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July 2012
Your hosts: Jody Rothe, MetaStar Stephanie Sobczak, WHA
Thank you to these organizations for sponsoring this webinar series:
A special thank you to the Wisconsin Clinical Resource Center for serving as the home base for recorded webinars and materials related to the INTERACT II collaborative
Readmissions in Wisconsin Overview of INTERACT II Convening a Team Measuring Case Review Tools Data Entry 30 day Action Items
Please be sure your phone lines are muted to keep background noise to a minimum.
Help patients heal without complication.
Reduce all hospital readmissions by 20%
Which means
1.6 million patients will recover from illness without
suffering a preventable complication requiring re-hospitalization within 30 days of discharge.
In one yearin Wisconsin
nearly 30,000 people experienced a
potentially preventable readmission
10,000 more residents will fall asleep on their own pillow.
Care is not interrupted Nursing Homes, Hospitals and Home Health
all work together for what’s best for the patients/residents.
Hospital Type
To Home To SNF To Home Health Agency
Other
Wisconsin PPS26,219
13,617 6,831 3,768 2,003
Wisconsin CAHs2,339
1,379 501 133 326
All Wisconsin Hospitals28,558
14,996 6,332 3,901 2,329
30 day All Cause, All Cases Readmissions to various sites(Medicare Beneficiaries only)
What past experience do you have in actively working on reducing readmissions to the hospital?
We have worked with other local organizations (hospitals, home health, community organizations, etc.)
We have worked on internal process improvements for many months
We’ve just started working on internal process improvements
We have not formally worked on reducing readmissions.
Invite & send
Agenda to Webinar/Conferenc
e Call
30 day Tasks
2 or 3 things to
try
Touch base
Survey
Serves as reminder
Learning Content
&
Interaction or
Guests
Interim Coaching, Reminders and Support
Data Submissio
n&
Analysis
Day 30
Day 15-ish
Day 10
Day 1
July Overview & Case Review Tools
August Communication ToolsSeptember Early Warning ToolsOctober Change in Condition ToolsNovember Resident Transfer ToolsDecember Continuous Improvement
Tools
Focused on Long-Term Care settings specifically
It is evidence based standard of practices It is proven to work It is a toolkit that can be customized to your
facility
http://interact2.net/
1.Is a charge nurse on your team?2.Are at least two staff members
involved in direct resident care on your team?
3.Can you have a social worker or admission/discharge planner on your team?
17
Organizer
Meeting Convener
Data Reporter
Can someone ensure there is a room to meet in with a phone, and a screen when needed? Print materials? Put dates on calendars?
Can someone help define meeting topics and planned discussions?
Can someone gather data for display? Can some be in charge sending data to Megastars?
18
Documenter
Implementation Leader
Can someone track tests of change and decisions on adopting tools?
Can someone help determine when and how to write the P & P and when and how to train others?
What type of representation is on your INTERACT II team?
Primarily organization leaders and managers
Managers only Managers and front-line staff together Mostly front-line staff and a manager
Three things are required for success:1. Attendance on calls –
Will be based on webinar login by facility
2. Submitting data – Outcome and Process measures Send data collected by the end of the month
3. Trying out and testing the tools in between monthly webinars.
21
Aims
Measurement
Change ideas
Testing ideas before implementing changes
Plan:
Systematically Review the past 5 hospital admissions or ER transfers.
Are there common occurrences across the sampled residents?
From this review, can you summarize what your team would like to accomplish in the next 6 months?
AIM Statement:
Are there any questions so far?
Collecting data doesn’t have to be complicated
It can be extracted from your electronic record keeping systemOR
A team member, or two, can take on a task of keeping track of each hospital admission or ER transfer
Date # Hospital Admissions
# ER Transfers
Data Collector
7/12/12 0 2
7/13/12 0 0
7/14/12 1 0
7/15/12 0 1
This can be kept track of DAILY or WEEKLY
Need to track improvement to enhance the learning
Answers: “How do we know these changes have made a difference?”
Shows were improvements can be targeted.
Tracking Hospital Admissions and Transfers to ER per month.
Number of Admissions & Transfers
July Aug Sept Oct Nov Dec
20
15
10
5
0
Linking Improvement to Interventions
Number of Admissions & Transfers
July Aug Sept Oct Nov Dec
20
15
10
5
0
SBAR Trial Stop & Watch
Tools Trial
Change in Condition Tools
Are you currently tracking your readmission rate or number of transfers to the hospital/ER?
YesNo
https://www.metastar.com/web/custom/WiQCINTERACTdataentry.asp
This is a secure web page provided by MetaStar for this INTERACT II collaborative
Determine your data tracking method Determine who will enter the data on the MetaStar
website. Team members will receive an e-mail with secure
login information (will be sent by July 19th) Data should be entered by the 30th of the month
for the month prior (example: submit by July 30 for June data)
Aggregate data will be posted to the WCRC website.
You should track your own data from month to month
This will be your CMS provider number
This will be sent to you from MetaStar (via e-mail)
1. Case Review Tool2. Example check sheet for data collection3. Graph format for posting4. Dr. Ouslander’s slides:http://innovations.cms.gov/Files/slides/rahnfr_hospitalizations_slides.pdf
https://wcrc.chsra.wisc.edu
Review 5 cases of transfers or readmissions from hospitals
Use the tool to analyze the factors leading to the readmission
Plan your team gatherings Begin collecting data
An on-line Feedback Tool will be send after August 1st to assess your progress on these tasks.
Thank you!
See you next month
Next month: Communication Tools
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