Context

1. From Knowledge to Practice Translation A Multidisciplinary Intervention to Reduce 30 day Heart Failure Readmissions

2. Context • Rehospitalization ≤30 days marker of poor quality • Reduction of unnecessary rehospitalization is a way to improve quality and decrease cost • Limited data re: patterns of rehospitalization in U.S. • Jencks et al. (2009) NEJM • What is the frequency of rehospitalization of Medicare patients within 30 days after discharge? • How long does the risk of rehospitalization persist? • What is the frequency of outpatient followup after hospitalization? Jencks S et al. (2009) NEJM 360(14): 1418-1428

3. 30 day rehospitalization • 19.6% of all Medicare patients rehospitalized within 30 days of discharge • Medical diagnoses – 21.1% • Heart failure – 26.9% • Surgical diagnoses – 15.6% • No record of outpatient follow-up visit for 50.1% of patients rehospitalized within 30 days after discharge • No outpatient follow-up visit for 52% of those rehospitalized within 30 days after discharge for heart failure Jencks S et al. (2009) NEJM 360(14): 1418-1428

4. Heart failure readmission and HLOS relationship Winslow R, Wall Street Journal, June 2, 2010

5. The Allen Hospital Project Graham et al., 2006

6. 28.3%

7. The population

9. Strategy

10. Teambuilding

11. Preparatory work

12. Intervention components

13. Practice change

14. Effect on 30 day readmission

15. Would improvement have happened anyway?

16. Core measure improvement

17. Lessons Learned But the story doesn’t end here…..

18. Ongoing Monitoring 2012 • Rise in readmission rates • Characteristics of those readmitted analyzed • Chronic kidney disease • Dementia • Respiratory diseases • Poor social support • Medication discrepancies • Review of meds by pharmacist prior to discharge • Need for palliative care team