Transforming Healthcare
Nancy M. Strassel
Senior Vice President
Greater Cincinnati Health Council
Where Are the Connections?
• 270,000 discharges
• 1 in 5 patients readmitted
• We can do better
P
Laser Focus
•
•
•
•
18 hospital learning collaborative
Reduce heart failure readmissions
Improve transitions of care
Know who our patients are – equity in
care
These 5 areas are targeted for high risk CHF patients in support of the ACT Hospitals.
Readmission Reduction and Care
Transitions Standards (T5)
1)
2)
3)
4)
5)
Upon admission implement a risk assessment tool with a focus on Heart Failure to
identify patients who are at high risk of readmission considering social factors

Include a comprehensive assessment of the post hospital needs
Use the teach-back method during the hospital stay from admission to discharge
during key clinical interventions.
Provide real-time handover communications (IHI, 2011)

Provide patient and primary care givers a patient-friendly post-hospital care plan
which includes a clear medication list

Provide customized, real-time critical information to the next clinical care provider(s)

For high risk patients, have a clinician call the individual(s) listed as the patient’s
emergency contact to discuss the patient’s status and plan of care as applicable
Address timely physician follow-up (appt to occur within 5-7 days of discharge)

Either schedule follow up physician appointment for the patient, provide scheduling
info to the patient or sit with the patient while they make the appointment prior to
discharge – appointment should be tailored to the care giver’s schedule (include
primary care specialist and therapy appointments if possible)
Follow up with the patient or primary care giver (or emergency contact) within 48-72
hours of discharge via telephone or home visit.
Adopted by the ACT Leadership on 10/12/11 from a variety of sources including Project BOOST, STAAR and IHI.
Chart Reviews and Patient
Interviews
• 36% had a follow-up appointment scheduled prior
to discharge (6/7/12 sample)
• 52% did not call a health professional for guidance
before being readmitted (10/18/12 sample)
• 39% made and/or kept appointment within 7 days
(4/11/13 sample)
Care Transitions – New
Approaches
P
• 5 hospitals, Health Council, COA
• Christ, Mercy FF, Jewish, University,
Clinton
• Patient coaching and empowerment model
• Two-year contract with CMS
• RESULTS: Baseline of 25% to a current
readmission rate of 15.2% (coached
patients)
Equity in Care
• Standardized categories and methodology for
the collection of patient race, ethnicity and
language data
• Data integrity standards
• Spread to primary care practices
• 56% collecting all three fields (REL) to 100%
• LEP improvement project underway
P9
What Did We Learn?
One model doesn’t fit all
Focus on entire continuum of care
This is not linear work
IT has to integrate into the work processes
Leadership and grassroots group needed to drive change
Power of patient interviews; test staff perceptions
Measure!
Pull in physicians to be part of the dialogue
Build on common ground with post-acute providers
Data delays can be a challenge
Questions
Thank You……….
www.gchc.org
Nancy Strassel, SVP
nstrassel@gchc.org