Proven Strategies for

Reducing Readmission Rates

Earl Parker, Chief Operating Officer, Commonwealth Senior Living

Sandi Flores RN, President, Sandi Flores Consulting Group

(consulting VP of Resident Care to Commonwealth)

Commonwealth Assisted Living (CAL) Hospital Readmission Summary

Commonwealth Total (All Communities)

Beginning

(4th Qtr. 2014)

Current

12 Month Average

(2nd Qtr. 2015–1st Qtr.

2016)

Most Recent

Month –

April 2016

Hospital

Readmission

Percentage*

21.4% 12.1% 6.7%

Readmission

Rate per 1000

Resident Days

.44 .18 .10

*CAL percentages calculated by using: Number of Resident 30-day Hospital Readmissions/Number of

Resident Inpatient Hospitalizations

Reducing Rehospitalization Rates

As with most things, we believe that success is a

combination of PEOPLE and PROCESSES.

I am going to share with you a few things that we feel

have helped us to assure our PEOPLE are the right people,

in the right roles, and that they have the right focus.

Sandi is going to then share with you some of the

PROCESSES that have helped our PEOPLE to be successful.

CORE Values are built into all that we do C.        OVERALL RATING:

6Models the core values extremely well

Low Job Skills

8Models the core values extremely well

Average to Solid Job Skills

HIGH

(7-9)

3Does not always model the core values

(average)

Low Job Skills

5Does not always model the core values

(average)

Average to Solid Job Skills

MED

(4-6)

1Poor example of core values

Low Job Skills

2Poor example of core values

Average to Solid Job Skills

LOW

(1-3)

LOW (1-3) MEDIUM (4-6) HIGH (7-9)

JOB SKILLS

V

A

L

U

E

S

9Models the core values extremely well

High Job Skills

7Does not always model the core values

(average)

High Job Skills

4Poor example of core values

High Job Skills

Combined with Noble Purpose

Our Noble Selling Purpose:

We improve the lives of seniors, their

families, and each other.

These are our key behaviors:

We listen.

We love.

We care.

We serve.

Hearing from our front line

We Care About People We Speak Up!

Prepare to Reduce Readmissions

1. Resident Care Systems (service planning/change in condition/incident review)

2. Staff competency

3. Tracking Data

4. RN availability for “case management”

Initiating Interventions

1. Medication reconciliation

2. Disease management basics (Multi-department)

3. Physician communication (Inter-facility Transfer Tool)

4. Mastering the process of prepping for the return from acute care (Care

Coordination Form and Process)

5. Medical professional assessment within 7 days of discharge

6. On going analysis (Not just data collection alone)