Read admissi ssions s Reboo oot Webinar #3 January 16, 2020
A new focus on an old issue www.CynosureHealth.org
Wha hat Dr Drives es I Improvem emen ent i in R n Readmiss ssions? www.CynosureHealth.org
Drivers for r Improvement t in Readmissions Use data to inform improvement activities Improve standard hospital transitions of care Reduce Readmissions Deliver enhanced services based on need Collaborate with providers and services across the continuum www.CynosureHealth.org
Driver r #3: D Deliver r En Enhanced Services Based on Ne Need eds Palliative care Condition specific programs Deliver enhanced services based on Pharmacy interventions assessed needs of the patient Complex care management Emergency Department pause
• Additional services and supports in the time following care in your organization. • Services not provided to all patients as part of routine care. What are • Offered to subgroups identified as "high Enhanced risk" of readmission. Services? • Delivered prior to and after discharge, often for 30 days. • Deployed at provider expense to reduce readmissions. • Delivered by hospital staff or by contracted staff from other entities.
Match needs with resources • Which patients will probably do well with “normal discharge”? • Which patients need something more? • Which patients need far more? • How do you know? • What do you do? 7
How do we know which patients need enhanced services? www.CynosureHealth.org
Your Turn: How Have You Utilized Both Big and Little Data to Identify High Risk Patients? www.CynosureHealth.org
Bright Spots in the Room How are you approaching certain higher How did you find out this population need populations in your organization? needed assistance/focus?
• Community based elder care services: • Area Agency on Aging • Senior Centers • Behavioral Health Services What S Services es • Clinics, Drop in Centers • Referral Lines, NAMI Exi xist T That I Am • Social Services Not A Aware O Of? • YMCA • Shelters • Food, Transportation, Utilities Assistance, 2- 1-1
Inventory Community Resources
Finding t the B Bright S Spots
Finding t the B Bright S Spots
• What are the challenges? Palliative Care • Bright spots?
• Process to inform ED staff that this person had a prior admission • Pause to interact in-person or on the phone Emergency with a care transitions team member Department • Decision Efforts • Admit • Observation • Home with follow up What are you doing in your ED?
Lessons from the Field www.CynosureHealth.org
Many Resources Available to Guide Improvement www.CynosureHealth.org
• Readmissions Change Package • ASPIRE Guide • Trail Guide • Readmissions Top Ten Checklist • Readmissions Whiteboard Video Series • HRET-HIIN Hospital Wide Topics LISTSERV Readmissions • Huddle for Care Discussion Forum Resou ources es • IHI Improving Transitions How To Guide • BOOST – Better Outcomes by Optimizing Safe Transitions • LACE – Risk Assessment for Readmissions • Readmissions Action Planning Guide, Discovery Tool, Driver of Utilization Tool, Data Drill Down Tool, ASPIRE Interview Guide www.CynosureHealth.org
Kim Werkmeister, BA, RN, CPHQ, CPPS Thank You! Cynosure Health kwerkmeister@cynosurehealth.org www.CynosureHealth.org
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