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Hospital Story

Hospital Story. Donna Collins, RN,MS/ CPHQ, Quality Manager, Weeks Medical Center, NH. About Us. Weeks Medical Center, 25 bed CAH Single entity w/ full service hospital, OP oncology, 4 office practices, home health, hospice

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Hospital Story

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  1. Hospital Story Donna Collins, RN,MS/ CPHQ, Quality Manager, Weeks Medical Center, NH

  2. About Us Weeks Medical Center, 25 bed CAH Single entity w/ full service hospital, OP oncology, 4 office practices, home health, hospice Catchment area – primarily older population w/ multiple co-morbid conditions Lowest per capital income in State of NH Long standing history - high re-admission rate

  3. What Did We Test? • Follow-up appointments scheduled within 4 days of discharge; appointment phone line established for weekend discharges • Earlier referral to Home Care/Hospice/Palliative Care services • Post discharge patient phone calls by outpatient case manager/nurses • Transition of care summaries ( H&P, discharge summary, discharge medications, instructions) sent to PCP; EMR preparation prior to follow-up visit

  4. What Have We Learned So Far? • Aligning the readmission reduction goal throughout the organization elevates the goal to a priority status- CEO driven • Hospital, office and home health team leaders and representatives are essential ( CMO, CNO, Office Practice Director) • A new communication/coordination infrastructure is required- change in employee roles/functions in all care settings • Patient and family involvement with follow-up care gets you far but not 100%

  5. What Barriers Did We Encounter? • Hospital, office and home care information systems are not integrated • Medication Reconciliation is still a burden; most patients are discharged on >9 medications • Patients and families are optimistic for cure; often prefer acute hospital care late in disease process – delayed referrals to Hospice

  6. How Did We Overcome These Barriers? • Expanded roles and responsibilities of admitting/communication, case management and clinic nurses to build transition bridge • Continuing development of Medical Home model • Continuing development of Palliative care program • Involvement of Home care and hospice staff in design • Patient education regarding palliative care options

  7. How Are We Doing Now?

  8. Weeks Medical Center Acute Care Readmission

  9. What Can Others Learn From Our Journey? • Share team activities/ updates with medical staff- they are concerned about re-admissions and will offer valuable improvement suggestions • Conduct case reviews using a standardized tool; helpful in identifying subtle quality issues and barriers • Refer cases into QA peer review process if indicated • Re-visit basic processes to check all are functioning well- consistency in patient activity orders; PT/OT evaluations

  10. Attempt to implement major changes without MD input and involvement • Assume that one or two strategies will fix the problem ( we know it can’t) • Implement new work processes without adequate staff education and training Do Not Try This At Home (Suggestions for What Not to Do…)

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