Attachment 1
HOSPITAL ENGAGEMENT NETWORK
PUTTING PATIENTS FIRST: 40/20 BY ‘13
CARE TRANSITION ADVISORY ACTION GROUP
JULY 31, 2012 MEETING SUMMARY
Participants:
Chair: Marie Cameron ( Georgia State University); Katherine Abraham (Evercare); Soyna Baker (Georgia
Association of Home Health Agencies); Tommy Baker (Visiting Nurse Health System); Jennifer Hale (Georgia
Hospice and Palliative Care Association); Jon Howell (Georgia Health Care Association); Anita Rich (Emory
Johns Creek Hospital); Mendee Rock (Georgia Health Care Association); Addie Sims (Consumer
Representative)
Alliant|GMCF: Linda Kluge, Mary Perloe; Kim Rask, M.D. GHA: Joyce Reid
Vision: Every Georgian will receive the necessary tools and information that prepares and supports them to
participate in their health and healthcare.
Mission: Improve the overall health outcomes of the patient we serve through a patient/family centered,
seamless, continuum of care addressing care coordinating efforts and issues.
Aims:
1. Decrease readmissions rates to 11.6% by December, 2013
2. Full Court Press: Decrease readmissions 10% by 2012 –
(avoiding approximately 3,500 readmissions)
3. Increase patient satisfaction relating to discharge planning (HCAHPs 15, 16,17, 19 & 20)
4. Increase chronic condition self-management through patient/family centered care
Meeting Objectives
The Care Transitions Advisory/Action Group members:
1. Mutual agreed upon the five identified action steps
2. Obtained Status reports on Action steps
3. Provided updates
4. Created Next Steps
Recognizing that the patient and family are the center of health continuum, we mutually agree upon the
following action steps:
1. Build relationships to encourage trust and engagement
2. Have each partner determine cause of readmissions
3. Encourage use of proven tools and initiatives such as Interact (Nursing Homes), Home Health Quality
Improvement (HHQI), Medication Reconciliation (MATCH) (All)
4. Set aim to reduce readmission at respective organization
5. Encourage bi-directional communication specifically to ensure effective handover
Status reports on Action steps
1. Communication - Newsletter Note
Michael Cunningham wrote article. Will provide links. (See the following links to the newsletter
highlighted the Care Transition Advisory Action Group) Full Court Press on Reducing Readmissions
Full Newsletter
2. Share Aims at partner meetings and through newsletters
Jennifer Hodge to present at the Georgia Home Health Agency annual conference on August 21.
3. Encourage participation in offerings such as the Reducing Readmissions Learning
Collaborative/Learning Action sessions
Eve Esslinger provided an overview of the Home Health Quality Improvement Initiative on the July 11,
2012 Reducing Readmission Learning Collaborative Action Network. All RRLC sessions are available
on-line.
Dr. Resar presented the Reliable Systems Process July 17 (Base information) and during the August 1
RRLC using one hospitals journey with reducing readmission.
4. Root Cause Analysis of Reasons for Readmission by each partner to determine course of action
a. Home Health – According to the National data of the 6 million Medicare patients receiving home
health care, the reason(s) for emergent/hospitalization was respiratory (included COPD) -10%;
MI – 4.2%; Dehydration – 4.69%; UTI – 6.18%; Pain – 5.45%; Fall – 7.45%; HF – 7.51%;
Wounds – 4.8%; Respiratory infection – 8.81%. Home Health Agencies are individualized and
are gathering information on avoidable, unavoidable/not avoidable. Could Allient|GMCF
provide the top 10 reasons for Home Health Care?
b. Hospice/Palliative Care – three main root causes identified – 1) Comprehension of hospice –
how it works, transitions to “managed care” process 2) (Lack of) Providers mechanism in place,
3) Mechanism when “panic” present – go to what they know – call 911
5. Identify evidence-based tools
a. Report from Alliant|GMCF Survey conducted to assess use of Interact within the Nursing
Homes.
Respondents – 133/340
93% were complete
99% recognized that reducing readmissions is important
53% implemented Interact with 9 using all of the tools. The most frequently used tools are the
“Stop & Watch” (CNA required) with the SBAR identified as the most useful tool.
Drivers are being identified through Root Cause with 3 Targeted Drivers noted
b. SBAR has been use to bundle calls – urgent/non-urgent calls
c. Tools to track readmission rates – MDS; Trend Tracker
IV. Partner updates
1. Hospice (Jennifer Hale)
They will pull data. There are currently 190 Hospice organizations in Georgia. There is no requirement
at this time to report outcomes. This will be required in January, 2013 focusing on pain management
and the QI process. They are targeting teaching during the evaluation intake and are looking at the
process of advanced illness care and management and how to improve. Annual conference is in
February.
2. Nursing Home (Jon Howell)
The newsletter is being used to disseminate information. They are in the process of obtaining baseline
data. In June, Allient|GMCF toured 8 Council meetings and discussed the tools and resources available.
The Fall Council meetings (October) will include a discussion on the use of the Interact tools. Next
conference is set for January.
3. Evercare (Katherine Abraham-Evans)
An Advanced Care Planning over 3 – 6 months if done early is avoiding readmissions. They are
training the use of the Interact Tools, Homes are seeing a reduction. They are working on a national
Call with Ethica on the Interact Tools. GAMDA is having and meeting in January which will include a
discussion on Care Transitions. Alliant|GMCF will have a booth with the Personal heath Records,
Medicine Bags, SBAR Communication tools
4. Home Health Care (Sonya Baker) As noted in above
5. Alliant | GMCF (Mary Perloe, Linda Kluge, Dr. Rask)
Mary showed the maps depicting the highest readmission rates in the US and Georgia
The Community Healthcare Connection meetings are being held. Locations are based on the ability for
participants to travel within a 2 hour radius. It was noted that often times in the rural setting, the
conversation needs to be more local. According to the map, there needs to be a more concentrated effort
in the South Central and Central Eastern areas. Check out the Alliant |GMCF readmissions Do your Part
webpage where you will find the community health care connection site map and care transitions
resources.
V. Physician Ordered Life Sustaining Treatment (Added agenda item)
Jennifer provided a summary of the July 30, 2012 Georgia POLST Collaborative meeting. The goal is to
have one document that is transferrable among all providers. It is physician driven. The legal implications
were discussed. The current POLST document is available on-line.
The group is in the forming stages. They will be joining the National effort. Barrier noted: Inability for
Advanced Practice Nurse to sign. Future discussion will include: how to disseminate to consumer and
providers, funding.
VI. Next Steps
A. Who is missing from the table?
1. Representatives invited but unable to attend: Atlanta Regional Commission – Community-based
Care Transition Program; Aging and Disability Resource Center Georgia Charitable Network;
Georgia Primary Health Care
2. Others include:
a. Pharmacist (Community-based)
b. Case Management
c. AARP
d. Department of Public Health
e. Physician – Hospitalist; MAG; FP; IM
3. Please recommend individuals who may be interested in active membership. (Group)
Next meeting set for Friday September 7, 2012 from 10 a.m. – 12 Noon
Meetings:
October 10, 2012 10 a.m. – 12 Noon
November 14, 2012 10 a.m. – 12 Noon
Meeting Agenda items – Action Items Follow Up
1. Data
a. HEN
b. OASIS
2. RRLC Evaluations Review
3. Branding – Invitation
4. SBAR – Monthly Session topic?
5. Feedback from Jennifer’s (8/21) presentation
Community Healthcare Connections' Meetings
These meetings are open to health care providers in the community of care.
Upcoming Community Healthcare Connections meetings (2012):
September 6
2 p.m.
Macon - MCCG, Trice Auditorium
September 11 2-3:30 p.m.
Mt. Division - Dalton Community Center
September 27 10 a.m. - 12 p.m.
Broad River/Athens - Athens/Clarke County Dept. of Children & Family
Services Bldg., Conf. Rooms A&B
October 24
9-11 a.m.
WellStar - Cobb Hospital-Professional Building, Oran Conference Room
October 24
12 p.m.
Augusta - Brandon Wilde, Augusta
November 15 10 a.m. - 12 p.m.
Broad River/Athens - Athens/Clarke County Dept. of Children & Family
Services Bldg., Conf. Rooms A&B
December 6
Macon - MCCG, Trice Auditorium
2 p.m.
December 12 9-11 a.m.
WellStar - WellStar Development Center, Allatoona Room
For more information, contact Alliant | GMCF by calling (800) 982-0411
Reducing Readmissions Learning Collaborative
2012 Sessions At a Glance
January 3-4
February 8
Patient Safety Summit Building the Will
Learning Collaborative Kick off Reducing Readmission Learning Action Network (LAN)
March 7
Focus
Structure & Foundation
Session Topic*
April 4
Patient/Family Centric
May 2
Coalition Building and Community Partnerships to Reduce Readmissions
Community Organizing Part 1: Nursing Home – Tools – Interact Tools
Mary Perloe, RN, MS, GNP| Regional Coordinator
Integrating Care for Populations and Communities Alliant/GMCF
June 6
Patient/Family Centric
Structure & Foundation
Risk Assessment – Identifying post hospital need and risk of
readmission
Vivian Rayburn Director of Coordinated Care, Gwinnett Medical Center
July 11
Coalition Building and
Community Organizing
Community Partners: Part 2 – Home Health
August 1
Structure & Foundation
Reducing Readmissions Using Reliable System Process –
Dr. Roger Resar
September 5
Coalition Building and
Community Organizing
Area Agency on Aging/Aging Disability Resource Connection Centers
Cheryl Harris, CIRS-A Gateway/ADRC Program Coordinator
October 3
Coalition Building and
Community Organizing
Enhanced Services Program (ESP)
Community Based Service Demo/Implementation
November 7
Patient and Family
Engagement
Engaging the patient and caregiver in after hospital care plan
December 5
Celebrate
Celebrate Lessons learned and Sustaining the Gain
Proven Interventions
Mary Perloe, RN, MS, GNP| Regional Coordinator
Integrating Care for Populations and Communities Alliant/GMCF
Teach back Methodology
Mari Lou Keberly, RN Technical Advisor
Who is using Teach Back?
Sheila Martin, BSN, RN
Manager 4 South Acute Pulmonary Unit
COPD Teach Back Program Wellstar Kennestone
*Sessions are available on the Hospital Engagement Network Learning Collaborative
Focus
and Session Topics subject to change based on needs. Call in number: 770-980-9900
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