Shawnee Mission Medical Center
Kim Fuller, MSW, MBA, CCE
Janet Ahlstrom, MSN, ACNS-BC
Selected populations:
Congestive Heart Failure
Pneumonia
Acute Myocardial Infarction (AMI)

IHI Collaborative on Reducing Readmissions in
2009/2010.
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Developed multidisciplinary internal team to
participate in the Collaborative and to begin
designing program.
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Did chart reviews of readmissions to assess
patterns, failure points, potential interventions
and conducted tests of change.
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Discovered many readmissions coming back from
SNF’s, so invited key partners to join
Collaborative.
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Split internal team and external community
partner group into separate meetings.

Justified initial addition of an FTE by quantifying
potential cost to the bottom line following
implementation of CMS penalties.

Hired .5 MSW and .5RN and Transition Coach role
fully implemented in August, 2011.
 Enhanced
Admission Assessment for Post
Hospital Needs
 Effective
Teaching and Enhanced Learning
 Real
– time Patient and Family Centered
Handoff Communication
 Post-Hospital
Care Follow Up
 Membership
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includes:
Nursing representation from cohort areas for
CHF, AMI and Pneumonia.
Pharmacy
Social Work/Utilization Review
Ask a Nurse Call Center
SMMC Home Health
Cardio-Vascular Services
Nursing Education
 Membership
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includes
Home health
Skilled nursing facilities
Assisted Living Facilities
Hospice
Private Duty
LTAC
Emergency Medical Response

Case studies of readmissions from various
facilities, identifying breakdowns and creating
new processes.

Education re: disease specific protocols provided
to SNF’s. i.e. importance of daily weights and
use of the zone chart for CHF patients.

Development of common hand off tool that
meets needs of hospital and external agencies.

Strategies to increase involvement of palliative
care and hospice when appropriate.
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Education about national movement toward use
of Transportable Physician orders for End of Life
treatment wishes.

Development of special interest sub-committees
to concentrate and problem solve issues that are
unique to different settings.

Trend readmission data specific to various
agencies/facilities to use in forming stronger
community partners with those that have lower
readmission rates.
Shawnee Mission Medical Center
Melanie Davis-Hale, LMSW
Cathy Lauridsen, RN, BSN
 0.5
Social Worker/ 0.5 RN
 Identify high risk patients in hospital
 Initiate individualized program
 Follow for 30 – 45 days regardless of setting
 Facilitate smooth TRANSITIONS
 Early intervention with any readmissions
 Meet weekly with physician champions at
SMMC
 Provide education for patients and
healthcare team partners
 Currently
utilizing the Better Outcomes for
Older adults through Safe Transitions
(BOOST) Tool
 Collaborative
Care Team (CCT) process at
SMMC
 Chart
review of Electronic Medical Record
8P screening tool:
 Problem Medications –(anticoag, insulin, aspirin, digoxin)
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Punk (depression) - screen positive or diagnosis
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Principle diagnosis – COPD, cancer, stroke, DM, heart failure
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Polypharmacy - >5 or more routine meds
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Poor health literacy - inability to do teachback
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Patient Support – support for d/c and home care
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Prior Hospitalization - non-elective in last 6 months
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Palliative Care – pt has an advanced or progressive serious
illness
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Initial contact with patients/family during the
hospitalization.

Schedule follow-up PCP/Specialist appointment
prior to hospital discharge.
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Follow patient across all levels of care for up to
45 days post discharge.
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Phone/in person home visits.
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Continually assess patient needs post discharge.
 Medication
 Follow
 Patient
management
up with PCP/Specialist
centered record
 Knowledge
of Red flags and how to respond
 Develop
a relationship with patient and/or
family prior to hospital discharge
 Identifying patients’ healthcare goals
 Matching patients to Social Worker or RN
based on patient needs
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Financial needs
Psycho-Social needs
Community resources
Patient/Family/Caregiver Education
Facility/Service Provider Education
Symptom management
 Interventions
to prevent readmission based
on patients’ discharge plan
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Visit/phone call to patient, patient’s nurse, social
worker, PT/OT, Medical Director.
 Ensure patient has seen Medical Director within 72
hours
 Identify medication issues/concerns/changes and
other areas of symptom management.
 Awareness of patient discharge plan from facility
Maintain communication with patient’s PCP/specialist
Prepare patient for transition to lower level of
care/home
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Collaborate with Home Health Agency/Case Manager
to develop care plan to prevent readmission
Ensure patient attends follow-up PCP/specialist
appointment
Continue post-discharge education to
patient/family/caregiver
Identify medications issues/concerns
Identify and referred to needed services
Encourage self-management when possible
 Identifying
patients that will code out as
CHF, Pneumonia, AMI
 Continually
educating service providers on
role of transition coach
 End
of life issues
August 2011 - December 2011
Total # of Patients Followed by Transition Coaches
Total # of Medicare Patients Discharged from SMMC
154
141
60
50
42
15
7
CHF
PNA
AMI
Other DRGs
SMMC CHF Readmission Rates
August 2011-December 2011
Non-Transition Coach
Transition Coach
47% (8/17)
38% (5/13)
35% (8/23)
31% (4/13)
25% (7/28)
17% (4/23)
17% (2/12)
13% (1/8)
0% (0/9)
August
September
0% (0/8)
October
November
December
SMMC PNA Readmission Rates
August 2011-December 2011
Non-Transition Coach
Transition Coach
100% (1/1)
33% (1/3)
23% (6/26)
17% (1/6)
23% (3/26)
11% (3/27)
0% (0/2)
August
September
10% (3/30)
0% (0/17)
October
0% (0/3)
November
December
SMMC AMI Readmission Rates
October 2011-November 2011
Non-Transition Coach
Transition Coach
23% (3/13)
0% (0/3)
October
0% (0/4)
November
25% (0/4)
Where Transition Coach Patients Readmitted From
August 2011-December 2011
SNF
30%
Home Health
40%
Home
30%
Pt originally admitted to
hospital for:
Pt admitted from:
Pt discharged to:
Readmission reason:
PNA
Home
SNF
Dehydration
CHF
Home w/ Home Health
SNF
CHF
CHF
SNF
SNF
CHF
CHF
Home
Home w/ Home Health
CHF
CHF
Home
Home w/ Home Health
Hemorrhage of
Gastrointestinal
CHF
Home w/ HH
Home w/ Home Health
Transient Cerebral
Ischemia
CHF
Home
Home w/ Home Health
A-Fib
PNA
Home
Home
Mitral Valve Disorder
CHF
Home
Home
CHF
PNA
Home
Home
Pulmonary Embolism

Kim Fuller
913-676-2293
 Kim.fuller@shawneemission.org
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Janet Ahlstrom
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913-676-2032
Janet.ahlstrom@shawneemission.org
Cathy Lauridsen
913-676-8611
 Catherine.lauridsen@shawneemission.org
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
Melanie Davis-Hale
913-676-2168
 melanie.davis-hale@shawneemission.org
