Transforming Healthcare

1. Transforming Healthcare Nancy M. Strassel Senior Vice President Greater Cincinnati Health Council

2. Where Are the Connections? • 270,000 discharges • 1 in 5 patients readmitted • We can do better

3. Laser Focus • 18 hospital learning collaborative • Reduce heart failure readmissions • Improve transitions of care • Know who our patients are – equity in care

4. These 5 areas are targeted for high risk CHF patients in support of the ACT Hospitals. Readmission Reduction and Care Transitions Standards (T5) • Upon admission implement a risk assessment tool with a focus on Heart Failure to identify patients who are at high risk of readmission considering social factors • Include a comprehensive assessment of the post hospital needs • Use the teach-back method during the hospital stay from admission to discharge during key clinical interventions. • Provide real-time handover communications (IHI, 2011) • Provide patient and primary care givers a patient-friendly post-hospital care plan which includes a clear medication list • Provide customized, real-time critical information to the next clinical care provider(s) • For high risk patients, have a clinician call the individual(s) listed as the patient’s emergency contact to discuss the patient’s status and plan of care as applicable • Address timely physician follow-up (appt to occur within 5-7 days of discharge) • Either schedule follow up physician appointment for the patient, provide scheduling info to the patient or sit with the patient while they make the appointment prior to discharge – appointment should be tailored to the care giver’s schedule (include primary care specialist and therapy appointments if possible) • Follow up with the patient or primary care giver (or emergency contact) within 48-72 hours of discharge via telephone or home visit. Adopted by the ACT Leadership on 10/12/11 from a variety of sources including Project BOOST, STAAR and IHI.

5. Chart Reviews and Patient Interviews • 36% had a follow-up appointment scheduled prior to discharge (6/7/12 sample) • 52% did not call a health professional for guidance before being readmitted (10/18/12 sample) • 39% made and/or kept appointment within 7 days (4/11/13 sample)

6. Care Transitions – New Approaches • 5 hospitals, Health Council, COA • Christ, Mercy FF, Jewish, University, Clinton • Patient coaching and empowerment model • Two-year contract with CMS • RESULTS: Baseline of 25% to a current readmission rate of 15.2% (coached patients)

7. Equity in Care • Standardized categories and methodology for the collection of patient race, ethnicity and language data • Data integrity standards • Spread to primary care practices • 56% collecting all three fields (REL) to 100% • LEP improvement project underway

9. What Did We Learn? • One model doesn’t fit all • Focus on entire continuum of care • This is not linear work • IT has to integrate into the work processes • Leadership and grassroots group needed to drive change • Power of patient interviews; test staff perceptions • Measure! • Pull in physicians to be part of the dialogue • Build on common ground with post-acute providers • Data delays can be a challenge

10. Questions Thank You………. www.gchc.org Nancy Strassel, SVP nstrassel@gchc.org