Risk Assessment - What are we Learning?

1. Risk Assessment- What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH Presented by Washington State Hospital Association Safe Table, 7/10/13

2. Background • Pierce County Community – Readmission Reduction pilot project (August 2012) • Research for Readmission Risk Tools • Adapted a tool from Mary Naylor’s readmission risk tool • Started using it in April, 2013 • Goal • Risk assessment on 100% of patients • Implement Care Management Strategies related to risk Presented by Washington State Hospital Association Safe Table, 7/10/13

3. Tool Presented by Washington State Hospital Association Safe Table, 7/10/13

4. Process • Care Management assessment within 48 hours of admission • Readmission Risk Score Completed and Documented in Epic • Risk Score listed on hospital censes • Case Manager prioritizes patients according to scores • Care Conference arranged • Referrals Made • Discharge Report sent to PCP including Readmission Risk Score • PCP offices prioritizing their patients follow up phone calls based on readmission risk score Presented by Washington State Hospital Association Safe Table, 7/10/13

5. Intensive Readmission Risk • Care Conference • Evaluate Skilled Nursing Facility versus Home Health • Referrals • Palliative • Social Work • Pharmacy Medication Reconciliation • Community Referrals • Follow up appointment made for patient to be seen by PCP within 2 days • Care Management Discharge Summary Completed Presented by Washington State Hospital Association Safe Table, 7/10/13

6. High Risk Readmission Risk • Care Conference Recommended • Evaluate Skilled Nursing Facility versus Home Health • Referrals to Consider • Social Work • Palliative • Community Referrals • Follow up appointment made for patient to be seen within 2 to 4 days • Care Management Discharge Summary Completed Presented by Washington State Hospital Association Safe Table, 7/10/13

7. Medium Readmission Risk • Evaluate Skilled Nursing versus Home Health • Community Referrals • Out patient palliative care consult for goal setting • For CHF assess for Heart Failure Clinic follow up • PCP appointment for follow up within 5-7 days • (Unless patient is cognitively impaired, patient would arrange their own follow up appointment. CM to confirm that appointment is made) • Care Management Discharge Summary Suggested Presented by Washington State Hospital Association Safe Table, 7/10/13

8. Low Risk Readmission Risk • Skilled Nursing versus Home Health • Community Referrals • For CHF assess for Heart Failure Clinic follow up • PCP follow up within 7-10 days • (patient to make unless cognitively impaired) • PCP to determine if Palliative Consult needed • Care Management Discharge Summary not required Presented by Washington State Hospital Association Safe Table, 7/10/13

9. Lessons Learned • We had to add the ability for MD, Social Worker, Case Manager to score higher at their discretion (Example Trauma patients) • Adjust the scores as they overlapped Presented by Washington State Hospital Association Safe Table, 7/10/13

10. Validation • Review readmitted cases weekly and do chart review to • Validate the effectiveness of the tool • Identify education and training opportunities Presented by Washington State Hospital Association Safe Table, 7/10/13

11. Next Steps • Continue to monitor validity of the tool • Maintain risk assessment completed on 100% of admission • Revise the tool as necessary per the findings Presented by Washington State Hospital Association Safe Table, 7/10/13