Using the Centralized Care Transition Call Model and Discharge Lounge to Reduce Readmissions and Improve Patient Experience

Pam Castleman,CNO Gwendolyn Reese, Nursing Director

Regional One Health Regional One Health is home to the oldest hospital in Tennessee, chartered in 1829.

Care Transition Call Model Outcomes of hardwiring care transition calls     

Reduction in readmissions Improvement in compliance Increase in patient perception of care Opportunity to recognize staff Improvement in clinical outcomes

Care Transition Call Model CNO early supporter of a centralized model for calls due to the following:     

Scheduled implementation of new clinical documentation system Request of new CNL for more responsibility Budget cycle Presence of discharge lounge Availability of prn clinical staff

Business Case for Centralized Model  No additional FTE’s required for pilot  Evaluation of nursing workload  Readmission rates for patient populations  Discharge instruction scores

 Presence of patient educator

Centralized Model Development  Identification of Nursing Director passionate about project  Assignment of CNL as Project Manager  Assignment of IT partner  Development of population specific questions

 Development of profile for assigned staff

Planning Phase of Centralized Model  Assignment of CNL as Project Manager  Determination of IT requirements  Selection of questions for patient populations  Development of job description for quality screeners

Planning Phase of Centralized Model • The most important decision during the planning phase was to make sure the questions were relevant to the patient population we serve

 Do you know the date and time of your follow-up appointments?  Do you have questions about your medication regimen?  Do you have any questions about how to care for yourself since discharge?

 Special questions for CHF, Sickle Cell ,CAP

Early Challenges  Inability to reach patients after discharge  No transition preparing patients for post-discharge calls  Escalations shared with managers but no knowledge of actions  Inclusion of patient population discharges as staff added

Creative Solutions  Incorporation of staff in discharge lounge to link discharge with care transition calls  Addition of prn staff to increase number of calls and visit all pending discharge patients  Utilization of patient education nurse to reinforce discharge teaching as well as introduce post visit call  Assignment of nurse managers to listen to calls  Posting of escalation information on units

• Video of quality screener with patient

Contact Summary By Unit – Discharge/Encounter Dates from: 6/1/2012– 8/31/2012 Patients Attempted

Patient Contacts Completed

Patients Completed

Patients Do Not Call

Patients Wrong Number

Patients Patients Contacts Not In Progress Contacted Contacts In Progress

Patients Not Attempted

Patients Dropped

Due To Attempts

Due To Time

Patient Counts

Patient Patients Total Removed

Net Patient Total

Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent 545

95.11%

321

56.02%

12

2.09%

97 16.93%

0

0.00%

0

0.00%

115

20.07%

28

4.89%

578

5

573

B41 4N Jefferson

81 100.00%

57

70.37%

3

3.70%

11 13.58%

0

0.00%

0

0.00%

10

12.35%

0

0.00%

81

0

81

B42 Trauma Stp Dn 4S Jefferson

20 100.00%

15

75.00%

0

0.00%

3 15.00%

0

0.00%

0

0.00%

2

10.00%

0

0.00%

20

0

20

B51 Med/Sur 5N Jeff (J5b1)

35 100.00%

18

51.43%

1

2.86%

11 31.43%

0

0.00%

0

0.00%

5

14.29%

0

0.00%

35

0

35

B52 Med/Surg 5S Jeff (J5b2)

35 100.00%

23

65.71%

0

0.00%

4 11.43%

0

0.00%

0

0.00%

8

22.86%

0

0.00%

35

0

35

C41 Pcu 4 Center Jeff (J4c)

27 100.00%

15

55.56%

0

0.00%

5 18.52%

0

0.00%

0

0.00%

7

25.93%

0

0.00%

29

2

27

C51 5N Center Jefferson (J5c1)

48 100.00%

24

50.00%

3

6.25%

11 22.92%

0

0.00%

0

0.00%

10

20.83%

0

0.00%

48

0

48

C52 5S Center Jefferson (J5c2)

41 100.00%

24

58.54%

1

2.44%

8 19.51%

0

0.00%

0

0.00%

8

19.51%

0

0.00%

42

1

41

D42 Sicu 4S Jefferson

2 100.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

2 100.00%

0

0.00%

2

0

2

D43 Micu 4S Jefferson

6 100.00%

3

50.00%

0

0.00%

2 33.33%

0

0.00%

0

0.00%

1

16.67%

0

0.00%

6

0

6

D44 Cicu 4S Jefferson

2 100.00%

2 100.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

2

0

2

Total Unit

Discharge/Encounter Date

D51 5S Post Trauma Jeff (J51) Discharge Room

92 100.00%

50

54.35%

2

2.17%

18 19.57%

0

0.00%

0

0.00%

22

23.91%

0

0.00%

92

0

92

136 100.00%

76

55.88%

1

0.74%

20 14.71%

0

0.00%

0

0.00%

39

28.68%

0

0.00%

138

2

136

Jefferson Er Inpatient

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

5 100.00%

5

0

5

Jts Ticu Ground Jefferson

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

3 100.00%

3

0

3

Med Rehabilitation Inpatient

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

20 100.00%

20

0

20

20 100.00%

14

70.00%

1

5.00%

4 20.00%

0

0.00%

0

0.00%

1

5.00%

20

0

20

Tbc Turner Burn Center

0

0.00%

Contact Summary By Unit – Discharge/Encounter Dates from: 1/1/2014 – 3/31/2014 Patients Attempted

Patient Contacts Completed

Patients Completed

Patients Do Not Call

Patients Wrong Number

Patients Patients Contacts Not In Progress Contacted Contacts In Progress

Patients Not Attempted

Patients Dropped

Due To Attempts

Due To Time

Patient Counts

Patient Patients Total Removed

Net Patient Total

Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent 1014

99.80%

775 76.28%

35

3.44%

19

1.87%

0

0.00%

0

0.00%

185 18.21%

2

0.20%

1114

98

1016

159 100.00%

125 78.62%

5

3.14%

3

1.89%

0

0.00%

0

0.00%

26 16.35%

0

0.00%

165

6

159

B42 Trauma Stp Dn 4S Jefferson

50 100.00%

37 74.00%

1

2.00%

0

0.00%

0

0.00%

0

0.00%

12 24.00%

0

0.00%

54

4

50

B51 Med/Sur 5N Jeff (J5b1)

80 100.00%

60 75.00%

2

2.50%

2

2.50%

0

0.00%

0

0.00%

16 20.00%

0

0.00%

84

4

80

B52 Med/Surg 5S Jeff (J5b2)

76 100.00%

55 72.37%

4

5.26%

1

1.32%

0

0.00%

0

0.00%

16 21.05%

0

0.00%

84

8

76

C41 Pcu 4 Center Jeff (J4c)

64 100.00%

48 75.00%

3

4.69%

2

3.13%

0

0.00%

0

0.00%

11 17.19%

0

0.00%

68

4

64

C51 5N Center Jefferson (J5c1)

72 100.00%

52 72.22%

0

0.00%

3

4.17%

0

0.00%

0

0.00%

17 23.61%

0

0.00%

84

12

72

C52 5S Center Jefferson (J5c2)

79 100.00%

63 79.75%

5

6.33%

0

0.00%

0

0.00%

0

0.00%

11 13.92%

0

0.00%

86

7

79

D42 Sicu 4S Jefferson

9 100.00%

7 77.78%

0

0.00%

0

0.00%

0

0.00%

0

0.00%

2 22.22%

0

0.00%

11

2

9

D43 Micu 4S Jefferson

14 100.00%

12 85.71%

1

7.14%

0

0.00%

0

0.00%

0

0.00%

1

7.14%

0

0.00%

15

1

14

D44 Cicu 4S Jefferson

13 100.00%

9 69.23%

3 23.08%

0

0.00%

0

0.00%

0

0.00%

1

7.69%

0

0.00%

14

1

13

Total Unit

Discharge/Encounter Date

B41 4N Jefferson

D51 5S Post Trauma Jeff (J51)

124

99.20%

95 76.00%

4

3.20%

3

2.40%

0

0.00%

0

0.00%

22 17.60%

1

0.80%

140

15

125

Discharge Room

254

99.61%

197 77.25%

6

2.35%

3

1.18%

0

0.00%

0

0.00%

48 18.82%

1

0.39%

287

32

255

20 100.00%

15 75.00%

1

5.00%

2 10.00%

0

0.00%

0

0.00%

2 10.00%

0

0.00%

22

2

20

Jts Ticu Ground Jefferson

Escalation Data Drives Improvement PCM Escalation Reasons

Pain

Cleanliness of Hospital

MD Communication

Other

Patient's Response

Discharge Process

Nursing Communication

Responsiveness of Staff

0

5

10

15

20

25

Benefits of Centralized Model •

Serial phone calls and special features for clinical follow-up to reduce preventable readmissions. CHF, DM, and CAP patients are called every 7 days after discharge for a total of 3 surveys.

• Call documentation that meets medical record requirements • Ability to identify and update patient registration information • Excellent data collection with detailed reports

Regional One Health Readmissions Hospital Admissions vs. Readmissions 2012

1122

1200 1000

940

866

Number of Patients

800

991

897

842

974

987

986

978

970

989

Hospital Total Admissions

600 400

Hospital Total Readmissions 65

200

53

50

44

46

60

38

0 JAN

FEB

MAR

APR

MAY

JUNE

JULY

54

AUG

32

SEP

53

OCT

62

NOV

Readmit Excludes : -Deliveries - Newborns - Rehab admits

63

DEC

2012

Hospital Total Admissions

Hospital Total Readmissions

JAN 1122

FEB 866

MAR 940

APR 842

MAY 897

JUNE 991

JULY 974

AUG 987

SEP 986

OCT 978

NOV 970

DEC 989

65

53

50

44

46

60

38

54

32

53

62

63

Regional One Health Overall Hospital and Sickle Cell Patient Readmission Rate MED vs. Sickle Cell Disease Readmission Rate - 2012

30.94%

25.94%

Rate

20.94%

15.94%

SSD READMIT % MED READMIT % Linear (SSD READMIT %)

10.94%

Linear (MED READMIT %) 5.94%

0.94% JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Averag e

SSD READMIT % 14.29% 12.50% 20.00% 15.79% 8.33% 12.50% 4.55% 13.64% 20.00% 17.39% 26.32% 12.50% 14.82% MED READMIT % 5.79% 6.12% 5.32% 5.23% 5.13% 6.05% 3.90% 2012 5.47% 3.25% 5.42% 6.39% 6.37% 5.37%

Impact of Care Transition Calls on Readmissions

Financial Impact of Discharge Teaching and Care Transition Calls on Sickle Cell Readmissions

SICKLE CELL

Annual Charges

BASELINE $ 14,755,744 GOAL Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Project To Date

IP Patients 272 7 5 10 12 7 8 11 8 12 80

Charges/IP Patient $

54,249

$ 379,743 $ 271,245 $ 542,491 $ 650,989 $ 379,743 $ 433,992 $ 596,740 $ 433,992 $ 650,989 $ 2,224,211

Estimated Readmisssion Readmissions Based Rate on Actual Volume 14.80% 5.00% 14.29% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 8.33% 2.50%

*Includes benefit of shifting IP Volume to OP Setting, Avoiding Readmissions

3.35 3.35 3.35 3.35 3.35 3.35 3.35 3.35 3.35 16.77

Actual Readmissions

Cost Of Est. Readmission

40 14 1 0 0 0 0 0 0 0 1 2

$ 2,183,850 $ 737,787 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951

Estimated Cost Avoidance $ 1,446,063 $ 127,702 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 181,951 $ 127,702 $ 1,529,064

Thank you for your time Pam Castleman, Chief Nursing Office [email protected] Gwendolyn Reese, Director of Nursing [email protected]