Time for action: pulling up our sleeves

1. Time for action: pulling up our sleeves • What is preventing us from getting to target? • What is working? • What actions do we take for 2014?

2. What is preventing us from getting to target? • Lack of consistency (3) • Too many hats/Many different responsibilities (3) • Lack of funds • Lack of communication between sources (2) • Lack of coordinated approach – physician, hospital, community resources (2) • No PCP referral • Lack of staff - No staff for scheduling appointment; No staff for follow up phone call (3) • Lower socioeconomic, (un)insured, homeless, patients difficult to track and treat (2) • Non-compliance on patients part (3) • No action plan to reduce 30 day readmits • Lack of community resources (2) • Lack of access to community resources • Changing staff • One project after another • Readmissions to area facilities • Knowledge deficit about resources in community • Disconnect between case management leadership and nursing • Lack of inclusion of patient/family in daily interdisciplinary meetings • Patient not wanting to be discharged to appropriate level of care • Patient on paper does not qualify for services when in reality they do really need the services • Competing initiatives • Family resistance

3. What is working? • Analysis of each readmission • Referral to home health agency (2) • Heart Failure Clinic • Making follow up appointments • Educate patients prior to and at discharge (Needs to be better implemented) • Readmission tool (ID high risk patients)/8P reassessment tools (2) • New discharge process • Meeting with post-acute providers • Education • Partnership with Health System • We have better response from SNF & HHN agencies (2) • Daily IDT meetings on all patients • White board include expected discharge date and discharge needs • Bedside Delivery • Community Collaboration with SNF, Health System • Care Transition Coach

4. What actions do we take for 2014? • Involve front line staff and families • Pharmacy review meds with patient at time of discharge • Follow up appointments within 4-5 days instead of 7-10 days • Reframe our process • Meeting next week with CMO, Each manager, director, Heart Failure Director, Quality Director • Discharge call backs • Readmit (reduction) plan and take action with appointing someone to head and implement • Call backs from hospitalist within 48 hours and case management in 7 days • Educate staff on using resources when case management isn’t around • Improve patient education • Increase physician awareness • Community partnerships • Continued collaboration • Readmission task force partner with providers • Learn about Interact • Review the degree of implementation of the elements of the Coleman Model • Improve referrals to CCTP program • Provide Data to Case Management & Nursing staff on readmission rates • Begin physician education on Medicare readmission – begin with hospitalist • Develop a consistent transitional care plan • More recognition • Follow up phone calls