Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar 2016 IHI Webinar Series Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association’s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement work, particularly in the area of readmissions. She is also the clinical manager of the Tennessee Center for Patient Safety’s PSO (patient safety organization). Rhonda has worked in the field of hospital quality management since 2006 and has a clinical background in trauma, critical care, oncology, and organ donation. rdickman@tha.com 615-401-7404 1
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar Introduction to Webinar Series Exclusive program for clinical leaders in hospitals that are part of the Tennessee Hospital Association Hospital Engagement Network (HEN) Focused on supporting clinical leaders who supervise front-line staff 18 webinars in total 1.5 contact hours for each webinar Transitioning to new webinar platform How to chat 2
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to chat How to chat 3
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to chat How to chat Roll Call Please chat your name, organization, and number of people listening with you today 4
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to communicate with presenters How to make your mark 5
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to make your mark How to point to a spot 6
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to make your mark How to make your mark 7
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to make your mark How to make your mark 8
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How to answer a poll How to find materials 9
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar Kathy Duncan, RN Kathy D. Duncan, RN, Director, Institute for Healthcare Improvement (IHI), oversees multiple areas of content, directs multiple virtual multiple learning webinar series. Currently she serves as Faculty for the AHA/HRET Hospital Engagement Network (HEN) 2.0 Improvement Leadership Fellowship Ms. Duncan also directed content development and spread expertise for IHI’s Project JOINTS, an initiative funded by the Federal Government to study adoption of evidenced-based practices. In 10 US States, Project JOINTS spread three evidence-based pre-and perioperative practices to reduce the risk of surgical site infections in patients undergoing total hip or knee replacement. Previously, she co-led the 5 Million Lives Campaign National Field Team and was faculty for the Improving Outcomes for High Risk and Critically Ill Patients Innovation Community. She has also served as a member of the Scientific Advisory Board for the American Heart Association’s Get with the Guidelines Resuscitation, NQF’s Coordination of Care Advisory Panel and NDNQI’s Pressure Ulcer Advisory Committee. Prior to joining IHI, Ms. Duncan led initiatives to decrease ICU mortality and morbidity as the Director of Critical Care, Orthopedics and Neuro for a large community hospital. Peg Bradke, RN, MA Peg M. Bradke, RN, MA , has held various administrative positions in her 25-year career in heart care services. Currently she is Vice President of Post-Acute Care at St. Luke's Hospital in Cedar Rapids, Iowa, where she oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also serves as faculty for the Institute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (STate Action on Avoidable Rehospitalizations) initiative. 10
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar Gail A. Nielson, BSHCA, RT(R), FAHRA Fellow and Faculty of the Institute for Healthcare Improvement (IHI). Nielsen is the former system-wide Director of Learning and Innovation for UnityPoint Health (formerly Iowa Health System). Her current work as faculty for IHI includes reducing avoidable readmissions and improving transitions in care, leading 2-day Reducing Readmissions seminars, improving the quality of care in nursing facilities, and other assignments. Nielsen’s ten years of experience in improving care transitions and reducing avoidable readmissions began during her 1-year IHI Fellowship. Her most recent experience includes system- wide work in Iowa; four years in the STAAR initiative across three states: Massachusetts, Michigan, and Washington; and support to Hospital Engagement Networks in multiple states. Additional past areas of expertise and work with IHI includes six years on the Patient Safety faculty; four years on the faculty for Transforming Care at the Bedside; engagement and patient-centered care; reducing falls and related injuries; spread and scale-up of innovations; and ACOs-Post Acute Care. Objectives: Assess their current challenges in reducing avoidable readmissions and identify opportunities for improvement. Use proven communication methods to better understand a patient’s post -acute care needs and capabilities Make their care more person-and family-centered to improve coordination and transitions across the continuum of care Describe methodologies for clarifying opportunities for improvement from the diagnostic review Assess current challenges in reducing avoidable rehospitalizations and identify opportunities for improvement Build an effective improvement team including patients and families as well as acute, post-acute and community care partners 11
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar Action Period Assignment: Go Observe: “Be a patient” The Always Use Teach-back! Toolkit www.Teachbacktraining.org (view at least one training module and review the site). Teach Back Observation tool with one patient being taught by a nurse. (this is also in the online toolkit) Teachback: How did it go? 12
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar These presenters have nothing to disclose Developing Post- Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke March 2016 : THA Assume one of the following roles : Patient Caregiver Sending Hospital dept. Receiving SNF Hospitalist Medical Director SNF Home Care Clinic Physician Outpatient Social Worker Community Serv. Agency Chat in your ideal transition into the that setting………. (what would you need or want in that transition) 13
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar How Might We …. “….effectively communicate the plan of care (based on the assessed needs and capabilities) to the patient/caregiver and community-based providers of care?” Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org. Simply What do we know about the patient/caregiver that will help the next level provide the needed care in the transitions? How will we communicate that? Sender Role vs Receiver Role 14
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar Identifying Opportunities 29 • Visually display the patterns of return to hospital within 30 days; what questions arise? Frequency of Readmissions by Number of Days Between Discharge and Readmission 25 20 # of patients readmitted 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 # of days between discharge and readmission 15
Institute for Healthcare Improvement 3/20/2014 Reducing Avoidable Readmissions Seminar Opportunities: Observe Current Discharge Processes Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org. Identifying Opportunities (cont.) Follow a patient as they transition to a SNF facility, or home care visit. – Was the information the receiver need there? – Did the patient see/feel that information important to them had been communicated? – Where were opportunities for improvement? Interview a Primary Care Office to determine if they are receiving the appropriate information to receive the patient back in the clinic 16
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