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Thinking Differently about Hospital Readmissions
Presented by Glenna Yaroch, MBA,PTOwner/President
Home Instead Senior Care
September 12, 2014
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Senior Care Continuum
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Nutrition Medication Management
Doctor Appointments
Warning Signs
Four Areas of Focus
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Personal Side of Care
Knowledge
Compliance
Meeting Basic Need
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Richmond, VA
Re-Admissions Study
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Partner with large for-profit hospital system• 55 patient pilot study• Primary diagnosis – Heart Failure• 30 Day plan of care
GOAL: Reduce hospital readmissions by 1%
Pilot Study
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• Risk assessment done on each patient who had heart failure based upon their risk factors
• Categorized patients level of care
- Decided on hours of care based upon the assessment
• Care plan created on all patients upon discharge
Risk Factors and Assessment
Limited
Moderate
Significant
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Follow-Up Physician
Visit Assistance
Nutrition Management
Warning Signs Monitoring and
Notification
Medication Management
Care Management with Patient
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• Hospital readmission rate overall dropped 23.5% (16% to 12.5%)
• Total hours based on patient need and additional care available (81-100 hours)
• Able to fill gap in education and compliance
Outcome
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Livonia, MI
Glenna Yaroch
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• July 2012 to November 2012 with 2 non-profit hospitals- Hospital #1 part of the tenth largest national healthcare system in the U.S. and is a 304 bed acute care community hospital- Hospital #2 is a 220 bed medical/surgical hospital
• 30 Patient Study• Primary diagnosis – CHF (Heart Failure) and COPD• 30 Day plan of care (Day 1 is discharge from
hospital)
GOAL: Reduce unnecessary hospital readmissions within the first 30 days of discharge while improving patient self-reliance
Test and Goals
Pilot Study
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• Main focus on patient-centered goals with action plans- Functional goals: drive, grocery shop, wedding, garden
• A care consultation to be done in the hospital with Home Instead Senior Care, to determine patient specific needs- Build trust, clarify discharge instructions, understand the program
• Base 30 day planWeek 1: one
hour of service for five visits
Week 2: one hour of
service for four visits
Week 3: one hour of
service for three visits
Week 4: one hour of
service for one or two
visits
Model
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Teach-Back Show-Me Method
• Patients remember and understand <50% of what clinicians explain to them
• The model must shift from patient education to patient engagement
• Critical components for success:• Medication management (reconciliation from discharge)• Appointment with Primary Care Physician (first week
home)• Diet (salt)• Monitoring vital signs (blood pressure, weight, fluid
intake)• Warning signs (red flags – red, yellow, green zones)• Organization of medical records in the home
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Outcomes
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Person-centered solutions to reduce hospital readmissions