LEAN HEALTHCARE - OAHHS · LEAN HEALTHCARE: Readmission Pioneer ... Jean McCalmont, RN Care ... •...
Transcript of LEAN HEALTHCARE - OAHHS · LEAN HEALTHCARE: Readmission Pioneer ... Jean McCalmont, RN Care ... •...
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LEAN HEALTHCARE: Readmission
Pioneer Memorial Hospital
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About Us
Pioneer Memorial Hospital
• Prineville, Oregon
• Critical Access Hospital
• Part of St. Charles Health System
Prineville
Madras
Bend
Redmond
St. Charles Health System
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Our Lean Project
Readmission What: Create a standard Readmission Risk Assessment tool Why: Evidence Based Best Practice Aim: By June 30, 2014, all patients hospitalized at PMH will be assessed for their social and medical risk for readmission during their hospitalization. Outcome Measure: All patients hospitalized at PMH will have their risk for readmission assessed on admission. Original Process Measures:
1) Number of patients discharged that had their medical and social risk for readmission assessed during hospitalization.
2) Number of patients that had their risk for readmission re-assessed daily
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Project Team
Team Members & Roles
Holli Holland, Director Home Health Angie Taylor, Case Manager Redmond
Claudia McDonald, Case Manager
IMCU Bend
Emily Salmon, Program Manager
Medical Home
Janice Pendroy, Clinical Education
Coordinator
Jen Laughlin, DO; Hospitalist Medical
Director
Marian Morris-Fox, Case Manager
Madras
Teresa Parsons, RN Care Coordinator
SCMG Prineville
Verneene Fox, Case Manager
Prineville
Jean McCalmont, RN Care
Coordinator, Mosiac Medical,
Prineville
Darlene Henderson, Quality
Improvement Coordinator, Prineville
and Madras
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Define
• Current SCHS standard for planning post-hospital care is to schedule a follow-up office visit prior to discharge
• One “Top Ten” action to reduce preventable readmissions is a formal assessment of readmission risk followed by aligning the post-hospital care interventions to the readmission risk
• This approach to planning care after hospitalization is expected to mitigate a patients risk for readmission and improve their transition to home or a community setting
Baseline Data
total number of readmissions 7
number of patients that had follow-
up apointment scheduled before
discharge
4
number of patients hospitalized
day of or before planned follow-
up visit
3
October and November 2013
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Measure Voice of Customer • Reason for follow-up office visit not always clear – this leads to “guessing” reason when making the appointment • Primary Care providers not always aware of hospitalization • “Next available appointment” may not be within desired parameters for follow-up visit • Patient, family and caregivers not included in scheduling • Current process for planning care after discharge is a “one size fits all” • No process to schedule appointments for evening, weekend or holiday discharges
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Analyze
Evidence Based Best Practice
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Improve
Main point
Test of change #1
Test of change #9
Test of Change Summary: •Gap analysis of 6 different Readmission Risk Assessments • Decided on IHI Risk of Re-hospitalization from How-to Guide as starting point •Replaced teach back with assessment of health / disease state as teach back not commonly used at SCHS •Added section to annotate daily re-assessment •Added section to identify Primary Care Provider •Added section to include patient specific notes
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Control
Weekly Measurement Monthly Measurement
Monthly updates and status reports:
• Med Surg Caregivers
• Readmission Improvement team
• PMH Leadership
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Spread of project
The SCHS Readmission Team continues to meet to: • Track completion of Readmission Risk Assessment at time of admission and daily • Spread Readmission Risk Assessment to Madras, Redmond and Bend • Plan, test and implement post-hospital care specific for each level of risk • Plan, test and implement a standard workflow to:
1. Communicate Readmission Risk to primary care provider at time of admission
2. Include Community Providers in planning post-hospital care
3. Include patients, family and caregivers in planning post-hospital care
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Sustainability of project
Test of Change #11 Second page added that outlines the recommended follow-up care for each level of risk
Test of Change #12 Testing flow that will “pull” patient into Community Provider’s care
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Advice to Others & Lessons Learned
• Improving across a “system” of 4 unique campuses can be slow but yields good results
• Including the Community Provider voice at the table was important
• Need the right team members and access to decision makers
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QUESTIONS?
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Contact Information
Darlene Henderson Quality Improvement Coordinator
Pioneer Memorial Hospital and St. Charles - Madras
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