Hospital to Home:
Keeping our patients safe
IHS Leadership Symposium
Breakout Session I
April 20, 2010
Peg M. Bradke, RN, MA
St. Luke’s Hospital, Cedar Rapids, Iowa
Who Owns the Transition?
Are we placing the burden on the
patient?
 What is causing the readmissions?
Do we know?
 Are we being proactive?

Reducing Re-Hospitalizations:
Background


If re-hospitalizations are prevalent, costly, and able to be reduced,
why haven’t they been?
Hospital-level barriers


Community-level barriers


Financial disincentives (volume-revenue), no financial incentives,
not part of P4P contracts, not high on priority list, limited diseasespecific efforts
Not common to engage organizations across continuum to
collaborate on improving care, frustration between inpatient and
post-acute providers, lack of IT connectivity, no reimbursement for
coordination
State-level barriers

Lack of population-based data, lack of understanding costs of poor
quality on systems, effect of fragmented payer market and lack of
CMS participation
Need for Paradigm Shift






Traditional focus on discharging patients > facilitating
transitions in care and a shift to handoffs (senders and
receivers design the process)
Hospital Problem to Continuum issue
Focus on what clinicians are teaching > to focus on what
the patient is learning
Patient is the focus of the care team > patient and
defined family are essential members of the care team
Immediate focus on clinical needs > to a focus on the
whole person and their social situation over time
Focus on patient care needs in various settings > focus
on the patient’s experience over time
Transition to Home Team





Heart Failure team since 2001
St. Luke’s joined the Institute for Health Care
Improvement (IHI) Innovation Project for
Transitions to Home in February 2006
Work concentrated on the Heart Failure
patient to provide the “ideal” transition to home
Goal: To Improve the reliability of the care
patients receive and resultant outcomes
Worked in tandem with compliance to CMS
Core Measures
St. Luke’s Heart Failure Continuum



Standardized care through order sets
Teaching
Utilizing Universal Health Literacy Concepts
 Enhanced teaching materials
 Teach back
Touchpoints
 Home Care - care coordination visit 24 to 48 hours post
discharge
 Follow-up physician clinic visit appointment in three to
five days
 APN - follow-up phone call on seventh day post
discharge
 Outpatient Heart Failure class
 Collaboration with cardiology office Heart Failure Clinic
What Changes Can We Make
That Will Result in Improvement?
Key Changes to Achieve an Ideal Transition
from Hospital to Home:
1. Perform an Enhanced Assessment of PostHospital Needs
2. Provide Effective Teaching and Facilitate Learning
3. Provide Real-time Patient and Family-Centered
Handoff Communications
4. Ensure Post-Hospital Care Follow-Up
Creating an Ideal Transition Home
I. Perform Enhanced Admission Assessment for Post-Hospital Needs
A. Include family caregivers and community providers as full partners in completing
standardized assessments, planning discharge, and predicting home-going needs.
B. Reconcile medications upon admission.
C. Initiate a standard plan of care based on the results of the assessment.
II. Provide Effective Teaching and Enhanced Learning
A. Identify all learners on admission.
B. Customize the patient education process for patients, family caregivers, and providers
in community settings.
C. Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the
patient’s and family caregivers’ understanding of discharge instructions and ability to
perform self-care.
III. Conduct Real-Time Patient and Family-Centered Handoff Communication
A. Reconcile medications at discharge.
B. Provide customized, real-time critical information to the next care provider(s).
IV. Ensure Post-Hospital Care Follow-Up
A. High-risk patients: Prior to discharge, schedule a face-to-face follow-up visit (home
care visit, care coordination visit, or physician office visit) to occur within 48 hours after
discharge.
B. Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48
hours and schedule a physician office visit within five days.
How-to Guide: Creating an Ideal Transition Home -- Page 6
Although the care that
prevents rehospitalization
occurs largely outside the
hospital, it starts in the
hospital.
Steve Jencks, NEJM 2009 260:1417-28
Enhanced Admission Assessment for
Post-Discharge Needs






Identify the appropriate family caregivers
Partner with home care agencies, primary care offices
and clinics, and long-term care facilities
Initiate a standard plan of care based on the results of
the assessment
Designate a person accountable for the effective
discharge of each patient
Estimate the home-going date on admission and
anticipate needs
Key learner may be different than Care Provider
 Who is managing medications?
 Who do you want to be included in your discharge
instructions?
Emphasis on Cross Continuum
Team/Interdisciplinary Team
These views added new context to our
efforts.
•
•
•
•
•
Home Care representative
Family member of a HF patient
Long-Term Care representative
Physician Clinic representative
Patient
Facilitating Patient-Centered Care




“Nothing about me without me”
Patient and family needs and goals for the
day associated with going home are listed
on the white board
Consider what it would be like to be a
patient going home
Care Plan Partner – if they are included,
they will be engaged; include in rounds,
shift handoffs, and all discharge preparation
discussions
The richest source of
information is under our
nose…
The Patient
Interventions to Enhance Assessment
for Post-Discharge Needs
Take 5
 Daily discharge huddle
 Bedside reporting

All opportunities to review plan for day and
anticipate discharge needs
Identify Opportunities:
Chart Review Tool

Known reason(s) for readmission.
What did the patient or family think contributed to the
readmission?
Any self-care instructions misunderstood?
Evidence of teach back documented?
Was a follow-up physician visit scheduled? Attended?
Number of days between the discharge and physician’s
office visit. Number of days between discharge and
readmission
Any urgent clinic/ED visits before readmission?
Was discharge plan clear?

Functional status of patient on discharge







Interview Questions
For patients with HF that are readmitted within 30 days of last
admission:
 Can you tell me in your own words why you think you ended up sick
enough to be readmitted again?





17
Can you tell me what a typical meal has been for you since you left
the hospital? What did you have for dinner last night?
Where are your scale and calendar located?
Have you seen your doctor since you were discharged from the
hospital?
Do you have all of your medications? How do you set your pills up
every day?
Were there any appointments that kept you from taking any of your
pills?
Creating an Ideal Transition Home
I. Perform Enhanced Admission Assessment for Post-Hospital Needs
A. Include family caregivers and community providers as full partners in completing
standardized assessments, planning discharge, and predicting home-going needs.
B. Reconcile medications upon admission.
C. Initiate a standard plan of care based on the results of the assessment.
II. Provide Effective Teaching and Enhanced Learning
A. Identify all learners on admission.
B. Customize the patient education process for patients, family caregivers, and providers
in community settings.
C. Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the
patient’s and family caregivers’ understanding of discharge instructions and ability to
perform self-care.
III. Conduct Real-Time Patient and Family-Centered Handoff Communication
A.Reconcile medications at discharge.
B.Provide customized, real-time critical information to the next care provider(s).
IV. Ensure Post-Hospital Care Follow-Up
A. High-risk patients: Prior to discharge, schedule a face-to-face follow-up visit (home
care visit, care coordination visit, or physician office visit) to occur within 48 hours after
discharge.
B. Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48
hours and schedule a physician office visit within five days.
How-to Guide: Creating an Ideal Transition Home --
Intervention:
Patient Education Material




19
Key “small tests of change”
Reviewed content of educational
materials utilizing health literacy
concepts
Outpatient Heart Failure class utilized as
focus group for content
Family member on team, along with her
siblings, reviewed content for
understanding Health Literacy
Paradigm Shift
“The patient is noncompliant”
vs.
Asking: What is our responsibility as the
sender of the information?
Health Literacy
“If
they don’t do what we
want, we haven’t given
them the right
information.”
Vice Admiral Richard Carmona, Former Surgeon
General
Redesign Patient Teaching Materials

During acute care hospitalizations for
HF, only essential education is
recommended
 Reinforce within one to two weeks
after discharge
 Continue for three to six months
Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice
Guideline. Journal of Cardiac Failure Vol. 12, No. 1, pg 61
February 2006
22
Universal Communication
Principles
Focus on key points
 Need to know vs. nice to know
 Emphasize what patient should do
 Avoid duplicating paperwork
 Be careful with color

23
Keys to Success with Health Literacy


Use universal health literacy communication principles
to redesign written teaching materials
User-friendly written materials use:






24
Simple words (1-2 syllables)
Short sentences (4-6 words)
Short paragraphs (2-3 sentences)
No medical jargon
Two-word explanations, e.g., “water pill/
blood pressure pill”
Keys to Success with Health Literacy








Add more white space
Highlight or circle key information
Headings and bullet points
Increase font size
Remove ranges
On all written material, assure words/
terminology match
Use visual aids
Provide a health context for numbers or
values
Heart Failure Magnet
Heart Failure Zones
Heart Failure Zones
EVERY
DAY
GREEN ZONE
Every day:
 Weigh yourself in the morning before breakfast and write it
down.
 Take your medicine the way you should.
 Check for swelling in your feet, ankles, legs and stomach
 Eat low salt food
 Balance activity and rest periods
Which Heart Failure Zone are you today? Green, Yellow or Red
All Clear This zone is your goal
Your symptoms are under control
You have:
 No shortness of breath
 No weight gain more than 2 pounds
(it may change 1 or 2 pounds some days)
 No swelling of your feet, ankles, legs or stomach
 No chest pain
Caution This zone is a warning
Call your doctor’s office if:
 You have a weight gain of 3 pounds in 1 day or
a weight gain of 5 pounds or more in 1 week
 More shortness of breath
 More swelling of your feet, ankles, legs, or stomach
YELLOW ZONE
 Feeling more tired. No energy
 Dry hacky cough
 Dizziness
 Feeling uneasy, you know something is not right
 It is harder for you to breathe when lying down. You are needing to
sleep sitting up in a chair
RED ZONE
2/6/09
EMERGENCY
Go to the emergency room or call 911 if you have any
of the following:
 Struggling to breathe. Unrelieved shortness of breath while sitting
still
 Have chest pain
 Have confusion or can’t think clearly
Heart Failure
 One measurement your doctor may use to see how well your heart is working
is called ejection fraction or EF
 The ejection fraction (EF) is the amount of blood your heart pumps with each
heart beat
 The normal EF of the pumping heart is 50% to 60%
 Heart failure may happen if the EF is less than 40%
Heart failure means your heart is not
pumping well. Symptoms of heart failure
may develop over weeks or months.
Your heart becomes weaker over
time and not able to pump the amount
of blood your body needs.
Over time your heart may enlarge
or get bigger.
Treatment for heart failure
Your heart
When you have heart failure, it does not mean that your heart has stopped
beating. Your heart keeps working, but it can’t keep up with what your body needs
for blood and oxygen. Your heart is not able to pump as forcefully or as hard as it
should to move the blood to all parts of your body.
Heart failure can get worse if it is not treated. Do what your doctor tells you to do.
Make healthy choices to feel better.
Changes that can happen when you have heart failure
 Blood backs up in your veins
 Your body holds on to extra fluid
 Fluid builds up, causing swelling
in feet, ankles, legs or stomach
This build up is called edema
Signs of heart failure
 Shortness of breath
 Weight gain from fluid build up
 Swelling in feet, ankles, legs or
stomach
Some causes of heart failure
 Heart attack damage to your
heart muscle
 Blockages in the heart’s arteries
which doesn’t let enough blood
flow to the heart
 High blood pressure
Ejection Fraction
 Fluid builds up in your lungs
This is called congestion
 Your body does not get enough
blood, food or oxygen
 Feeling more tired. No energy
 Dry hacky cough
 It’s harder for you to breathe
when lying down
 Heart valve problems
 Cardiomyopathy
 Infection of the heart or heart
valves
 Eat less salt and salty type foods
 Take medicines to strengthen your heart and water pills to help your body
get rid of extra fluid
 Balance your activity with rest. Be as active as you can each day,
but take rest periods also
 Do not smoke
Medicines you might take




Diuretic “water pills”- these help your body get rid of extra fluid
Beta blocker- lowers blood pressure, slows your heart rate
Ace Inhibitor-decreases the work for your heart, lowers blood pressure
Digoxin-helps your heart pump better
Things for you to do to feel better each day
 Follow the guidelines on the St. Luke’s Heart Failure Zone paper
 Check yourself each day-Which heart failure zone are you today?
 Watch for warning signs and symptoms, call your doctor if you are in the
yellow zone. Catch the signs early, rather than late
 Do not eat foods high in salt
 Do what your doctor tells you to
To learn more about heart failure
 Attend St. Luke’s FREE heart failure class
Phone (319) 369-7736 for more information
 Visit the following web sites
www.americanheart.org
www.abouthf.org
www.heartfailure.org
Adapted from American Heart Association 7/2006
American Heart Association
Heart Failure Society of America
Heart Failure Online
28
Online Discharge Instructions
St Luke’s Hospital, Cedar Rapids, Iowa
31
Evaluation of New Patient Education
Material

Results from 15 follow-up phone calls:
“Information very helpful.”
 Able to state where information was
and reported that they were referring
to it.
 Understood content.

St Luke’s Hospital, Cedar Rapids, Iowa
32
Evaluation of New Patient
Education Material
Successfully answered teach back
questions related to “water pill,” diet
and weight.
 Improvement opportunity – patients
were often unclear when they had
multiple physicians which one to call
for the symptoms (magnet revised).

St Luke’s Hospital, Cedar Rapids, Iowa
33
34
Arch Intern Med, 2003;163:83-90 Copyright © 2003, American Medical Association. All Rights reserved
Closing the Loop
Check points to evaluate how well
transactions are going
 How well we are doing giving the
information

How often do we close the loop?
Enhanced Teaching and Learning
Utilizing “Teach Back”



37
Explain needed information to the patient
or family caregiver.
You do not want your patient to view
TeachBack as a test, but rather of how
well you explained the concept. You can
place the responsibility on yourself.
Can be both a diagnostic and teaching
tool
Enhanced Teaching and Learning


38
Ask in a non-shaming way for the
individual to explain in his or her own
words what was understood
Example: “I want to be sure that I did a
good job of teaching you today about
how to stay safe after you go home.
Could you please tell me in your own
words the reasons you should call the
doctor?”
Enhanced Teaching and Learning

Redesign patient teaching:



39
Stop and check for understanding using
Teach Back after teaching each segment of
the information
If there is a gap, review again
If your patient is not able to repeat the
information accurately, try to re-phrase the
information rather than just repeat it. Then,
ask the patient to repeat again until you fee
comfortable that the patient understood.
Redesign Patient Teaching





40
Slow down when speaking to the patient and
family and break messages into short
statements
Take a pause
Be an active listener
Use plain language, breaking content into short
statements
Segment education to allow for mastery
Teach Back Questions

What is the name of your water pill?

What weight gain should you report to
your doctor?

What foods should you avoid?

Do you know what symptoms to report
to your doctor?
St Luke’s Hospital, Cedar Rapids, Iowa
41
Enhance Teaching and
Facilitate Learning
Use Teach Back daily:
• In the hospital
• During home visits and follow-up phone calls
• To assess the patient’s and family caregivers’
understanding of discharge instructions and
ability to do self-care
• To close understanding gaps between:
• Caregivers and patients
• Professional caregivers and family
caregivers
42
Teach Back Competency Validation
St Luke’s Hospital, Cedar Rapids, Iowa
Nursing Competency Assessment
Annual competency validation day
 Methodology


43
The learning station will use discussion,
role playing and patient teaching
scenarios to help RN’s communicate
effectively to patient/family.
Creating an Ideal Transition Home
I. Perform Enhanced Admission Assessment for Post-Hospital Needs
A. Include family caregivers and community providers as full partners in completing
standardized assessments, planning discharge, and predicting home-going needs.
B. Reconcile medications upon admission.
C. Initiate a standard plan of care based on the results of the assessment.
II. Provide Effective Teaching and Enhanced Learning
A. Identify all learners on admission.
B. Customize the patient education process for patients, family caregivers, and providers
in community settings.
C. Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the
patient’s and family caregivers’ understanding of discharge instructions and ability to
perform self-care.
III. Conduct Real-Time Patient and Family-Centered Handoff Communication
A. Reconcile medications at discharge.
B. Provide customized, real-time critical information to the next care provider(s).
IV. Ensure Post-Hospital Care Follow-Up
A. High-risk patients: Prior to discharge, schedule a face-to-face follow-up visit (home
care visit, care coordination visit, or physician office visit) to occur within 48 hours after
discharge.
B. Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48
hours and schedule a physician office visit within five days.
How-to Guide: Creating an Ideal Transition Home
Opportunities for Improvement
 81%
of patients requiring assistance with
basic functional needs failed to have a
home care referral
 64% said no one at the hospital talked to
them about managing their care at home
Clark PA. Patient Satisfaction and Discharge Process: Evidence-Based Best Practice.
Marblehead, MA: HCPro, Inc., 2006
Patients sometimes do not see
readmissions as a failure
Reconcile Medications for Discharge

Communicate clearly to the patient, family
caregiver and next care team:



47
Names of each medication, reason to take it
New medications and pre-hospital
medications the patient is to discontinue
Whether there are any recommended
changes in the dose or frequency from prehospital instructions
Reconcile Medications for Discharge
Pre-hospital medications to be
continued with the same instructions
 Medications and over-the-counter
medications that should not be taken
 The cost of the medication


48
Can patients read their medication
labels, afford the necessary
medications and food, and get to the
pharmacy?
Real-Time Patient and FamilyCentered Handoff Communication
Patients going home:
 Provide patient and family
 Easy-to-read self-care instructions
 What to expect at home
 Medication card with current medications
 Reasons to call for help
 Numbers for emergent needs and nonemergent questions
49
Real-Time Patient and FamilyCentered Handoff Communication
Patients going home:
 Identify the appropriate care providers (physicians, home
care, other providers)
 Transmit critical information at time of discharge
 Ideally precedes or accompanies patient to next care
location
 Be sure the information adequately delineates patient status
and recommendations for plan of care
 Speak with emergency contact listed in medical record
before discharge and provide critical information on patient
safety
50
Example of Calendar
51
Real-Time Patient and FamilyCentered Handoff Communication
Patients going to community facility:
 Alert next care providers to patient’s discharge
readiness and needs post discharge
 Nursing home or SNF liaison with hospital
 Ask receiving care teams for their preferred
format, mode of communication and specific
information needs about patient’s functional
status.
 Share patient education materials and
educational processes across all care settings
Long-Term Care/Skilled Nursing
Facility
• Patient education is sent with all nursing
home patients at discharge.
• Educational offerings for the staff conducted
in the LTC/SNF
• Long-term care/Skilled Nursing Facility
representative added to our HF Team.
St Luke’s Hospital, Cedar Rapids, Iowa
Schade et al; Impact of a national campaign on
hospital readmission in home care patient; Journal
of Quality Health Care vol 21, no 3
 Hospitalization
rates appeared to improve
in agencies participating in the National
Campaign compared with those not
participating.
 Use of the material was significantly more
common among agencies whose
performance improved.
Home Health Quality Initiative
National Campaign Intervention Used











Hospitalization risk assessment
Patient emergency plan
Phone monitoring and loading visits
Teletriage
Medication management
Telemonitoring
Immunization
Physician relationships
Fall prevention
Patient self-management/disease management
Transitional care coordination
Mor et al; The Revolving Door of
Rehospitalization from Skilled Nursing
Facilities, Health Affairs Jan. 2010 29:1

Almost one-fourth of Medicare beneficiaries
discharged from the hospital to a skilled nursing
facility were readmitted to the hospital within
thirty days; this cost Medicare $4.34 billion in
2006.
 The overall rate increased from 18.2% in 2000
to more that 23.5% in 2006.
Case Management Monthly
Reducing Hospital-SNF 30-day Readmission
(2007 Pfizer)

Finding from 931 hospitals and SNF
interviews in 2009 indicated that 30-day
hospital readmission could be reduced if:

SNF had better access to hospital staff
and documentation

Medication changes for non-medical
or formulary reasons were minimized as
patients transition between settings
Which Setting is Most Responsible
for Readmission in 30 Days?
1.
2.
3.
4.
5.
6.
7.
Hospital View
Patient
SNF
Physician Practice
Hospitals
Government
All of above
None of above
1.
2.
3.
4.
5.
6.
7.
SNF View
Hospitals
Patients
Physician Practice
SNF
Government
All of above
None of above
Barriers to Efficient Transitions

The two settings agree that better
communication and better education
management, including support for
discharge planners, are highly likely to
reduce readmissions

Yet, less than 9% of Hospitals and 14% of
SNF’s reported regular meetings or hold
multiple facility transition of care meetings to
discuss cases or processes.
Establish Cross-Venue or
Continuum Collaboration


61
Develop creative solutions for bidirectional communication and feedback
processes, coordination and greater
understanding of patient needs
Continually improve by aggregating the
experience of patients, families, and
caregivers and designing improvements
Creating an Ideal Transition Home
I. Perform Enhanced Admission Assessment for Post-Hospital Needs
A. Include family caregivers and community providers as full partners in completing
standardized assessments, planning discharge, and predicting home-going needs.
B. Reconcile medications upon admission.
C. Initiate a standard plan of care based on the results of the assessment.
II. Provide Effective Teaching and Enhanced Learning
A. Identify all learners on admission.
B. Customize the patient education process for patients, family caregivers, and providers
in community settings.
C. Use “Teach Back” daily in the hospital and during follow-up phone calls to assess the
patient’s and family caregivers’ understanding of discharge instructions and ability to
perform self-care.
III. Conduct Real-Time Patient and Family-Centered Handoff Communication
A. Reconcile medications at discharge.
B. Provide customized, real-time critical information to the next care provider(s).
IV. Ensure Post-Hospital Care Follow-Up
A. High-risk patients: Prior to discharge, schedule a face-to-face follow-up visit (home
care visit, care coordination visit, or physician office visit) to occur within 48 hours after
discharge.
B. Moderate-risk patients: Prior to discharge, schedule a follow-up phone call within 48
hours and schedule a physician office visit within five days.
How-to Guide: Creating an Ideal Transition Home -- Page 6
Post Acute Follow-Up
High-Risk Patients
 Patient has been admitted two or more times in
the past year
 Patient failed “Teach Back” or the patient or
family caregiver has a low degree of confidence
to carry out self-care at home
 Patient and family caregiver have the phone
number for questions and concerns
 Consider home care or discharge coach
Identifying High Risk
History of rehospitalization
 Failed teach back
 Longer stay than expected
 High-risk conditions
 Poor, disabled, or on dialysis
 But, the resources used in screening
might be better spent on system
changes

Post Acute Follow-Up
Moderate risk patients:
 Patient has been admitted once in the past
year
 Patient or family caregiver has moderate
degree of confidence to carry out self-care
at home


Prior to discharge, schedule follow-up phone
call within 48 hours
Schedule a physician office visit within five
days
Controlled Trials
 Clinic
visit only is not enough
 Nursing support alone is equivalent to
telemonitoring
 Early follow-up appointment important, but
not clear if it is 3-5-7 days; some data
show after seven days is too long
 Multidisciplinary team most effective
 Single home visit can make a difference
Intervention: Dietitian Visits

Mandatory on all patients
Intervention: Home Care Visit
24-48 Hours Post Discharge




Small test of change October 2006
Education to all Home Care staff
Visit 24-48 hours after discharge
Visit outline
 Medication Reconciliation
 Review of diet and foods in-house
 Teach back on water pill, diet and weight
 Vital signs
 Hardwired process in January 2007
Intervention: Nursing Home



Patient education sent with all nursing
home patients at discharge.
Educational offerings for the staff
conducted in the nursing homes.
Nursing home representative added to our
HF Team.
Intervention: Primary Care
Follow-Up Appointment
Worked with Primary Care to assure
follow-up visits scheduled three to five
days post discharge
 Particularly on high-risk patient for
readmission

Intervention: Follow-Up Phone Call
Advance Practice Nurse makes follow-up
phone call at seven days post-discharge
 Standardize questions
 Results monitored and changes made as
needed based on feedback
 Results monitored globally and per
individual unit

Data Speaks: Evaluating
Progress in Reducing Heart
Failure Readmissions
Facility Assessment







Is reducing Readmission a strategic priority for
Executive Leaders?
What is you understanding of the problem?
Have you established improvement goals?
What will help you drive the Success in the
Improvement process?
What and how are you providing oversight?
What investments are we willing to make
What are you measuring?
Measurement
How will we know
change is an improvement?
Outcome Measures: Readmission
Measure Name
Description
Numerator
30-Day All-Cause
Readmissions
Percent of discharges
with readmission for any
cause within 30 days
Number of discharges
with readmission for
any cause within 30
days of discharge
Exclusion: planned
readmissions (e.g.,
chemotherapy
schedule)
30-Day All-Cause
Readmissions for
Chronic Conditions
such as heart failure
and COPD
Percent of discharges
with heart failure,
COPD, etc., who were
readmitted for any cause
within 30 days of
discharge
Denominator
The number of
discharges in the
measurement
month Exclusions:
transfers to
another acute care
hospital, patients
who die before
discharge
Number of discharges Number of
with heart failure or
discharges in the
other chronic
measurement
conditions readmitted
period with heart
for any cause within 30 failure or other
days of discharge
chronic conditions
Exclusion: planned
Exclusions:
readmissions (e.g.,
transfers to
chemotherapy
another acute care
schedule)
hospital, patients
who die before
discharge
Harvard Public Health
Literacy
Finding that current efforts to collect and
publicly reported data on discharge
planning are unlikely to yield large
reductions in unnecessary readmissions.
Jha, NEJM 361:27 Dec. 2009
Attending MD During Hospitalization
(Nov 07 – Dec 09)
22%
60%
18%
Cardiology
Hospitalist
PCP
Discharge Status (Nov 07- Dec 09)
9%
12%
52%
27%
Comp Visit
VNA/Other Referral
Refused
Missed
Histogram of Days Between Admissions (with Outlier removed)
Normal
Mean
StDev
N
12
Frequency
10
8
6
4
2
0
-6
-3
0
3
6
9
12 15 18 21 24
Number of Days Between Admissions
27
30
10.36
8.389
56
Palliative Care Referral
•Year-to-date, 10% referred to Palliative Care
•In 2007, averaged less than 5%
35%
31.3%
30%
25%
27%
26%
20%
20%
19%
15%
30.4%
15% 15%
21.4%
20%
18.8%
18.5%
16.7%
16%
15.2%
14.6%
15%
14.8%
13%
10%
5%
3%
O
ct
N
ov
D
ec
l
ug
Se
p
A
Ju
N
O
ct
l
ug
Se
p
A
Ju
n
Ju
M
ay
0%
ov
D
e
Ja c
n09
Fe
b
M
ar
A
pr
M
ay
Ju
n
A
pr
-0
8
0%
Successful Teachback Rate
100%
95%
90%
85%
80%
75%
70%
APN
VNA
In Hospital
Nov
Aug
May
Feb
Nov
Aug
May
Feb
Nov
Aug
May
Feb
Nov
Aug 06
65%
Patient Satisfaction on Discharge Handoff
100%
95%
90%
85%
80%
75%
Nov
Aug
May
Feb
Nov-
Aug-08
May-
Feb-08
Nov-
Aug-07
May-
Feb 07
Nov
Aug 06
70%
“I had a great time tonight and I’d like to see you
again in four to six weeks.”
3-5 Day Follow-up
100%
88.2%
90%
84%
81%
80%
73.9%
69.4%
66.7%
68%
70%
88.9%
64%
72.2%
66.7%
57.9%
60%
51.9%
50%
50%
45%
42%
40.0%
40%
30%
19% 17%19%
20%
6% 6% 6% 4% 4%
10%
O
ct
No
v
De
c
Ju
l
Au
g
Se
p
O
ct
No
v
De
Ja c
n09
Fe
b
M
ar
Ap
r
M
ay
Ju
n
Se
p
Au
g
Ju
l
No
v
-0
7
De
Ja c
n08
Fe
b
M
ar
Ap
r
M
ay
Ju
n
0%
'And this is the period when the cat was away. '
Percent of Heart Failure Patients Readmitted
within 30 Days with Heart Failure
35%
Good
30%
25%
20%
15%
10%
5%
Percent
Median
Linear (Percent)
(Numerator based on discharge date; denominator is number of discharges excluding deaths.)
Oct-09
Jul-09
Apr-09
Jan-09
Oct-08
Jul-08
Apr-08
Jan-08
Oct-07
Jul-07
Apr-07
Jan-07
Oct-06
Jul-06
Apr-06
Jan-06
0%
Percent of Heart Failure Patients Readmitted
within 30 Days for Any Cause
60%
Good
50%
40%
30%
20%
10%
Percent
Median
Linear (Percent)
(Numerator based on discharge date; denominator is number of discharges excluding deaths.)
Oct-09
Jul-09
Apr-09
Jan-09
Oct-08
Jul-08
Apr-08
Jan-08
Oct-07
Jul-07
Apr-07
Jan-07
Oct-06
Jul-06
Apr-06
Jan-06
0%
Peg Bradke
St. Luke’s Hospital
Cedar Rapids Iowa
Bradkemm@crstlukes.com
COPD/Pneumonia
What would your teachback questions
be?
 What are the vital few?
