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

Nutrition Medication Management

Doctor Appointments

Warning Signs

Four Areas of Focus

Personal Side of Care

Knowledge

Compliance

Meeting Basic Need

Richmond, VA

Re-Admissions Study

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

• 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

Follow-Up Physician

Visit Assistance

Nutrition Management

Warning Signs Monitoring and

Notification

Medication Management

Care Management with Patient

• 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

Livonia, MI

Glenna Yaroch

• 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

• 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

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

Outcomes

Person-centered solutions to reduce hospital readmissions