Winthrop University Hospital Home Health Agency

1. Winthrop University HospitalHome Health Agency Strategic Planning: Acute Care Hospitalization 2005-2006

2. Hospital based agency located in Mineola, NY Consists of CHHA and LTHHCP Active patients: 450-500 on CHHA and 150 on LTHHCP Average number of weekly admissions=>100

3. 8th Scope of Practice • Participated in 2005 Pilot Project • Goal: Reduce Acute Care Hospitalization • Plan: Decrease National average of 27.9% (12/00-12/04) • Decrease NY State <38.8%

4. Organizational Change • Utilize PDCA Methodology • Form a CQI Committee • Review factors relating to increased ACH rates • Develop an Action Plan • Educate our front line=professional staff

5. OBQI Data on Acute Care Hospitalization

6. Communication • All levels of staff involved • Introduced at Mandatory Staff meetings • Follow-up monthly at the team level • Multi-disciplinary Approach • New hires educated during orientation

7. Communication • Key to change within the organization • Effects both the culture and the way we deliver care • Open lines of communication both upwards and downwards • Leadership “buy in” is essential

8. Plan of Action • Intake coordinators perform a risk assessment • At SOC RN assesses risk factors for rehospitalization • Appropriate disciplines placed • Patient’s educated and provided with “Emergency care Plan”

9. Emergency Care Plan • On Call # (516) 663-0333 • RN Name/#______________ • ___________________________ • Supervisor________________ • **CALL the RN if the patient is hospitalized • Emergency Care Plan • This plan outlines what to do in case of an emergency. Please keep this information where you can find it. • Our agency has nursing staff on call 24 hours a day including nights, weekends and holidays.

10. Plan of Action • Educate pt on s/s disease process • MSW for supportive counseling and planning • Education of on-call RN’s in “how to prevent re-hospitalization” • Implementation of telemonitoring

11. Telehealth • Implemented in 10/05 • NY State DOH Grant • Currently 59 patients on program • All diagnostic groups (mainly cardiac) • Both CHHA and LTHHCP’s • Participating in IPRO/HCA 2006 Telehealth Demo

12. Telehealth Data1/06-7/06

13. Quality Monitoring • Utilization of Clinical Guidelines (10 diagnosis) • Participate with our hospital in “Get with the Guidelines” • Focused clinical record reviews • Track/trend results to share with staff/administration/board • Revise forms/tracking tools accordingly to facilitate outcomes

14. Quality Monitoring and Education • Share results of ACH record audits with managers/staff • During monthly team meetings educate staff on OBQM data • Quarterly collaboration with our hospital to provide supportive data to prevent rehospitalization

15. Future Plans • Expand the telemonitoring program • Correlate data from telehealth to determine if ACH rate decreases • Mentoring of professional staff to educate patients on “how to access” our on-call system to prevent a return to the hospital • Continued implementation of Best Practices to improve all patient outcomes

16. Key to Successful Outcomes # 1 • Ongoing communication with administration/physicians/staff to improve communication • Further development of educational tools and technology to improve practice • Strong commitment to involving the entire “Team” in the Quality Improvement Process