{"id":137,"date":"2016-05-03T14:56:22","date_gmt":"2016-05-03T18:56:22","guid":{"rendered":"http:\/\/blog.camberry.ca\/?page_id=137"},"modified":"2016-05-25T12:13:53","modified_gmt":"2016-05-25T16:13:53","slug":"137-2","status":"publish","type":"page","link":"https:\/\/blog.camberry.ca\/?page_id=137","title":{"rendered":"30 Day Hospital Readmission"},"content":{"rendered":"<p><strong><u>Hospital Readmission Rate for Primary Care Population <\/u><\/strong><\/p>\n<p>Percentage of acute hospital inpatients discharged with selected HIGs that are readmitted to any acute inpatient hospital for non-elective patient care within 30 days of the discharge for index admission, by primary care practice model.<\/p>\n<p>&nbsp;<\/p>\n<p>Indicator Calculation<\/p>\n<p>Total number of rostered patients with a hospital readmission in a given period x 100\/Total number of rostered patients who were admitted for a selected condition (based on HIG) in a given period<\/p>\n<p><strong><br \/>\n<\/strong><em>Direction of improvement: decrease<\/em><\/p>\n<p><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter size-full wp-image-131\" src=\"http:\/\/blog.camberry.ca\/wp-content\/uploads\/2016\/05\/HospitalReadmits.png\" alt=\"HospitalReadmits\" width=\"926\" height=\"573\" srcset=\"https:\/\/blog.camberry.ca\/wp-content\/uploads\/2016\/05\/HospitalReadmits.png 926w, https:\/\/blog.camberry.ca\/wp-content\/uploads\/2016\/05\/HospitalReadmits-300x186.png 300w, https:\/\/blog.camberry.ca\/wp-content\/uploads\/2016\/05\/HospitalReadmits-768x475.png 768w\" sizes=\"(max-width: 926px) 100vw, 926px\" \/><\/p>\n<p><strong>Summary\/Analysis<\/strong><\/p>\n<p>Trend appearing in regards to medication management. This is identified as an area of confusion and often a reason for readmission perhaps. Post discharge care in the form of house calls is a common approach.<\/p>\n<p><u>Effectiveness:<\/u><\/p>\n<p><strong>Alliston:<\/strong> focusing on COPD\/CHF group of patients to avoid readmissions<\/p>\n<p><strong>Aurora-Newmarket:<\/strong> Use of the HRM for post discharge care planning and use of advanced care planning and house calls where necessary<\/p>\n<p><strong>UHN Toronto Western:<\/strong> importance of medication reconciliation post discharge<\/p>\n<p><strong>Taddle Creek:<\/strong> working to combine approach with the 7-day follow up indicator, an important connection exists between the two. Focusing on collaboration of care between physicians and pharmacists.<\/p>\n<p><u>Recommendations:<\/u><\/p>\n<p>Not enough data to make recommendations for best practices.<\/p>\n<p>The importance of house calls is emerging from the other FHTs. Many of the successful FHT?s are implementing advanced care planning and communication with the hospital to receive discharge data and discharge planning.<\/p>\n<p><strong>DETAILS<\/strong><\/p>\n<p><u>Bancroft<\/u>????? <em>11.00 ?&gt; 24.00 <\/em><\/p>\n<ul>\n<li>Identify themes\/reasons why patients are readmitted<\/li>\n<li>To avoid readmission create a proactive CDM program and referral of patients to self-mgmt. programs<\/li>\n<\/ul>\n<p><strong>-&gt;?Once FHT has adequate access to hospital data through meditech, analyze this data to determine numbers and nature of hospital readmission<br \/>\n<\/strong><strong>-&gt;?educate patients and physicians about self-management programs available through CDM RN?s <\/strong><\/p>\n<p><u>?<\/u><\/p>\n<p><u>Kawartha North<\/u>?????? <em>11.00 ?&gt; 22.00 <\/em><\/p>\n<ul>\n<li>Ensure accurate data collection to ascertain current and future targets ? <strong>utilize QIDSS position and communication with hospital <\/strong>\n<ul>\n<li><em>Inpatient stay data is necessary from hospital to determine root cause <\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Alliston:?? ?<em>CB ? 8.00 <\/em><\/p>\n<ul>\n<li>Developed diverse system to follow patients to prevent readmissions<\/li>\n<li>Working closely with every COPD and CHF patient to ensure these patients have action plans, home care, or case manager within the team and within the community<\/li>\n<li>Patient and family education done via cardiac rehab, new pulmonary rehab or individual sessions at COPD\/CHF clinics<\/li>\n<li>These patients have priority access to rehabilitation programs<\/li>\n<\/ul>\n<p>Aurora-Newmarket FHT:??? <em>16.00 ? 10.00<\/em><\/p>\n<ul>\n<li>OT intervention by initiated House calls to ensure patient comfort at home<\/li>\n<li>Ensuring post-discharge follow up by accessing HRM for timely reports of patient discharge<\/li>\n<li>Care planning (advanced care planning when required)<\/li>\n<li>OT\/Physician\/NP House calls where necessary<\/li>\n<li>EPIC program to be in place to help ensure patients are getting proper care post-discharge and that they are following their care plans correctly<\/li>\n<\/ul>\n<p>Southlake FHT:? ?<em>0 ? 0<\/em><\/p>\n<p>UHN Toronto Western: ???<em>14.08 ? 18.41<\/em><\/p>\n<ul>\n<li>Engages with UHN to receive auto-notification of hospital readmissions, with HRM capability will be notified of patients beyond UHN being admitted to extend current protocols to those patients as well.\n<ul>\n<li><em>Recognize that small subset of patients in end stage of disease will be high ER users regardless of measures put in place<\/em><\/li>\n<\/ul>\n<\/li>\n<li>Pharmacy reconciliation for patients discharged with selected CMGs\n<ul>\n<li>Initiated an extension of our New patient BPMH (Best Possible Medication History) initiative where all patients post discharge have meds reviewed by pharmacist at time of first discharge appointment ? also working on process for patients followed in home bound program with a house call<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Taddle Creek:???? <em>4.00 ? 11.00 <\/em><\/p>\n<ul>\n<li>Went with the approach that improving 7 day follow up will also improve 30 day readmit rate<\/li>\n<li>Over time MDs did appreciate having discharged pt.?s brought to their attention<\/li>\n<li>Joint follow up apt.?s with pharmacist to focus on med mgmt. to avoid confusion<\/li>\n<li>Creating encounter assistant tool in EMR is useful<\/li>\n<li>Lack of coordination between hospital and community CCAC, no one knows who is handling discharge planning<\/li>\n<li>Need to record if pt. contacts physician before discharge summary is rec?d so it is caught as within the 7 days<\/li>\n<li>Some pt.?s live too far to come in or for home visits (define catchment area in future)<\/li>\n<li>Make process as collaborative as possible b\/c of resources\/expertise involved<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Hospital Readmission Rate for Primary Care Population Percentage of acute hospital inpatients discharged with selected HIGs that are readmitted to any acute inpatient hospital for non-elective patient care within 30 days of the discharge for index admission, by primary care practice model. &nbsp; Indicator Calculation Total number of rostered patients with a hospital readmission in [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":85,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-137","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/137","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=137"}],"version-history":[{"count":2,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/137\/revisions"}],"predecessor-version":[{"id":139,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/137\/revisions\/139"}],"up":[{"embeddable":true,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/85"}],"wp:attachment":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=137"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}