July 2012

Your hosts: Jody Rothe, MetaStar Stephanie Sobczak, WHA

Thank you to these organizations for sponsoring this webinar series:

A special thank you to the Wisconsin Clinical Resource Center for serving as the home base for recorded webinars and materials related to the INTERACT II collaborative

Readmissions in Wisconsin Overview of INTERACT II Convening a Team Measuring Case Review Tools Data Entry 30 day Action Items

Please be sure your phone lines are muted to keep background noise to a minimum.

Help patients heal without complication.

Reduce all hospital readmissions by 20%

Which means

1.6 million patients will recover from illness without

suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

In one yearin Wisconsin

nearly 30,000 people experienced a

potentially preventable readmission

10,000 more residents will fall asleep on their own pillow.

Care is not interrupted Nursing Homes, Hospitals and Home Health

all work together for what’s best for the patients/residents.

Hospital Type

To Home To SNF To Home Health Agency

Other

Wisconsin PPS26,219

13,617 6,831 3,768 2,003

Wisconsin CAHs2,339

1,379 501 133 326

All Wisconsin Hospitals28,558

14,996 6,332 3,901 2,329

30 day All Cause, All Cases Readmissions to various sites(Medicare Beneficiaries only)

What past experience do you have in actively working on reducing readmissions to the hospital?

We have worked with other local organizations (hospitals, home health, community organizations, etc.)

We have worked on internal process improvements for many months

We’ve just started working on internal process improvements

We have not formally worked on reducing readmissions.

Invite & send

Agenda to Webinar/Conferenc

e Call

30 day Tasks

2 or 3 things to

try

Touch base

Survey

Serves as reminder

Learning Content

&

Interaction or

Guests

Interim Coaching, Reminders and Support

Data Submissio

n&

Analysis

Day 30

Day 15-ish

Day 10

Day 1

July Overview & Case Review Tools

August Communication ToolsSeptember Early Warning ToolsOctober Change in Condition ToolsNovember Resident Transfer ToolsDecember Continuous Improvement

Tools

Focused on Long-Term Care settings specifically

It is evidence based standard of practices It is proven to work It is a toolkit that can be customized to your

facility

http://interact2.net/

1.Is a charge nurse on your team?2.Are at least two staff members

involved in direct resident care on your team?

3.Can you have a social worker or admission/discharge planner on your team?

17

Organizer

Meeting Convener

Data Reporter

Can someone ensure there is a room to meet in with a phone, and a screen when needed? Print materials? Put dates on calendars?

Can someone help define meeting topics and planned discussions?

Can someone gather data for display? Can some be in charge sending data to Megastars?

18

Documenter

Implementation Leader

Can someone track tests of change and decisions on adopting tools?

Can someone help determine when and how to write the P & P and when and how to train others?

What type of representation is on your INTERACT II team?

Primarily organization leaders and managers

Managers only Managers and front-line staff together Mostly front-line staff and a manager

Three things are required for success:1. Attendance on calls –

Will be based on webinar login by facility

2. Submitting data – Outcome and Process measures Send data collected by the end of the month

3. Trying out and testing the tools in between monthly webinars.

21

Aims

Measurement

Change ideas

Testing ideas before implementing changes

Plan:

Systematically Review the past 5 hospital admissions or ER transfers.

Are there common occurrences across the sampled residents?

From this review, can you summarize what your team would like to accomplish in the next 6 months?

AIM Statement:

Are there any questions so far?

Collecting data doesn’t have to be complicated

It can be extracted from your electronic record keeping systemOR

A team member, or two, can take on a task of keeping track of each hospital admission or ER transfer

Date # Hospital Admissions

# ER Transfers

Data Collector

7/12/12 0 2

7/13/12 0 0

7/14/12 1 0

7/15/12 0 1

This can be kept track of DAILY or WEEKLY

Need to track improvement to enhance the learning

Answers: “How do we know these changes have made a difference?”

Shows were improvements can be targeted.

Tracking Hospital Admissions and Transfers to ER per month.

Number of Admissions & Transfers

July Aug Sept Oct Nov Dec

20

15

10

5

0

Linking Improvement to Interventions

Number of Admissions & Transfers

July Aug Sept Oct Nov Dec

20

15

10

5

0

SBAR Trial Stop & Watch

Tools Trial

Change in Condition Tools

Are you currently tracking your readmission rate or number of transfers to the hospital/ER?

YesNo

https://www.metastar.com/web/custom/WiQCINTERACTdataentry.asp

This is a secure web page provided by MetaStar for this INTERACT II collaborative

Determine your data tracking method Determine who will enter the data on the MetaStar

website. Team members will receive an e-mail with secure

login information (will be sent by July 19th) Data should be entered by the 30th of the month

for the month prior (example: submit by July 30 for June data)

Aggregate data will be posted to the WCRC website.

You should track your own data from month to month

This will be your CMS provider number

This will be sent to you from MetaStar (via e-mail)

1. Case Review Tool2. Example check sheet for data collection3. Graph format for posting4. Dr. Ouslander’s slides:http://innovations.cms.gov/Files/slides/rahnfr_hospitalizations_slides.pdf

https://wcrc.chsra.wisc.edu

Review 5 cases of transfers or readmissions from hospitals

Use the tool to analyze the factors leading to the readmission

Plan your team gatherings Begin collecting data

An on-line Feedback Tool will be send after August 1st to assess your progress on these tasks.

Thank you!

See you next month

Next month: Communication Tools