Strategies to Prevent Rehospitalizations in Post-Acute Care

1. Strategies to Prevent Rehospitalizations in Post-Acute Care

2. Strategies to Reduce Re-Hospitalization • Change in Condition Monitoring • Thursday Triage with at Risk List/Alert Charting System • Advanced Care Management • 72 hour Care Management Model • Four Pillars of Care • Improved clinical outcomes • IDT Collaboration • Leveraging technology • Use of Amalga Operating System for data analysis • EMR 2

3. Change in Condition Monitoring Thursday Triage with At Risk List/Alert Charting System • Patients at Risk for Re-hospitalization • All patients/residents assessed as at risk must have alert charting • Alert charting must include VS, SBAR Note if COC, information specific to reason for the risk • Alert charting each shift • All new admissions are considered at risk for re-hosp 3

4. Advanced Care Management SBAR: Interact II* tool developed to improve nurse communications to physician Stop and Watch: Interact II* tool developed to improve nurse communications to physician Disease Specific Training: Developing expertise throughout the clinical team Care Management Meeting: IDT bedside visit within 72 hours of patient admit *Evaluation of INTERACT II - Funded by the Commonwealth Fund : Co-Principal Investigator: Dr. Gerri Lamb - Independence Foundation and Wesley Woods Chair Associate - Professor of Nursing Emory University 4

5. Comprehensive assessment per status change Early identification of a change of status Improved documentation around changes in clinical status Enhanced communication among healthcare providers Four Pillars of Care 5

6. Leveraging Technology Rehospitalization LC Summary This view shows the LivingCenter year to date percentagerate of rehospitalizations, the day of the week in which most of the rehospitalizations are occurring and the number of days they are in the LivingCenter before being rehospitalized 6

7. Questions 7