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Inspiring Improvement:

Creating an Ideal Transition Home

Susan Seeman, Director of Strategic Initiatives

Goldie Luong, Director, Special Projects

Vancouver Acute Services, VGH

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Breakthrough Strategy

Matching capacity &

demand

Reducing Readmissions

Ideal Transition Home

Initiative

How do we

reduce readmissions?

VCH – Vancouver’s True North Goals &

Strategic Priorities

How do we match

capacity to demand

to provide

best care?

3

Ideal Transition Home Initiative Problem Statement

• Our readmission rates have increased

from 8.9%(FY08/09) to 9.7%(FY10/11)

• Implemented iCARE on Medicine Units

which identified:

o a lack of standard processes associated

with discharge/transition planning

o an opportunity to improve linkages with

community partners to support the plan

of care after discharge

o sporadic communication and

engagement with family physicians when

their patients were admitted coupled with

minimal involvement in discharge plan

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Ideal Transition Home initiative Goals

• To improve the patient and family

experience and provide quality care

by implementing 4 key

recommendations from the Institute

for Healthcare Improvement (IHI).

• Areas of focus:

o Improve core discharge planning and

transition processes out of acute care

o Improve transitions and care

coordination to primary and community

care providers

o Enhance patient coaching, education,

and support for self management

Some members of our ITH team

representing allied health, nursing,

transition services, physicians and

care management.

Creating an Ideal Transition Home Process

Process Tools

Enhanced

Admission

Assessment

for Post

Hospital

Needs

Effective

Teaching and

Enhanced

Learning

Real-time

Patient and

Family-Centred

Handoff

Communication

Post Hospital

Care Follow

Up

1. iCare Admission Assessment 2. Readmit Risk Score 3. Readmit Risk Factors/Mitigation 4. Readmit Interview

1. Standardized patient transition (discharge) instructions-My Discharge Plan

1. Book follow up appointments

2. Follow up call

% of patients with

risk assessments

completed within 48

hours

% of patients who

can teach back >

two thirds of

content taught

% of time transition

plan transferred

with patient

% of patients with

scheduled follow up

appts before

discharge

1. Chronic Disease

Action Plans 2. Teach Back

methodology 3. Acute to

community learning plans

Real-time Quality Measures

Enhanced

Admission

Assessment

for Post

Hospital

Needs

Real-time

Patient and

Family-Centred

Handoff

Communication

Post Hospital

Care Follow

Up

Effective

Teaching and

Enhanced

Learning

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Ideal Transition Home Initiative Update Phase 1- Implemented on 250 Medicine beds

Within 48 hours of admission:

Readmission Risk assessment

score initiated (early identification

of patients at moderate to high risk

for readmission)

Readmission Risk mitigation

checklist initiated (standardized

interventions)

Hospitalization notice faxed to GP

in community

Referral sent to community for

moderate and high risk clients

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Ideal Transition Home Initiative Update Phase 1- Implemented on 250 Medicine beds

Upon discharge:

My Discharge Plan completed and

given to patient/family and faxed

to community and community GP

(discharge notification fax)

High risk patients - Follow up GP

appointment made prior to

discharge for 48 hours post

discharge

Moderate risk patients - Follow up

phone call to patient/family by

Care Management Leader 48 hrs

post discharge

Readmission interviews with

patients and families

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Ideal Transition Home – Phase 2 Enhance Coaching, Education and

Support for Self Management

IHI Recommendations:

• During the acute care hospitalization only essential

education is recommended

• Focus on key need-to-know points (not nice-to-know)

• Emphasize what the patient should do, what action to

take

• Use Teach back to ensure learning

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Coaching and Education Focus

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Primary &

Home Care and

Specialized

Clinics

Creating the Ideal Transition

Chronic Disease Action Plan

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My

Chronic

Disease

Action

Plan

Teach

back

Next Page

My Discharge Plan

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My Discharge Prescription

Get Well Soon

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16%

51%

33%

Patient Risk Level

Low Moderate High

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• 302 Discharged Patients

– 49 Low Risk Patients

– 155 Moderate Risk Patients

– 98 High Risk Patients

Getting to Know the ITH Population

How are we doing?

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Period

Readmissions as a % of Total Discharges from iCare Units

Readmission Rate Readmission (Pre Pull/Partial iCARE Impl)

Readmission (Post Pull/Partial iCARE Impl) Readmission (Post IHT)

CIHI Readmission Rate CIHI Readmission (Pre Pull/Partial iCARE Impl)

CIHI Readmission (Post Pull/Partial iCARE Impl) CIHI Readmission (Post IHT)

iCare ITHPull Strategy / Partial iCARE Impl

iCARE readmissions as a % of total discharges decreased 0.5% (0.9 beds per day) pre

and post ITH implementation, which is 3.5% reduction; and it decreased 2.2% (3.9 beds

per day) based on CIHI readmissions methodology (unplanned and related diagnose).

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Notification of thepatients admission

TIMELY

Easy to find contactinformation on

nursing or the MRP

Clear about your role in the patient’s

discharge

Easy for you/youroffice to see thepatient urgently

90%

70%

90% 90%

10%

30%

10% 10%

Preliminary Results: Primary Care Physician Interview: Ideal Transition Home

Patients

YES NO

Feedback from GPs

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Receive dischargesummary in timely

manner

Done anythingdifferently toimprove the

standard of care ormake your

participation easier

Recommend thisnotification process

Other suggestionsor observations

90%

20%

90%

10% 10%

80%

10%

90%

Preliminary Results: Primary Care Physician Interview: Ideal Transition Home

Patients

YES NO

Feedback from GPs

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• Community Care services need faster response times to

receive the demand from acute

• Community GPs really like the process, want this

throughout the hospital

• Unit audits show the importance of compliancy with

process and standard work

• Weekly pareto analysis determines themes and action

plans for readmissions – Chronic Disease Action Plans

Lessons Learned

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Patient Experience

From Mrs. P. (61 y.o. female, admitted to VGH 10

times in 2011 and twice in 2012, multiple chronic

health conditions)

“After coming back again to VGH, it was nice to

speak with someone at the hospital who was

familiar with my story and who was going to try to

help me to spend more time at home with my

grandchildren.”

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Team Experience

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“The biggest difference I have seen since the

implementation of the ITH initiative is the

seamless transition from hospital to home. The

focused education on My Discharge Plan and

the increased communication at discharge with

patients encourages them to be involved in their

care. This initiative is truly demonstrating

continuity of care.” –Denise Kendrick, OT

Appendix

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GP

Hospital

Notification

Form