reducing hospital readmission

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  1. Issue and trends evidence for change
    • national readmission rate for medicare pt is 18-18.5%
    • one in nine hospital admission is readmission
    • 25% of medicare pts return to the hospital within 30 days
    • 64% fall within the immediate 7 days of post op disch (not stable to go home or disc to a place that was not safe)
    • 90% of medicare readmission is unplanned
    • 75% of medicare readmission may be preventable
  2. issue con't
    • hospitalization is extremely expensive
    • hospitalization inpt care accounts for 3% of total healthcare
    • estimated annual impact of 30 day readmission for medicare is 17 billion
    • 2/3 medicare pts who are readmitted die with a yr (chronic health and multi chronic health)
    • Initiative are working- safe with pt education
  3. causes of readmission
    prelim findings
    • medicare clients with multple chronic condition incr risk for readmission (CHF ie)
    • 29-47 % of elderly with HF are readmitted within 3-6 mons of disc
    • African americans with DM, asthma, or stroke are likely to be readmitted
    • end stage renal disease to have above average readmission (DM, HTN, hyperlipidemia)
    • hospitlization contributes to deterioration of patient health status and quality of life
    • lack of f/u calls by pcp/nurse and/or timely f/u to visit pcp
  4. causes con't
    • adverse events within 30 days usually related to medication mismanagement, poor coordination and continuity (don't know much about meds)
    • not understanding disch/transition instructions or inability to self manage (bc we rush pt and they just want to go home)
    • the lack of seamless communication and information exchange bw the providers and care settings (hospitalist and pcp) (know when to call md)
    • socialization: pts with multi-chronic diseases may have up to 16 different providers
    • missing a consistent plan for recognizing and responding to red flags (don't know who they should go to PCP v ED)
    • we need to coordinate care so we can all have the same information
  5. causes: summary
    • inadequate quality of care: we are not where we shoulc be)
    • inadequate transition: are we communicating vna ex
    • lack of resources
    • lack of seamless communicate- talk to each other
  6. incentives for change
    • oct 2012 centers for medicaid and medicare services began penalizing hospitals with the highest readmission rates: nearly 2000 hospitals...280 million dollars
    • affordable care act 2012 will not allow hospitals to bill for readmissions within 24 hr of disc
    • hospt hardest hit: those that care for the elderly and vulnerable (lower income higher risk)
    • kaiser health news report: NY NJ, DC, mass, illinois, ark, kentucky, and miss, are most at risk
  7. *** five ways to reduced readmission
    • 1. inc medication management: talk to pts about their meds at every opportunity
    • 2. pt education (nurse role): every opportunity we should teach. teach back method
    • 3. regular and consisitent f/u: f/u pcp 4-7 days
    • 4. home care services:
    • 5 real time monitoring (tele-health)
  8. *** continous quality improvement
    • similar to the nursing process using multidisciplinary approach (team)
    • organizations with highest quality service with capture the greatest share of health care market (best pt satisfication will get more customers)
    • emphasis on meeting/exceeding expectation of consumers (pt satisfaction) goal
    • preventing problems, resolving issues and constant scrutiny for improvement (always looking for improvement)
    • evidence based plan: clinical research, quality improvement data, expert opinion- researched based
  9. Case manager
    • improve quality of care
    • doesn't provide direct care to pt
    • cooridinate and communicates pt care to also help cuts cost
    • eds, using communication and available
  10. case managements
    • case manager can be a nurse, social worker or designated health care professional
    • assumes responsibility for the coordination of client care from admission to after disch
    • establishes a plan of care with the client, coordinates consultation/referrals, pt education and facilites disch
    • consults and collab with interdisplinary team
    • advocates for clients and families
    • acts as liaison bw the doctors, specialized care, ins company
    • decre duplication and fragmentation in care
  11. clinical pathways
    • all members of the team use this
    • ie COPD- u know what nursing, respiratory
    • based on expert opinion, research etc- every knows the plan
    • facilites continuity of care
    • help to streamline charting
    • encourages documentation across multidisciplanary team
    • maintains quality control measure
    • can be monitored for variances
    • helps to cut cost
  12. best practices for reducing hospital readmission
    • efforts should target better care cooridation: case managers at community sites communication with hospital team in first 2 days following disch
    • a. pt assessments
    • b. reconcile meds- admission and dc
    • c. multidisciplinary f/u: pcp, pt, VNA
    • d. ensure f/u with pcp 4-7 days
    • improve disch planning: smooth hand off or transition between and among care sites
    • a. plan in place at first admission- nursing notes
    • b. prescrip and refill rx prior to disch
    • c. schedule f/u appt
    • d. web-portal to informa pcp of pts admission and track progress incr communication
  13. best practices evidence cont's
    • identifying high risk pts and increasing the number of home visit immediately following disch
    • a. care and disease management- talk about dx
    • b. identify barriers- to learning
    • c. support pt self management
    • d. ensure every pt has an emergency plan posted at home call 911 (do u know red flags)
    • e. post disch f/u call within 72 hr and ongoing prn (24-48)
    • further study: plans for indiv populations: evidence based solutions
    • pt education
  14. role of the nurse
    • pt education and transition
    • 1. timely well designed teach back
    • 2. disch planner/case manager
    • 3. improve compliance, health literacy, self management
    • 4. medication management
    • 5. encourage engagement. post acute f/u appts/phone calls
    • 6. in home caregivers: enhance multidisciplinary communication
    • 7. thorough individualized referrals
    • 8. demostrates-include family in car
  15. role of the nurse
    • real time monitoring high risk seniors and individuals chronic illness
    • recognizing and responding to red flags: care pathways/maps and early warning tools
    • SBAR communication: situation, background, assessment, request tools
    • continued quality improvement
    • a. improve outcomes
    • b. improve pt satisfication
    • c. address cost
  16. *** SBAR
    • Situation: who is the pt? what is the admitting dx, chief complaints
    • backgroud: hx, relevant hx, story, allergies
    • assessment: vital signs, relevant labs, mental status, activity, iV, meds pain
    • recommendations: d/c plan, pt ed. consults, admiss- d/c, pending orders
  17. last role of nurse
    • interact: interventions to reduce acute care transfers
    • quality improvement program focused on the management of acute changes in resident condition
    • includes: clinical evalutation tool. and strategies for every day practices in LTC
Card Set:
reducing hospital readmission
2015-09-27 16:47:11

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