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

Readmission Track

Board

Robert Zubrod, Director Clinical Resource Management

ESD Readmission Trackboard

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ESD Visit 30-Day Assessments: Percent by Reason

Emergent 35.9% Dialysis 34.5% Medication Issues 9.9% Non-adherence with treatment / lifestyle plan 8.5% Inability to

• btain MD

follow-up 7.6% Other 6.6% Funding / Financial issues 3.9% Inadequate support system 3.1% Discharge planning 2.8% Surgical Complications 2.6% Health care knowledge gap 2.5% Failure of outside providers / vendors 1.2% Transportation Issues 0.9%

DY3

(Oct 13 – Sept 14)

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ESD Visit 30-Day Assessments

EMERGENT NON-ADHERENCE WITH TREATMENT / LIFE STYLE PLAN 68.5% 31.5%

Related diagnosis Unrelated disgnosis

19.0% 81.0%

Patient likely did NOT understand treatment/life style plan Patient likely did understand treatment/life style plan

INADEQUATE SUPPORT SYSTEM MEDICATION ISSUES 43.2% 44.2% 12.6%

Housing Caregiver Nutrition

3.8% 18.7% 1.1% 33.5% 35.7% 7.1%

Difficulty obtaining medication from PHHS pharmacy Patient cannot afford copay-medications Prescription sent to the incorrect pharmacy Non adherence- medication plan Other medication issues-not funding Medication refills Page 4

ARC Referrals from the ESD: Sept 14 – Mar 16

103 120 211 208 260 200 303 370 437 543 541 651 619 698 637 680 690 675 787 9 15 20 23 16 24 34 46 57 66 66 85 73 95 87 128 92 101 57 1 4 4 5 2 2 12 9 11 13 19 23 5 14 14 22 17 15 11

100 200 300 400 500 600 700 800 900

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Volume ESD Admitted Linear (Volume )

* *

*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

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Inpatient Admission/ESD 30 day presentation percentage with All-Cause Readmission Feb 14 – Sept 14

41.9% 39.5% 32.1% 24.9% 25.4% 27.8% 24.6% 27.8% 9.6% 9.3% 9.1% 8.5% 8.7% 8.7% 8.4%

8.0% 8.2% 8.4% 8.6% 8.8% 9.0% 9.2% 9.4% 9.6% 9.8% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%

Feb Mar Apr May Jun Jul Aug Sep

30-Day ESD Assessment All Cause Readmission % Linear (30-Day ESD Assessment) 157 / 565 99 / 403 200 / 477 211 / 534 184 / 574 122 / 489 143 / 563 146 / 524

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ESD Visit 30-Day Assessments: Percent by Reason

Emergent 35.9% Dialysis 34.5% Medication Issues 9.9% Non- adherence with treatment / lifestyle plan 8.5% Inability to

• btain

MD follow-up 7.6% Other 6.6% Funding / Financial issues 3.9% Inadequate support system 3.1% Discharge planning 2.8% Surgical Complications 2.6% Health care knowledge gap 2.5% Failure of

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providers / vendors 1.2% Transportation Issues 0.9%

DY3

(Oct 13 – Sept 14)

DY4

(Oct 14 – Sept 15)

Emergent 48.9% Dialysis 32.0% Non Adherence with life style plan - Psych 6.2% Non Adherence with life style plan – Medical 3.4% Surgical Complications 3.2% Medication issues 2.9% Inability to

• btain MD

follow-up 1.2% Inadequate support system 1.2% Discharge planning 0.5% Funding issues 0.3% Outside provider or vendor issues 0.2% Transportation Issues 0.1%

DY5

(Oct 15 – Sept 16)

Emergent 57.0% Dialysis 24.9% Non Adherence with life style plan - Psych 7.6% Non Adherence with life style plan - Medical 4.9% Surgical complications 1.4% Medication issues 1.2% Inadequate support system 1.2% Inability to

• btain MD

follow-up 0.7% Discharge planning 0.3% Transportation 0.3% Outside provider or vendor issues 0.2% Funding issues 0.2%

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Number of ARC Follow-up Appointments Scheduled Directly from the ESD

100 103 120 211 208 260 200 303 370 437 543 541 651 619 698 637 680 690 675 787 674 783 785 834 1046 1100 1094 1113 1111 1158 1049 1200 1136 1186 1075 1173 1073 1093 1135 1156 1212 1162 1168 1254 1352 1444 1433 1457 1474 1433 1444 1381

200 400 600 800 1000 1200 1400

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

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All-Cause Readmission Percentage

9.6% 9.1% 9.0% 8.4% 8.7% 8.4% 8.2% 8.7% 8.8% 8.7% 8.8% 7.9% 9.3% 9.8% 9.5% 8.2% 7.9% 9.3% 8.7% 7.7% 7.7% 7.7% 7.7% 7.2% 8.1% 7.8% 7.4% 7.9% 7.0% 7.2% 8.4% 7.2% 7.5% 7.9% 8.1% 7.3% 7.4% 7.8% 7.6% 8.2% 7.4% 7.1% 7.4% 7.5% 6.4% 7.4% 7.1% 7.1% 6.6% 7.1% 7.6% 7.2% 6.1% 5.2% 5.00% 5.50% 6.00% 6.50% 7.00% 7.50% 8.00% 8.50% 9.00% 9.50% 10.00% 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

Readmission Percentage

High ESD Utilization: Dec 2016 – Dec 2018

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

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Questions?