Breakout A: Ensuring PostHospital Care Follow-up
Saint Anne’s Hospital
A Catholic Community Hospital – Saint Anne’s Hospital
• 160 beds including 16-bed geriatric psychiatry unit with
medical, surgical, oncology and pediatric units
• No maternity unit
• Multiple satellite outpatient services
Founded in 1906 by the
Dominican Sisters of the Presentation
Service Area
Legend
Primary Service Area
Secondary Service Area
Extended Service Area
Community Health Status
Greater Fall River Area
• Highest incidence rate for cardiac disease in the state
of Massachusetts
– 24% higher incidence rate for coronary heart disease
• Highest prevalence for diabetes in the state
– 42.26 per 1000 persons
– USA average is 34.1 per 1000
– Diabetes incidence has risen 49% since 1990.
Community Health Status
Greater Fall River Area
As compared to state average:
– Higher concentration of area residents
with risk factors for developing heart
disease, cancer, and diabetes including:
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30% higher rates for smoking
Higher obesity rates: 28.0% vs. 25.8 % state
Higher cholesterol: 36.8% vs. 28.3% state
High blood pressure: 29.2% vs. 21.6% state
Community Demographics
• Median household income for Fall River
– $33,124 vs. $64,081 state (2009)
• Nearly 1 in 5 families with children live below the
official poverty level in Fall River.
• Only 25% of Fall River residents have obtained a
high school diploma.
• Higher than state avg. of residents over age 65
• 13.2% Unemployment in Fall River (Sept. 2011)
MASS state unemployment average 7.4%
Community Demographics
City of Fall River
• Fall River has been an economically disadvantaged city
for many years after mass closings of the it’s textile mills.
• It is a federally designated medically underserved area.
• Violent crime has been on the rise accompanied by
increasing drug use, notably heroin.
• Largest Portuguese American population in the US
between 43-49% depending on data source.
• Hispanic American: 7.5% in 2010, up from 4.0% 2009
• African American: 4.0% in 2010, up from 2.5% 2009
• Asian American: 2.5%, in 2010, up from 2.2% 2009
World-class community health care where you live
Cross-Continuum Team Members
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Ann Archibald RN CRNI, Director Clinical
Operations & NE Infusion Resource Nurse,
Genesis Healthcare
Carole Billington MSN, RN, NEA-BC Vice
President Patient Care Services, Chief
Nursing Officer, SAH
Debbie Costello RN, BSN, MSM, Vice
President Quality & Safety, Steward Home
Care
Mary N. Dana MSW, LICSW, Supervisor Case
Management, SAH
Nicole Decoffe, Clinical Liaison, Kindred
Healthcare
Lisa DeMello MSN, RN, ACNS-BC, Clinical
Educator/Stroke Coordinator, SAH
Andrew Dousa RPh, Pharmacy Director, SAH
Erika Sundrud MA, System Director of
Performance Improvement, Steward Health
Care
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Katherine Librera, Clinical Admission
Director, Genesis Healthcare
Robin Lynch MS, RN, CAGS, CPHQ,
Director of Quality and Patient Safety, SAH
Erin McGough RN, CCM, Director of Case
Management, SAH
Theresa Moss MSN RN, Clinical Leader,
Telemetry, SAH
John Arcuri,MD, Medical Director and Chief,
Department of Emergency Medicine, SAH
Saira Nisar MD, Hospitalist, SAH
Robin Pelletier BSN, RN, CHPN, Director,
Hospice and Palliative Care, Steward Home
Care
Donna Rebello BSN, RN, OCN, Director St.
Mary’s and St. Dominic's, SAH
Lisa Shea MSN, RN, Patient Care Director,
SAH
Andrea Hodge, BSN, RN, ED Case
Manager, SAH
Cross-Continuum Team Members
(Continued)
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Gina Gough, Supervisor, Rehab
Department, SAH
Jennifer Davis, Catholic Memorial
Linda Perry RN, Nursing Informatics
Manager, SAH
Nancy Cooper RN, Nurse Liasion Steward
HomeCare
Susan Jamieson, VP of Integrated Services
Susan Oldrid VP, Mission of Community
Relations, SAH
Terence McGovern, Pulmonologist
Teresa Ferriera NP, Steward
Christine G. Leeman MS, RN, CCM, Patient
Care Coordinator, PrimaCARE
Tina Whitney BSN, RN, CCM, Director of
Case Management, Steward Network
Services
Lisa Souza, Wellness Director, Landmark
Assisted Living
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Barbara Wales RN, Health Service
Manager, Bristol Elder Care
Maureen Bannan, VP of Clinical Service
Steward
Michael Spearin, Kindred Health Care
Sheila Duval, Southpoint Skilled Nursing
and Rehab
Stephanie Weir RN, Steward Physician
Group
Tracy Faris, Kindred Health Care
Cynthia A. Anderson BSN, RN, Director,
ICU and Telemetry, SAH
Lena Gomes RN, CMSRN, Clinical Leader,
St. Mary’s, SAH
Edwina Cummings, Patient representative
Shannon Hebda, Director of Community
Supports, People Incorporated, Patient and
Family Advisory Committee Member
Identified Opportunities from Our
Starting Point
• Accuracy of Home Medication List
• Under utilization of Telehealth Resource
• Lack of person to person hand off transition to Home
Care
• Availability/Capacity for follow-up appointments
• Home Care Psychiatric Nurse
• Family (care giver) education
• End of life discussions with patients and families
• Social Disparities (transportation, poverty, housing,
education level, substance abuse etc.)
• Knowledge Gap – related to Community Resources
Year of the Family
• Identify Partner in Care at time of
admission
• Include Partner in care in discharge
planning, instructions/education,
pharmacist visit, follow up phone call
• Color coded one page Zone Discharge
Instruction sheets
Follow up Appointments
• Attempts made to schedule follow up appointments prior
to discharge on all 30-day readmits
• Patients decline staff scheduling of appointments related
to transportation issues and family members work
schedules
• Verification of follow up appointments made by patients
independently done at time of discharge
• Staff report greater success scheduling timely
appointments when made prior to discharge
• Barriers include late and weekend discharges. During
initiation, attempts were made to make all appointments
for all discharges. These efforts were unsuccessful
related to volume and time required.
Discharge Phone Calls
• All patients are called within 72 hours of
discharge
• If unable to reach on first attempt a second
attempt is made the following day
• Family present during the discharge call are
encouraged to ask questions
• Topics reviewed include: discharge medications,
diet, follow up appointments, reportable signs
and symptoms and any questions patient has
• All calls are made by a Registered Nurse
Handover Communication
• Implemented communication template to
promote standardized approach (SBAR)
• Nurse to nurse verbal report for all patients
discharged to SNF
• Nurse to nurse verbal report for all patients
discharged to Steward Home Care
Financial Counseling
• All self pay and underinsured are assessed by a financial
counselor the day of admission or following business day
• Patients are assessed for all public programs and
eligibility for private insurance
• Patients are assisted in navigating the process through
to determination
• Patient Advocate is available to all community members
to screen for eligibility and assist with navigating the
process
Inpatient Pharmacist Visit/ Medication Consult
Goal
• Provide medication education to patients considered high-risk for readmission within 30 days of discharge, in an attempt to prevent readmission due to lack of understanding of medication instructions once
discharged.
Process
• Once a high-risk has been identified, the case manager assesses the
patient and determines if patient needs, or is interested in, a medication
consultation.
• Eligible patient names are sent to pharmacy, who visits patient in their room
and provides education to them and preferably a family member or
caregiver as well.
• The consultation is geared towards determining if the patient understands
their medications, how to take them, and also compares meds upon last
discharge to current admission. Discrepancies, if thought to be
unintentional, are brought to the attention of the physician.
• All consultations are documented in the progress notes, with
recommendations for that particular patient’s discharge instructions to help
them better understand them.
• You’d be surprised what a patient tells a pharmacist, and not their
physician!
Steward Healthy Transitions
A 30-day program post-discharge for high risk Medicare patients with a
diagnosis of Heart Failure, Myocardial Infarction and Pneumonia
Service provides
• A thorough medication review and optimization with a Clinical
Pharmacist in the patients home within 2 days of discharge, and
ongoing telephonic support for 30 days
• Patient and caregiver disease state/medication education
• Special attention to adherence issues and medication organization
• Ensure patients are prepared for and attend their physician follow up
visit
• Patient and caregiver health coaching on self management of
chronic illnesses.
• Evaluation of falls risk and home safety risks for readmission.
Steward Home Care & Palliative Care
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Palliative Care Team
COPD & HF team
Telehealth
Home Care Psychiatric Nurse
Teach Back
Post Acute Collaborative Team
(PACT)
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What is PACT?
Compliment to Cross Continuum Team
Objectives
Members
How PACT has improved communication, care
transitions and reduction in re-admissions
• Case reviews indentify causes for readmission
Resource Manual for ED
• Clinical capabilities provided by area skilled
nursing facilities.
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Three resource books provided to ED listing
clinical capabilities for each facility. Resource
books are kept in physician and nurse areas for
ease of access.
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Overview of site capabilities and new
medication turn around time provided
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Saint Anne's Hospital
30 Day Readmissions (All Cause)
25.00
20.00
15.00
10.00
5.00
Readmission Rate per 100 discharges
Readmissions within 30
days
Discharges
Readmission Rate per
100 discharges
UHC Community 50th
UHC Community 75th Percentile (FY 2010)
-1
1
Ju
n
Ap
r- 1
1
M
ay
-1
1
ar
-1
1
M
Fe
b11
-1
0
De
c10
Ja
n11
No
v
-1
0
Se
p10
Oc
t -1
0
-1
0
Au
g
-1
0
Ju
l
Ju
n
Ap
r- 1
0
M
ay
-1
0
ar
-1
0
M
Fe
b10
De
c09
Ja
n10
-0
9
No
v
Se
p09
Oc
t -0
9
-0
9
-0
9
-0
9
Au
g
Ju
l
Ju
n
Ap
r- 0
9
M
ay
-0
9
ar
-0
9
M
Ja
n09
Fe
b09
0.00
UHC Community 50th Percentile (FY 2010)
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
84
486
76
453
66
427
60
428
72
436
77
422
81
463
75
425
60
415
75
461
88
460
96
509
77
500
75
497
104
587
110
543
91
554
17.28
16.78
15.46
14.02
16.51
18.25
17.49
17.65
14.46
16.27
19.13
18.86
15.40
15.09
17.72
20.26
16.43
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Heart Failure
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Heart Failure
60.00
50.00
40.00
30.00
20.00
10.00
Readmissions within 30 days
Readmissions within 30
days
Discharges
Readmission Rate per
100 discharges
UHC Community 50th
UHC Community 75th Percentile (FY 2010)
-1
1
Ju
n
ay
-1
1
-1
1
M
Ap
r
Ja
n11
Fe
b11
M
ar
-1
1
-1
0
Se
p10
Oc
t -1
0
No
v10
De
c10
-1
0
Au
g
Ju
l
-1
0
Ju
n
ay
-1
0
-1
0
M
Ap
r
Ja
n10
Fe
b10
M
ar
-1
0
Oc
t -0
9
No
v09
De
c09
ay
-0
9
Ju
n09
Ju
l-0
9
Au
g09
Se
p09
-0
9
M
Ap
r
Ja
n09
Fe
b09
M
ar
-0
9
0.00
UHC Community 50th Percentile (FY 2010)
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09 Sep-09
5
22
6
19
5
19
1
20
1
18
6
18
5
20
3
12
22.73
31.58
26.32
5.00
5.56
33.33
25.00
25.00
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
2
14
1
6
5
18
5
18
5
23
3
15
5
28
6
18
5
21
14.29
16.67
27.78
27.78
21.74
20.00
17.86
33.33
23.81
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Pneumonia
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Pneumonia
60.00
50.00
40.00
30.00
20.00
10.00
Readmissions within 30 days
Readmissions within 30 days
Discharges
Readmission Rate per 100
discharges
UHC Community 50th
Percentile (FY 2010)
UHC Community 75th
UHC Community 75th Percentile (FY 2010)
-1
1
ay
-1
1
Ju
n11
M
Ap
r
-1
0
Se
p10
O
ct
-1
0
No
v10
De
c10
Ja
n11
Fe
b11
M
ar
-1
1
-1
0
Ju
l
Au
g
-1
0
Ju
n
ay
-1
0
-1
0
M
Ap
r
Ja
n10
Fe
b10
M
ar
-1
0
-0
9
Se
p09
O
ct
-0
9
No
v09
De
c09
-0
9
Au
g
-0
9
Ju
l
Ju
n
ay
-0
9
-0
9
M
Ap
r
Ja
n09
Fe
b09
M
ar
-0
9
0.00
UHC Community 50th Percentile (FY 2010)
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
10
36
7
44
5
28
8
31
2
22
2
27
3
18
4
19
2
17
6
42
5
35
5
39
9
33
2
38
9
37
8
33
27.78
15.91
17.86
25.81
9.09
7.41
16.67
21.05
11.76
14.29
14.29
12.82
27.27
5.26
24.32
24.24
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
12.50
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Acute Myocardial Infarction
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Acute Myocardial Infarction
100.00
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
Readmissions within 30 days
Readmissions within 30 days
Discharges
Readmission Rate per 100
discharges
UHC Community 50th
Percentile (FY 2010)
UHC Community 75th Percentile (FY 2010)
ay
-1
1
Ju
n11
-1
1
M
Ap
r
ay
-1
0
Ju
n10
Ju
l-1
0
Au
g10
Se
p10
O
ct
-1
0
No
v10
De
c10
Ja
n11
Fe
b11
M
ar
-1
1
-1
0
M
Ap
r
ay
-0
9
Ju
n09
Ju
l-0
9
Au
g09
Se
p09
O
ct
-0
9
No
v09
De
c09
Ja
n10
Fe
b10
M
ar
-1
0
-0
9
M
Ap
r
Ja
n09
Fe
b09
M
ar
-0
9
0.00
UHC Community 50th Percentile (FY 2010)
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
1
3
0
2
0
5
1
2
1
3
0
3
0
1
0
1
0
1
1
4
3
7
3
5
2
6
0
2
0
5
2
4
33.33
0.00
0.00
50.00
33.33
0.00
0.00
0.00
0.00
25.00
42.86
60.00
33.33
0.00
0.00
50.00
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
12.70
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Chronic Obstructive Pulmonary Disorder
MS DRG 190,191,192
Saint Anne's Hospital
30 Day Readmissions (All Cause)
Chronic Obstructive Pulmonary Disorder
MS DRG 190,191,192
60.00
50.00
40.00
30.00
20.00
10.00
Readmissions within 30 days
Readmissions within 30
days
Discharges
Readmission Rate per
100 discharges
UHC Community 50th
Percentile (FY 2010)
UHC Community 75th
UHC Community 75th Percentile (FY 2010)
Ju
n11
-1
1
ay
-1
1
M
Ap
r
ar
-1
1
M
Ja
n11
Fe
b11
O
ct
-1
0
No
v10
De
c10
Ju
l-1
0
Au
g10
Se
p10
Ju
n10
ay
-1
0
-1
0
M
Ap
r
ar
-1
0
M
Ja
n10
Fe
b10
O
ct
-0
9
No
v09
De
c09
Ju
l-0
9
Au
g09
Se
p09
Ju
n09
ay
-0
9
-0
9
M
Ap
r
ar
-0
9
M
Ja
n09
Fe
b09
0.00
UHC Community 50th Percentile (FY 2010)
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
10
34
11
35
6
24
6
27
7
32
12
27
9
28
8
20
7
23
3
24
5
27
8
31
5
24
9
31
5
21
6
24
29.41
31.43
25.00
22.22
21.88
44.44
32.14
40.00
30.43
12.50
18.52
25.81
20.83
29.03
23.81
25.00
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
16.36
Next Steps
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Spiritual Care
Parish Nurses
High Risk identification algorithm
Spread beyond Pilot Unit and population
Address barriers to follow-up appointment
Electronic integration of enhanced admission
assessment
• Hospitalist ↔ PCP Communication
• Community Health Volunteers