30-Day Readmission Reduction for Skilled Nursing Facility Readmissions at an Urban Medical Center (TH323B)

Abstract

•Describe the factors that impact readmission of patients with chronic illness being managed at Skilled Nursing Facilities.•Recognize the key drivers that improved communication will try to achieve by the warm handoff protocol.•Describe creation of a comprehensive discharge packet with a relevant summary of hospital course. Unplanned 30-day hospital readmissions are an important measure of hospital quality and a focus of national regulations. The readmission rate for patients being discharged to skilled nursing facilities (SNF) has been an area of improvement for all healthcare systems. The vast majority of SNF will receive a penalty on their Medicare payments for fiscal year 2019 for poor 30-day readmission rates back to hospitals. We aim to reduce the 30 day all cause readmission rate at an urban medical center for skilled nursing facility discharges from the collaborative from Accountable Care Unit from 18% in 2018 to 16% from April to December 2019 at the largest teaching campus for the health system. We used our palliative care training to help improve the communication between 2 facilities. Through the discovery phase some potential Key Drivers identified for the readmissions are lack of verbal communication/wound care orders/nutrition and feeding orders/comprehensive discharge summary/advance directives. Change Concepts devised include a warm handoff between the discharging team and receiving team at SNF, creating a comprehensive discharge packet, improve the hospital course in the discharge summary, create a standardized system for discharge to a skilled nursing facility. We are in process of PDSA Cycle 3. Results of PDSA Cycle 1 and 2 for warm handoff and creating a comprehensive discharge packet show a reduction of 40% for the readmissions. PDSA Cycle 1: 10 patients were discharged after a warm handoff was given to SNF and left facility with a comprehensive discharge packet. At end of 30 days of PDSA Cycle 1, only 4 patients were readmitted. Multiple change concepts and PDSA cycles are ongoing. PDSA Cycle 2 is ongoing. By improving communication between 2 facilities, we achieved our aim in the initial PDSA Cycle by implementing our palliative care skills. We aim to continue to discover other factors and decrease readmission for chronically ill nursing home patients at our urban medical center.