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Improving Processes to Reduce Readmissions - Domain II SBH Health System/ Bronx Gardens Nursing Home Manisha Kulshreshtha, MD FACP Associate Medical Director SBH Health System January 23, 2018

Improving Processes to Reduce Readmissions - Domain II · Improving Processes to Reduce Readmissions - Domain II SBH Health System/ Bronx Gardens Nursing Home Manisha Kulshreshtha,

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Improving Processes to Reduce Readmissions - Domain II

SBH Health System/ Bronx Gardens Nursing Home

Manisha Kulshreshtha, MD FACP Associate Medical Director

SBH Health System

January 23, 2018

Background

SBH is a not-for-profit, nonsectarian, 422-bed,acute care, 911-receiving hospital that holdsstate designations as a Level II trauma center,stroke center and AIDS center.

The hospital’s emergency department hasnearly 100,000 visits annually.

SBH Medical/Surgical Units

All units approximately 30 beds Geographic distribution of clinical staff Each unit with one Case Manager/ one Social

Worker Multidisciplinary WhiteBoard Rounds weekdays Physicians, Social Workers, Case Managers, Nursing,

Clinical Pharmacist, Physical Therapists, Nutrition, Unit Clerks

Bronx Gardens- Center for Nursing & Rehabilitation - Overview

199 Beds

Certified Ventilator/ Tracheostomy Unit

Certified HIV/AIDS– Discrete Care Unit

IV Antibiotic & TPN Therapy

Methadone Maintenance

Bronx Gardens- Center for Nursing & Rehabilitation

• 567 Admissions - 2017

• 30 Day Re-Hospitalization Rate ~ 15%

Process

• Monthly interdisciplinary meetings between Bronx Gardens NH and SBH Health System

• Aim Statement• Process Flow Map• Challenges• Interventions

Hospital to SNF Process Flow Map

SBH Ideal Discharge to SNF Process Map

SH PfP OOml n 1 Kty~S 11'11 Ruouten tor tn,ap11 Plt1tnt

11'1d car. Partner

Assess tr.e potient's and are p1rtntr's dts1rts, 11ndtrst1nd1np and tlljl«tatioos of cl>• curr.nt ptan of cue, as w~tl as any po~ntoal Ml<I cart sattoncs Reconcile the care plan developed collaboratively with the rts1dtnt and family/care partnu

-Goals Of Trlntftr FttdbK~ from SNF t? hose tal i! netdtd ~ tn. patitnt 1rr1111 safe~>

Dots tht p1t11nt's pr.Jtnullon reflect tilt inform at.on Y-"' rtcti\oed> WIS adnuSJIOG !W'Olt 111 order Wtre medocation orders cornet> IS patitnt and/or 11111111' lcart 1W1r!Nr) 11:.sfltd w<tll IM lnl"llltlOtl,

Challenges

• Timely communication• SNF transfer documentation

• Medications• Code status

• Hospital discharge summary documentation• Medications• Required follow up

Challenges

• Mental Health & Substance Abuse• Weekend Communication with SNF• Patient/ Caregiver expectations &

engagement• Palliative Care • Health literacy/ patient responsibility• Accurate, actionable and timely readmission

data

Ongoing Interventions

• Multidisciplinary Whiteboard Rounds• ED readmission – hard stop• Identification of Nursing Home Physician on

admission – hard stop• Admission medication reconciliation – hard

stop• Discharge medication reconciliation – hard

stop• LACE score• LLOS >4 days weekly meetings

Ongoing Interventions

• Readmission Risk Tool• ACM readmission tool• Teachback• Multidisciplinary discharge document• Multidisciplinary meetings for high risk

patients• ED Case management

White Board Rounds

Discharge Planning Magnets

• DC Pending today

• DC Planned for tomorrow

Core Measures Magnets

AM I

c CHF

p Pneumonia

St roke -

Surgical Srte Infection

Other Magnets

I Check blood glucose levels

Readmitted within 30 days of last discharge

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Identifying PCP on Admission

,. **HP! rJ rrrJ I Adult Internal Medicine H&P

Adult Internal Medicine H&P !11:.

• PFSH ~ Patient Admitted On I 06 I 11 I 2014 ~©:D .ill I 20 : 43 ~I

• .,.ALLERGIES History Obtained from P' patient r family member r friend r co-worker

• ADVANCE DIRECTIVE rJ r nursing home trar1Sfer form r inter facility transfer personnel r trar1Slatar

• VITAL SIGNS

• SCREENING rJ r police r history unobtainable

• HN Screening D Chief Complaint I feel sick

• IMMUNIZATIONS ~ Headache

• ROS

• PE

• BODY IMAGES

• .,.ORDERS, RESULTS, OMP

• ASSESSMENT

• u !! FACULTY/ ATIENDING STATE

14

Attribute

L ength of Stay

A cute admission

C omorbidity:

(Comorbidity points are cu mulative to

maxim.um of 6 points)

E mergency Room visits

during previous 6 months

Value

Inpatient Obs.ervation

No rior histo DM no oom lications Cerebrovascular disease Hx of Mii PVD PUD Mild liver disease, DM with end organ damage, CHF, COPD, Cancer, Leukemia, I m homa, an tumor, cancer, moderate to severe renal dz

Dementia or connective tissue disease Moderate or s,evere liver disease or HIV infection

Metastatic cancer

0 visits 1 visits 2 visits 3 visits

4 or more visits

Take the sum of the · oin,ts and enter the total +

Prior Prese,nt p,oints Admit Admit

0 1 2 3 4 5 6

3

0

0 1

2

3 4 6

0 1 2 3 4

WT(kg): HT(cm): BMl: GIOLlP & Rh: LACE Score: l Preferred Languag~ ENG

Patient l ist Ord en M Vtt!W Vis1t Record

C4Jrrent Lisi. I~~ Tool [• ' Select Aii Patients 5 Visit(s)

ledicaid Prior Priof C..-e

ED Vi:5its in pilSt 6 mo... Hospil.t"auliorn In pa... Management Progr<llll5 Bet\aviofal.IS ubstance

Abuse Health bwe

Sav'" ~erected Patitr1ts .••

Chronic Hcalthkwc

Admit Ox:

Alltt"gies: No Known A!le191~

Polyf

Multidisciplinary Meetings

Top 50 readmitted patients identified:

Multidisciplinary meetings/RCA – involving PCP, Care transitions team (SW, CM), specialist, ED, hospitalist, clinical pharmacist, ambulatory care

Fifteen patients reviewed – work in progress

Work list – High Risk Patients

• Patient Name• Patient ID/Visit Number= Medical record number/Account Number unique to each visit• Birth Date• Current Location= Unit and Room number• Admit Date=Date of admission to the hospital• Visit Reason= Health Issue for visit• Medicare = Medicaid number of applicable• Medicaid= Medicare number if applicable• Prior ED visits in past 6 months= Number of visits to SBH ED in past 6 months• Prior Hospitalizations= Number of hospitalizations at SBH in past 6 months• Care Management= If currently being managed by Health Home• Behavioral/ Substance abuse= Documentation of either in health issue (ICD-10 codes)• Chronic Health issue= Documentation of chronic health issue (ICD-10 codes)• Health Home Eligible= Criteria of health home as documented by health issues (ICD-10 codes)• Polypharmacy=8 or more active medications in prescription writer• Primary Care Provider= Name of listed PCP

New Interventions

• Face to Face Hospitalist & Nursing Home physicians meeting

• Contact information exchange• Warm hand off – MD to MD prior to

discharge• Warm hand off – RN to RN using

SBAR prior to discharge

New Interventions

• Clear documentation on discharge summary of required follow up

• Circle back call as needed if discharge plan/ medications unclear or with discrepancy

Referrals/ Interventions

Risk Factor Category Referral/ Intervention

Medications Clinical Pharmacist Referral

Psycho-social Barriers/ Clinically Complex Social Work Department Nursing/Clinicians

Financial Barriers Credit Department

Nutritional Limitations Nutrition Department

Nursing/CliniciansLimited Patient Understanding/ Health Literacy Mental Health/ Substance Abuse Psychiatry/ Addiction Medicine Referral

Palliative Care Palliative Care Referral

30 Day Potentially Preventable Readmission Rate

Readmission Data

Year Readmission Rate (Internal – all cause, all payors)

2011 14.26%2012 13.82%2013 12.26%2014 12.24%2015 11.29%2016 10.85%2017* (Jan-Nov) 10.99%

Readmission Rates

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

2011 2012 2013 2014 2015 2016 2017 (Jan-Nov)

Readmission Rate – Internal (all cause, all payors)

Readmission Rate

Next Steps

• Data collection• Warm handoff• Circle back calls• Readmission rates for SNF population

• More frequent MD face to face meetings• Continue SBH Health System/ Bronx Gardens

NH meetings