safe transitions north memorial using society of hospital medicines boost toolkit to improve patient...
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Safe Transitions Safe Transitions North Memorial North Memorial
Using Society of Hospital Using Society of Hospital Medicine’s BOOST Toolkit To Medicine’s BOOST Toolkit To
Improve Patient & Family Improve Patient & Family Engagement Engagement
2010 NMR Data2010 NMR Data
Readmits w/in 30 days = 3,452Readmits w/in 30 days = 3,452 Unique Patients Readmitted = 2,249Unique Patients Readmitted = 2,249 Readmits w/in 72 hours = 654Readmits w/in 72 hours = 654 ED visits w/in 30 days = 2, 273ED visits w/in 30 days = 2, 273 ALOS 1ALOS 1stst visit = 4.13 visit = 4.13 ALOS 2ALOS 2ndnd Visit = 4.23 Visit = 4.23
Digging A little Deeper - CHFDigging A little Deeper - CHF
474 CHF patients 474 CHF patients 574 Hospitalizations574 Hospitalizations 22% Home Health Referrals22% Home Health Referrals 7% Seen by Cardiologists Within 7 days 7% Seen by Cardiologists Within 7 days 12% Seen by NM Primary Care Clinics 12% Seen by NM Primary Care Clinics
Within 7 daysWithin 7 days
MRN Patient Unit Room
PTA Meds - 2 = At Risk
(See Footer)Living
Situation
Prior Hospitalizations in Last 3
Months Primary Prob Phone # Primary Care Provider579099 Testpatient A (73 y.o. M) A6 A680 2 0 2 Gi Bleed (Principal Prob) 763-555-1234 PREBONICH, M (763-520-2980)
2127710 Testpatient B (54 y.o. M) A6 A681 2 5 1 Seizure (More) 952-555-1234HENNEPIN FACULTY ASSOC, (612-347-6449)
2950 Testpatient, C (74 y.o. M) A6 A683 2 0 0Sepsis Secondary To Lll Pneumonia (Principal Prob) 763-555-2345 KRIEGER, D (763-587-7900)
1595169 Testpatient, D (69 y.o. M) A6 A684 2 0 0 Atrial Fibrillation Or Flutter (More) 763-555-3456 LAGER, R (763-520-2980)592956 Testpatient, E (75 y.o. M) A6 A685 2 0 0 Htn (Hypertension) (More) 763-555-4567 FRANE, G (763-504-6400)72095 Testpatient, F (90 y.o. M) A6 A687 2 0 0 Atrial Fibrillation (More) 763-555-5678 NOONAN, D (763-420-1900)
598609 Testpatient, G (93 y.o. F) A6 A688 2 5 0Chest Pain, Unspecified (Principal Prob) 651-555-1234 UNKNOWN, M
295097 Testpatient, H (62 y.o. F) A6 A689 2 0 1Nstemi (Non-st Elevated Myocardial Infarction) (Principal Prob) 763-555-6789 SORENSEN, P (612-302-8200)
259096 Testpatient, I (69 y.o. F) A6 A690 2 0 0 Syncope And Collapse (Principal Prob) 763-555-7890 VINCENT, P (763-504-6500)296795 Testpatient, J (67 y.o. F) A6 A693 2 1 1 Lobar Pneumonia (Principal Prob) 763-555-8901 SHEFFELS, A (763-420-1900)
250608 Testpatient, K (88 y.o. F) A6 A697 2 2 [senior apt] 1Ckd (Chronic Kidney Disease) Stage 3, Gfr 30-59 Ml/min (More) 763-555-9012 SICORA, J (763-425-1888)
#PTA Meds: 0 = Less than 3, 1 = 3 - 5, 2 = More than 5Living Situation: 4 = Lives Alone, 5 = Nursing Home/Residential Care, 10 = Caregiver for Spouse or Family
A6 Daily Report
Who Are Our Patients At Risk For Who Are Our Patients At Risk For Readmission?Readmission?
Patient and Family EngagementPatient and Family Engagement
White BoardsWhite Boards Serve as a Serve as a
communication tool.communication tool. Used by all disciplines Used by all disciplines
and patient/family.and patient/family. Helps care team and Helps care team and
patient/family focus on patient/family focus on goals.goals.
Patient and Family EngagementPatient and Family Engagement
Patient/Family Patient/Family Centered RoundsCentered Rounds Identification of high Identification of high
risk patientsrisk patients Rounding script used Rounding script used
to develop plan for to develop plan for hospitalization and hospitalization and safe transition to safe transition to home. home.
Patient and Family EngagementPatient and Family Engagement
Follow-Up Follow-Up Appointments Appointments
Teach Back & Patient Teach Back & Patient Education Materials Education Materials
Medication Medication ReconciliationReconciliation
Home Health Phone Home Health Phone Call 24-48 hours post Call 24-48 hours post dischargedischarge
Palliative Care Palliative Care OptimizationOptimization
Family Care Family Care ConferencesConferences
Teach Back & Patient EducationTeach Back & Patient Education
Patient Education At BedsidePatient Education At Bedside RN conducting education rather than nurse RN conducting education rather than nurse
educatoreducator Teach Back added as methodology for patient Teach Back added as methodology for patient
educational assessmenteducational assessment Teach Back regarding medications & Teach Back regarding medications &
discharge instructionsdischarge instructions CHF Binder used during Teach Back and to CHF Binder used during Teach Back and to
build redundancy between hospital and clinicbuild redundancy between hospital and clinic
Did Someone On Hospital Staff Explain The Purpose Of The Medicines You Were To
Take At Home In Ways You Could Understand?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1st Q 2nd Q 3rd Q
A-6
A-5
Hospice
Did The Hospital Staff Include Your Family Or Someone Close To You In
Discussions About Your Care?
34%
36%
38%
40%
42%
44%
46%
48%
1st Q 2nd Q 3rd Q
A-6
A-5
Hospice
Key LearningsKey Learnings Follow up appointment compliance in 7 days tripled Follow up appointment compliance in 7 days tripled
by assisting in coordinating appointmentsby assisting in coordinating appointments Need the same tool for risk stratification across Need the same tool for risk stratification across
systemsystem Need system staffing model to support care Need system staffing model to support care
coordination across enterprisecoordination across enterprise Need community to help in preventing Need community to help in preventing
hospitalizationshospitalizations Need to "un-teach" how to conduct Teach Back Need to "un-teach" how to conduct Teach Back Need learning environment to help support change Need learning environment to help support change
efforteffort
Questions??Questions??
John Degelau, MDJohn Degelau, MD [email protected]
Sonne Rivers, BSN, MASonne Rivers, BSN, MA [email protected]
Society of Hospital MedicineSociety of Hospital Medicine http://www.hospitalmedicine.orghttp://www.hospitalmedicine.org