data through June 2009 showed Hallmark as worse than expected • Future financial implications

4. Readmission Profile • Elderly (>75) • 10 or more medications • Independent (refusing increased support at discharge) • Did not use discharge information • Multiple diagnoses for readmissions

5. 2010 Initiatives in Place • 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.

6. FOCUS on SNF ReturnsKey ChangesProvide Real – Time Handover Communication Provide customized, real time critical information to the next clinical care providers

7. Goal : Prevention of Readmission from Courtyard Nursing Facility to Lawrence Memorial Hospital

8. 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 SNF 3. Role of the ED physician; automatic admission vs treat and return 4. How time of day and medical availability affects decisions 5. What role could physician to physician contact play? 6. What role could nurse to nurse contact play?

9. Baseline Data LMH / Courtyard Nursing Care Center November / December 2010 # admitted from Courtyard = 48 # admitted from all SNFs = 188 26% of patients from SNF came from Courtyard # of readmissions = 13 # of admissions from Courtyard = 48 27% readmission rate

10. 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.

11. After reviewing all the data, the Readmission Committee decided that just concentrating on CHF was too limiting. We expanded this to include ‘all cause’ transfers to the emergency department.

12. 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

13. 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.

14. PROJECTAIM • 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 %