Readmission Track Board Robert Zubrod, Director Clinical Resource - PowerPoint PPT Presentation

Readmission Track Board Robert Zubrod, Director Clinical Resource Management

ESD Readmission Trackboard Page 2

ESD Visit 30-Day Assessments: Percent by Reason DY3 (Oct 13 – Sept 14) Surgical Health care Failure of outside Complications knowledge gap providers / vendors 2.6% 2.5% 1.2% Discharge planning 2.8% Transportation Issues Inadequate support 0.9% system 3.1% Funding / Financial issues Other 3.9% 6.6% Emergent 35.9% Inability to obtain MD follow-up 7.6% Non-adherence with treatment / lifestyle Dialysis plan 34.5% 8.5% Medication Issues 9.9% Page 3

ESD Visit 30-Day Assessments EMERGENT NON-ADHERENCE WITH TREATMENT / LIFE STYLE PLAN Patient likely did NOT 19.0% 31.5% understand Related diagnosis treatment/life style Unrelated disgnosis plan 68.5% Patient likely did 81.0% understand treatment/life style plan Difficulty obtaining medication from PHHS pharmacy Patient cannot afford INADEQUATE MEDICATION ISSUES copay-medications SUPPORT SYSTEM 3.8% Prescription sent to the incorrect pharmacy 7.1% 12.6% 18.7% Housing Non adherence- 1.1% 35.7% 43.2% medication plan Caregiver 44.2% 33.5% Other medication Nutrition issues-not funding Medication refills Page 4

ARC Referrals from the ESD: Sept 14 – Mar 16 900 787 800 698 680 690 675 700 651 637 619 600 543 541 500 Volume 437 ESD 400 370 303 Admitted 300 260 Linear 211 208 200 (Volume ) 200 128 103 120 101 95 92 87 85 100 73 66 66 57 57 20 16 24 15 23 34 46 * 9 19 22 13 23 14 14 17 15 11 11 4 4 5 5 * 1 2 2 12 9 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar *Pending 30 days Page 5

ER Readmission Reduction Interventions • Development of a direct ESD to ARC referral process to improve transitions of care and ensure timely post ESD discharge follow-up • Patients unable to follow the plan of care secondary to behavioral health or substance abuse issues were referred to the Peer Recovery Navigator program for evaluation and assistance • Discharge planning and transportation opportunities were referred to the Director of Care Management for review • Pharmacy related opportunities were referred to the pharmacist for review Page 6

Inpatient Admission/ESD 30 day presentation percentage with All-Cause Readmission Feb 14 – Sept 14 45.0% 9.8% 41.9% 9.6% 9.6% 39.5% 40.0% 9.4% 9.3% 9.2% 9.1% 35.0% 9.0% 32.1% 8.7% 8.7% 8.8% 30.0% 8.5% 27.8% 27.8% 8.6% 8.4% 24.9% 25.4% 24.6% 8.4% 200 / 477 25.0% 184 / 574 143 / 563 157 / 565 146 / 524 211 / 534 122 / 489 99 / 403 8.2% 20.0% 8.0% Feb Mar Apr May Jun Jul Aug Sep 30-Day ESD Assessment All Cause Readmission % Linear (30-Day ESD Assessment) Page 7

ESD Visit 30-Day Assessments: Percent by Reason DY3 DY4 DY5 (Oct 13 – Sept 14) (Oct 14 – Sept 15) (Oct 15 – Sept 16) Discharge Inadequate Discharge Health care Inadequate Funding issues Discharge Inability to planning support planning knowledge Failure of support Inability to 0.3% planning obtain MD 0.3% system 0.5% gap outside system obtain MD Transportation 2.8% Surgical follow-up 1.2% 2.5% Medication providers / 1.2% follow-up 0.3% Complications 1.2% Outside issues vendors 0.7% 2.6% provider or Outside 1.2% 1.2% Medication vendor issues provider or issues 0.2% Surgical Inadequate vendor issues 2.9% complications support 0.2% Transportation Transportation 1.4% system Surgical Issues Issues Funding 3.1% Complications Non 0.9% 0.1% issues 3.2% Adherence 0.2% with life style Non Funding / plan - Medical Adherence Financial 4.9% with life style Other issues plan – Non 6.6% Emergent 3.9% Medical Adherence 35.9% 3.4% with life style Inability Emergent plan - Psych Emergent Non to 57.0% 7.6% 48.9% Adherence obtain Dialysis Dialysis with life style MD 32.0% 24.9% plan - Psych follow-up 6.2% 7.6% Dialysis Non- 34.5% adherence with treatment / lifestyle plan 8.5% Medication Issues 9.9% Page 8

Number of ARC Follow-up Appointments Scheduled Directly from the ESD 1474 1457 1444 1433 1444 1433 1381 1400 1352 1254 1212 1200 1168 1186 1156 1173 1162 1200 1158 1113 1136 1135 1111 1100 1094 1093 1075 1073 1046 1049 1000 834 787 785 783 800 690 698 680 675 674 651 637 619 600 543 541 437 370 400 303 260 211 208 200 200 120 103 100 0 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Page 9

All-Cause Readmission Percentage 10.00% 9.8% 9.6% 9.5% 9.50% 9.3% 9.3% 9.1% 9.0% 9.00% 8.8% 8.8% 8.7% 8.7% 8.7% 8.7% Readmission Percentage 8.4% 8.4% 8.4% 8.50% 8.2% 8.2% 8.2% 8.1% 8.1% 7.9% 7.9% 7.9% 7.9% 8.00% 7.7% 7.7% 7.8% 7.8% 7.7% 7.7% 7.6% 7.6% 7.5% 7.5% 7.4% 7.4% 7.4% 7.4% 7.4% 7.50% 7.3% 7.2% 7.2% 7.2% 7.2% 7.1% 7.1% 7.1% 7.1% 7.0% 7.00% 6.6% 6.4% 6.50% 6.1% 6.00% 5.50% 5.2% 5.00% Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18

High ESD Utilization: Dec 2016 – Dec 2018 MD Follow-Up Access Prior Visit 0.2% (39) 0.1% (20) 0.3% (67) Other Discharge Plan 0.8% (183) Issue Medication 0.04% (10) 1.6% (362) Non-Adherence with Plan of Care - Medical New 6.1% (1,363) Complaint 12.9% (2,882) Barriers Preventing Completion of Previous Plan of Care - Psych 49.3% (11,029) Psychosocial 28.7% (6,429) Page 11

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