PREVENTING READMISSIONS

1. PREVENTING READMISSIONS October 16, 2014 Presented by Debbie Rivet, MSW, CCM Director of Case Management Los Alamitos Medical Center

2. PRESENTATION OBJECTIVES • Assist each health care organization in developing a collaborative across the continuum of care. • Demonstrate the impact to the community in reducing readmissions • Share the data regarding readmissions over the past year. • Review the process in developing a collaborative • Share the tools used for the collaborative to reduce readmissions • Empower all organizations to assist in the process to reduce readmissions. NRPC So Cal Readmissions Update October 16, 2014

3. Southern California Readmissions Summit – 10/16/2014 Preventing Readmissions • Establishing the Preventing Readmissions group goal was to improve patient care and reduce readmissions. • It is a non-judgmental environment to share information and work cohesively to reduce readmissions. It was initiated in response to the CMS mandate to reduce readmission or face a financial penalty. The group began in the fall of 2011. The initial group was comprised of approximately 15 (fifteen) members and has grown to 45 as of July 2014. This is a working group not a marketing based meeting. This is to change our community working relationships, reduce readmissions and increase patient satisfaction outcomes. • An initial meeting was held consisting of • Two local community skilled nursing facilities administrators • Local home health agency administrator • Los Alamitos Medical Center Director Case Management • Chief Nursing Officer • Coronary Artery Disease Coordinator • Director of Quality Support services • Nursing Directors from ICU,ER and Medical Surgical Units • Social Work Services • Dietary Clinicians • Director of Pharmacy • Director of Respiratory Care • Director of Rehabilitation Services NRPC So Cal Readmissions Update October 16, 2014

4. Goals • Each member of the group discussed the impact of readmissions to their particular agency and the overall impact to the hospital. • The goal of the first meeting was to set up oncoming monthly meetings to formulate strategies, evaluate and analyze the readmission scores. • The goal would be to establish a community network meeting to reduce readmissions. • Create and implement a community based supportive system that is united in using an evidenced based approach to reducing readmissions to hospitals. The initial focus is to decrease the rate of readmission of AMI, CHF and Pneumonia. Introduction • Los Alamitos created a community based coalition that meets monthly at the hospital to improve transitions of care, reduce readmissions rates, share readmission rates, level of care concerns and processes, • LTACs, Home Health, Hospice, DME and other stakeholders in this transition of care community approach.

5. HISTORY OF READMISSIONS • Los Alamitos Medical Center looked at readmissions each month and found 4(four) trends: • Patients came back within 15 (fifteen) days. • Patients did not have physician appointments, method to get to the appointment, or finances to get their medications. • Patients had left the SNF and were at home, felt poorly, called 911 and were brought to the Emergency Department. • This group quickly realized that patients and health care providers did not know the details of care, indications, insurance coverage, restrictions, etc. of the other healthcare providers. The group was comprised of entities working in silos without seeing the wholeness of the continuum of care with the patient and family at the center. The group has developed, built trust and increased attendance and members. They have created a patient clinical pamphlet that explains entities from SNF to DME and hospice. • After a readmission, we began to examine what happened in the patients’ life that we may have missed. Education in the community for both patients and health care providers is paramount to becoming astute in detecting and interceding in patient care to decrease readmissions. • We began interviewing patients who were readmitted to determine what had caused their return to the hospital: • Change in Medical condition exacerbation of symptoms • Medication management • Lack of caregiver support /appropriate level of care

6. Components of Group • The ongoing theme was to further analyze the readmission process and seek to develop key focuses that would reduce the readmission rate. • The CAD coordinator presented her role of specifically following any patient in the hospital that had a diagnosis related to CHF, and cardiac disease. • The hospital offered classes on site and in the community to patients and staff from the local SNF’s, opened to the community through providing ongoing classes to the community. These classes would provide education to the community. • The group set up agendas that are geared toward looking at the risk factors that would pre-exempt an admission to the acute care facility. • Evidence suggested that the patient was not aware of resources and levels of care available nor did the acute care hospital know what each facility or service post discharge could provide.

7. Classes Offered Sample of Classes (Available by e-mail) Congestive Heart Failure Congestive Heart Failure Tests Medications Nutrition Core Measures Exercise Activity Coping Coronary Artery Disease Coronary Artery Disease Tests Medications Nutrition Exercise and Activity Coping after a Heart Attack Core Measures and CAD

8. Community Follow-Up • Each service was to provide education at the community meeting to educate the group on what services were provided. • Members of the group were invited to ongoing educational sessions via the web thru IHI (Institute for Healthcare Improvement). • The group reviewed the high risk form which allowed provider to anticipate the risk of readmission. • Each organization was asked to prepare an outline of services provided to their specific population.

9. Agencies • The Skilled Nursing Facility presented on what services were provided in the facility. • Home Health did a presentation on telemonitoring in the home. • The outcome of these two presentations educated the group that there was a lack of communication when transferring a patient to one level of care to another. • The next step was to set up a written and verbal report to key personal at the next level of care to provide continuity for improved patient care (hand off communication). To the SNF, exam the impact. • The group examined the timeliness of arrival to the SNF and the impact and risk of late admissions.

10. Agencies • Hospice presented on available services, criteria for admission and the ability to evaluate the patient at all levels of care. • The outcome of their presentation led to engaging a physician to speak at the next monthly meeting on Palliative Care. • Each month the group presented statistics on their readmission rates in order to continue to evaluate what went wrong that required the patient readmission.

11. Developing a Brochure • Evidence suggested that there were resources available to prevent the readmission. • A plan was made to develop a brochure that could be utilized to educate all health care providers and patients and their families. • Once completed this brochure was introduced to the community, doctors offices and presented to HSAG as tool for best practice.

12. Health Services Advisory Group • A member of HSAG (Health Services Advisory Group) coalition was asked to present information on the Long Beach coalition as we served the outlying communities. • The two groups began to interact to formulate continued efforts. • One of the areas was to examine the patient arrival time to the SNF suggesting that the later the patient arrived the more likely the patient was at risk for readmission due to securing medications and starting therapeutic measures such as rehabilitation therapy.

13. Pharmacy Consultant • A speaker from the SNF included a Pharmacy consultant who presented on the effects of late arrivals and securing medications. • LAMC also presented a brochure containing information for the patient and family educating on all pharmaceutical issues.

14. Involving The Community • Two physicians participate in the group as well as the regional CMO of Tenet California region. • The CMO has presented information on readmissions and the impact to the acute care facilities. • The group also engaged a Home Health Care (HHC) medical director to speak regarding his efforts to prevent readmissions . The physician provided information on his interventions with the HHC agency. His ability to go and see the patient at home rather than the patient being sent to the ER. • The main factor is lack of concrete support adds to the risk of readmission. Noted is the patient and family need immediate attention to resolve what appears to be their crisis and lack of a service to fix the problem expressed.

17. Readmission Case Management • LAMC attended the Preventing Readmissions meeting at Torrance Memorial Hospital. • Their group has added a Preventing Readmission Case Manager who is assigned to the ER. • A speaker presented to LAMC to incorporate the process at LAMC. • Code 30 was initiated where the Case Manager would evaluate any patient admitted to the ER within 30 days.

18. Post Discharge Calls (for CHF) Patient Name: ________________________ Name: _______________________ Date of call: __________________________ Good (morning, afternoon, evening), I am _________________________, a staff member from Los Alamitos Medical Center and I’m calling to follow up on your stay with us and make sure all of your questions have been answered. • How have you been feeling? • Are you taking your medications as prescribed by your doctor? • Do you have any questions about your medications or side effects? • When is your follow-up doctor appointment? • Has Home Health come to see you? Follow up Item Re #1: • Are you on home oxygen? ____________________________________________________ • Do you have a breathing machine? ______________________________________________ • Are you doing the treatments? _________________________________________________ • Any problems with the equipment or doing the medications? _________________________ • Do you use an inhaler? ________________________________________________________ • When do you see the specialist? ________________________________________________ • Are there any other questions you have or do you need any other assistance or information?” ___________________________________________________________________________ • How are you sleeping at night? _________________________________________________ Comments: _______________________________________________________________________________________ Pt. Account #: ____________________________ D/C Date: ____________________________________________

19. Successes • Recent admission from the ER to the SNF. • Patient placed in SNF from HHC. • Overall readmissions scores reduced. • A weekly meeting has been established at LAMC to monitor readmissions from week to week and will be presented to the monthly group focusing on the root cause analysis of the patient readmission. • Next Step: Focus on the Pneumonia Readmissions – Follow Up Calls • Evaluate the SNF ability to provide higher levels of care related to IV Lasix , IV solumedrol. • Providing an education program to the SNF by the Respiratory Department.

20. Components of Mini-RCA • Chief Complaint • Reason for initial admission and reason for readmission. • Time of day for readmission, day of week • What services were in place prior to readmission – LTAC, SNF, HH, Transition Coach, Telephonic Care, Area Agency on Aging, community services • Include reports from these providers as appropriate • Who was contacted/involved prior to the call to the MD? • Did you follow a protocol, if so which one? • What interventions were provided prior to sending to the ED?

21. Components of Mini-RCA (Cont) • Did you use an SBAR with the MD? • What specifically happened prior to patient coming to the hospital? • Was it a 911 call? • Was PCP follow-up visit completed prior to the readmission? If yes, # days post initial hospital DC. • Med reconciliation, discrepancies, Rx filled. • What support person does the patient have. Does the family understand the needs of the patient? • Did you ascertain the wishes of the patient at the time, palliative care discussion/consult?

22. Components of Min-RCA (Cont.) • Code status • Is patient appropriate to return to the prior level of care? Is a higher level of care indicated? • Was readmission avoidable. If yes, what are recommended actions to prevent this in the future?

23. Tool Kit Resources

24. READMISSION DATA

25. What Have We Accomplished Major result has been the interface with multiple community organizations which has resulted in the primary focus of reduced readmissions goals • CHF Teaching – Community Outreach: SNFS – Interdisciplinary approach • Pharmacy Interventions – In-house – Outpatient • Rehabilitation – Choosing the correct level of care. • Respiratory programs” Community Outreach – SNFS – interdisciplinary approach • Education – Levels of Care • LTAC • Acute Rehabilitation • SNFs • Home Health Care • Physicians • Durable Medical Equipment • Financial – Medi-Cal • Hospice • Palliative Care • What we have learned and the results • Participate in TRAC Team • Code 30 (Forms on Educational Table) – Developed by Fountain Valley

26. CONCLUSIONS Improvements Next Steps Address the new two added diagnosis COPD Orthopedic

27. Josh Luke, Ph.D., FACHEFounder, The National Readmission Prevention Collaborative Contact: joshluke@nationalreadmissionprevention.com NRPC So Cal Readmissions Update October 16, 2014