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Improving Processes to Reduce Readmissions - Domain II
SBH Health System/ Bronx Gardens Nursing Home
Manisha Kulshreshtha, MD FACP Associate Medical Director
SBH Health System
January 23, 2018
Background
SBH is a not-for-profit, nonsectarian, 422-bed,acute care, 911-receiving hospital that holdsstate designations as a Level II trauma center,stroke center and AIDS center.
The hospital’s emergency department hasnearly 100,000 visits annually.
SBH Medical/Surgical Units
All units approximately 30 beds Geographic distribution of clinical staff Each unit with one Case Manager/ one Social
Worker Multidisciplinary WhiteBoard Rounds weekdays Physicians, Social Workers, Case Managers, Nursing,
Clinical Pharmacist, Physical Therapists, Nutrition, Unit Clerks
Bronx Gardens- Center for Nursing & Rehabilitation - Overview
199 Beds
Certified Ventilator/ Tracheostomy Unit
Certified HIV/AIDS– Discrete Care Unit
IV Antibiotic & TPN Therapy
Methadone Maintenance
Bronx Gardens- Center for Nursing & Rehabilitation
• 567 Admissions - 2017
• 30 Day Re-Hospitalization Rate ~ 15%
Process
• Monthly interdisciplinary meetings between Bronx Gardens NH and SBH Health System
• Aim Statement• Process Flow Map• Challenges• Interventions
Hospital to SNF Process Flow Map
SBH Ideal Discharge to SNF Process Map
SH PfP OOml n 1 Kty~S 11'11 Ruouten tor tn,ap11 Plt1tnt
11'1d car. Partner
Assess tr.e potient's and are p1rtntr's dts1rts, 11ndtrst1nd1np and tlljl«tatioos of cl>• curr.nt ptan of cue, as w~tl as any po~ntoal Ml<I cart sattoncs Reconcile the care plan developed collaboratively with the rts1dtnt and family/care partnu
-Goals Of Trlntftr FttdbK~ from SNF t? hose tal i! netdtd ~ tn. patitnt 1rr1111 safe~>
Dots tht p1t11nt's pr.Jtnullon reflect tilt inform at.on Y-"' rtcti\oed> WIS adnuSJIOG !W'Olt 111 order Wtre medocation orders cornet> IS patitnt and/or 11111111' lcart 1W1r!Nr) 11:.sfltd w<tll IM lnl"llltlOtl,
Challenges
• Timely communication• SNF transfer documentation
• Medications• Code status
• Hospital discharge summary documentation• Medications• Required follow up
Challenges
• Mental Health & Substance Abuse• Weekend Communication with SNF• Patient/ Caregiver expectations &
engagement• Palliative Care • Health literacy/ patient responsibility• Accurate, actionable and timely readmission
data
Ongoing Interventions
• Multidisciplinary Whiteboard Rounds• ED readmission – hard stop• Identification of Nursing Home Physician on
admission – hard stop• Admission medication reconciliation – hard
stop• Discharge medication reconciliation – hard
stop• LACE score• LLOS >4 days weekly meetings
Ongoing Interventions
• Readmission Risk Tool• ACM readmission tool• Teachback• Multidisciplinary discharge document• Multidisciplinary meetings for high risk
patients• ED Case management
White Board Rounds
Discharge Planning Magnets
• DC Pending today
• DC Planned for tomorrow
Core Measures Magnets
AM I
c CHF
p Pneumonia
St roke -
Surgical Srte Infection
Other Magnets
I Check blood glucose levels
Readmitted within 30 days of last discharge
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Identifying PCP on Admission
,. **HP! rJ rrrJ I Adult Internal Medicine H&P
Adult Internal Medicine H&P !11:.
• PFSH ~ Patient Admitted On I 06 I 11 I 2014 ~©:D .ill I 20 : 43 ~I
• .,.ALLERGIES History Obtained from P' patient r family member r friend r co-worker
• ADVANCE DIRECTIVE rJ r nursing home trar1Sfer form r inter facility transfer personnel r trar1Slatar
• VITAL SIGNS
• SCREENING rJ r police r history unobtainable
• HN Screening D Chief Complaint I feel sick
• IMMUNIZATIONS ~ Headache
• ROS
• PE
• BODY IMAGES
• .,.ORDERS, RESULTS, OMP
• ASSESSMENT
• u !! FACULTY/ ATIENDING STATE
14
Attribute
L ength of Stay
A cute admission
C omorbidity:
(Comorbidity points are cu mulative to
maxim.um of 6 points)
E mergency Room visits
during previous 6 months
Value
Inpatient Obs.ervation
No rior histo DM no oom lications Cerebrovascular disease Hx of Mii PVD PUD Mild liver disease, DM with end organ damage, CHF, COPD, Cancer, Leukemia, I m homa, an tumor, cancer, moderate to severe renal dz
Dementia or connective tissue disease Moderate or s,evere liver disease or HIV infection
Metastatic cancer
0 visits 1 visits 2 visits 3 visits
4 or more visits
Take the sum of the · oin,ts and enter the total +
Prior Prese,nt p,oints Admit Admit
0 1 2 3 4 5 6
3
0
0 1
2
3 4 6
0 1 2 3 4
WT(kg): HT(cm): BMl: GIOLlP & Rh: LACE Score: l Preferred Languag~ ENG
Patient l ist Ord en M Vtt!W Vis1t Record
C4Jrrent Lisi. I~~ Tool [• ' Select Aii Patients 5 Visit(s)
ledicaid Prior Priof C..-e
ED Vi:5its in pilSt 6 mo... Hospil.t"auliorn In pa... Management Progr<llll5 Bet\aviofal.IS ubstance
Abuse Health bwe
Sav'" ~erected Patitr1ts .••
Chronic Hcalthkwc
Admit Ox:
Alltt"gies: No Known A!le191~
Polyf
Multidisciplinary Meetings
Top 50 readmitted patients identified:
Multidisciplinary meetings/RCA – involving PCP, Care transitions team (SW, CM), specialist, ED, hospitalist, clinical pharmacist, ambulatory care
Fifteen patients reviewed – work in progress
Work list – High Risk Patients
• Patient Name• Patient ID/Visit Number= Medical record number/Account Number unique to each visit• Birth Date• Current Location= Unit and Room number• Admit Date=Date of admission to the hospital• Visit Reason= Health Issue for visit• Medicare = Medicaid number of applicable• Medicaid= Medicare number if applicable• Prior ED visits in past 6 months= Number of visits to SBH ED in past 6 months• Prior Hospitalizations= Number of hospitalizations at SBH in past 6 months• Care Management= If currently being managed by Health Home• Behavioral/ Substance abuse= Documentation of either in health issue (ICD-10 codes)• Chronic Health issue= Documentation of chronic health issue (ICD-10 codes)• Health Home Eligible= Criteria of health home as documented by health issues (ICD-10 codes)• Polypharmacy=8 or more active medications in prescription writer• Primary Care Provider= Name of listed PCP
New Interventions
• Face to Face Hospitalist & Nursing Home physicians meeting
• Contact information exchange• Warm hand off – MD to MD prior to
discharge• Warm hand off – RN to RN using
SBAR prior to discharge
New Interventions
• Clear documentation on discharge summary of required follow up
• Circle back call as needed if discharge plan/ medications unclear or with discrepancy
Referrals/ Interventions
Risk Factor Category Referral/ Intervention
Medications Clinical Pharmacist Referral
Psycho-social Barriers/ Clinically Complex Social Work Department Nursing/Clinicians
Financial Barriers Credit Department
Nutritional Limitations Nutrition Department
Nursing/CliniciansLimited Patient Understanding/ Health Literacy Mental Health/ Substance Abuse Psychiatry/ Addiction Medicine Referral
Palliative Care Palliative Care Referral
Readmission Data
Year Readmission Rate (Internal – all cause, all payors)
2011 14.26%2012 13.82%2013 12.26%2014 12.24%2015 11.29%2016 10.85%2017* (Jan-Nov) 10.99%
Readmission Rates
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
2011 2012 2013 2014 2015 2016 2017 (Jan-Nov)
Readmission Rate – Internal (all cause, all payors)
Readmission Rate
Next Steps
• Data collection• Warm handoff• Circle back calls• Readmission rates for SNF population
• More frequent MD face to face meetings• Continue SBH Health System/ Bronx Gardens
NH meetings
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