1. Transitions of Care Post Discharge:
Process, Focus and Lessons Learned
March 28, 2015

2. ACMQ – March 2015
Transitions of Care
Impact of Hospital Readmissions
• 39 million hospital discharges in the US in 2006
• ~ 20% of discharged hospitalized Medicare patients readmitted
within 30 days
• Unplanned readmissions accounted for 17% of total hospital
payments from Medicare in 2004 at a cost of $17.4 billion
• Preventing avoidable readmissions impact:
– patient’s quality of life
– hospital’s financial status

3. ACMQ – March 2015
Transitions of Care
• Interventions:
– multifaceted and complex
– support patient self care
• Collaborative interventions that impact favorably on outcomes:
– medication reconciliation
– structured electronic discharge summaries
– discharge planning
– facilitated communication

4. ACMQ – March 2015
Transitions of Care
• Medications and Medication reconciliation
– 2013 study reduced post-discharge ER visits but not
readmissions;
– Adverse drug reactions occur in 20% of discharged pts
– 2/3 of ADR’s may be preventable
– Home visits for medication optimization trends to reduction of
readmission rates by nearly 50%

5. ACMQ – March 2015
Transitions of Care
• Discharge summary as a Transition Document:
– communication between hospital physicians and the primary care
providers (PCPs)
– Available only 12-34% of the time at follow-up office visit
– Often lacks key information
– Pending tests mentioned only 25% of the time

6. ACMQ – March 2015

7. ACMQ – March 2015
Memorial Healthcare System (MHS) Pillars of Excellence
7

8. ACMQ – March 2015 8
Clinical Effectiveness Project Team
Clinical effectiveness enhancements:
External Collaborations Internal Enhancements
•South Broward Community Care
Coalition (SBCC)
•Transitional Care Pilots
•Utilization Review
•Care Coordination
•Clinical Effectiveness Coverage
Model

9. ACMQ – March 2015
Clinical Effectiveness Strategies
9
Prevention of
Readmissions
Transitional Care
Education /
Communication
Medication Reconciliation

10. ACMQ – March 2015
Transitional Care
10
• Identification and enhanced communication, appointment made with PCP
• Transitional coaches in the home
• Work with community care partners, e.g. SNF’s, HHA, to
meet needs of patient without hospitalization
Prevention of
Readmissions
Transitional Care
Education /
Communication
Medication Reconciliation

11. ACMQ – March 2015
South Broward Community Coalition Workgroups
11
The SBCC is comprised of MHS and ~ 20 community partners

12. ACMQ – March 2015
Work Group #2: Physician to Physician Communication
12
Goal Statement Team
Improve communication between providers by ensuring open
dialogue, adequate hand offs and delineation of responsibilities
Lead: Dan Westphal, M.D.
MHS: Scott Oxenhandler; M. D.
Jennifer Kadis, RN
Community:
Home Health:
SNF:
Opportunities Potential Solutions
 Breakdown in communication and lack of handoffs between
hospitalists and primary care physicians
 Shared information with PCPs
 Delineation of responsibilities post discharge
 Post-discharge call center
 Late discharges due to lack of adequate communication  Early identification of patient disposition
 Early initiation of discharge planning

13. ACMQ – March 2015
SBCC
PHYSICIAN COMMUNICATION
Goals and Key Deliverables
•‘Best Practice’ DC summary format and elements researched and completed
•Input from SBCC stakeholders
•Pilot with MHP hospitalists
•DC summary to be completed within 24 hours
•Monthly sampling per physician was to ensure timing and completeness

14. ACMQ – March 2015
SBCC
PHYSICIAN COMMUNICATION
Existing Barriers
•Physician buy-in to using new template
•24 hour timeframe
•Scale of expanding usage to the MHS Medical Staff
•Culture change: Discharge summary as transitional care document as
opposed to closure of hospitalization episode
– Hospitalist model of care
– Increasing Outpatient/ Home Care options

15. ACMQ – March 2015
DISCHARGE SUMMARY FORMAT
TJC Required elements
• Reason for hospitalization
• Procedures performed
• Care, treatment and services provided
• Patient’s condition and disposition at
discharge
• Information provided to patient and family
• Provisions for follow up care

16. ACMQ – March 2015
MHS Discharge Summary Format
• Date of Admission/Date of Discharge
• Primary and Secondary Discharge Diagnosis
• Consultation(s)
• Procedures
• Hospital Course
• Abnormal test results (lab and/or imaging)
• Discharge Medications (per Discharge Medication Reconciliation)
• Allergies or Adverse Drug Reactions

17. ACMQ – March 2015
MHS Discharge Summary Format – con’t
• Discharge Instructions
• Follow-up & Outstanding Issues/Tests
• Discharge Disposition
• Condition (functional status) at Discharge
• Special issues (pending tests or education requiring follow-up)
• Documentation of Physical or Mental Impairment or Handicap

18. ACMQ – March 2015
Primary Care Physician (PCP) Notification
• PCP office telephone numbers captured in EPIC with ongoing
updates
• PCP Admission and Discharge fax notification implemented by IT
• Starting 12/2/13, the MHS began automatically sending discharge
summaries by fax to the discharging physician and to the PCP of
record
• Concurrent with Stage II Meaningful Use - Transitions of Care

19. ACMQ – March 2015
Discharge Summary Gap Analysis
19
Industry Best Practices Current State
Admit Date Currently exists
Discharge Date Currently exists
Discharge Physician Currently exists
Primary Discharge Diagnosis Currently exists but MUST update Problem List in EPIC 1st
Secondary Discharge Diagnosis Currently exists but MUST update Problem List in EPIC 1st
Tertiary Discharge Diagnosis Currently exists but MUST update Problem List in EPIC 1st
Consultation / s MUST be dictated
Procedures
OR procedures can be populated, all others (e.g. Cardiac Cath, IR, Bedside etc..)
MUST be dictated
Hospital Course MUST be dictated
Abnormal Test Results (Lab or Imaging) Abnormal OR pertinent normals MUST be dictated
Discharge Medications (per Discharge Med Rec)
Currently exists
Allergies / Adverse Drug Reactions Currently exists
Discharge Instructions MUST be dictated
Pending Tests & Issues Pending Results currently exists
Discharge Disposition Currently exists if noted in Discharge Order
Condition at Discharge MUST be dictated
Documentation of Physical, Mental Impairment or Handicap MUST be dictated
Code Status Currently exists
Wound Issues and Care MUST be dictated
Diet MUST be dictated
Activity MUST be dictated
PCP Office Number Currently exists

20. ACMQ – March 2015
Physician to Physician Communications: Wrap Up
Goal Statement: Improve communications between providers and post discharge care
takers by ensuring open dialogue, adequate handoffs and delineation of
responsibilities by defining and enhancing what, when and how information should be
communicated.
20
In Scope Deliverables Status
• Admit Notifications between MHS
facilities and PCP’s
•Discharge Communications
between MHS facilities and PCP’s,
Long Term Care Facilities, Rehab,
Skilled Nursing Facilities, Home Health
/ Alternate Living Facilities, Hospice
Completed ‘best’ practice discharges summary research Completed
Enhanced transition document with input of SBCC stakeholders Completed
Captured PCP office telephone numbers in EPIC with ongoing updates Completed
Implemented discharge fax notification with IT Completed
Completed random telephone interview with physician office managers to confirm transition
care document delivery – positive response from PCPs
Completed
Lessons Learned: Using a small group pilot; eliminating duplication of efforts and information; making
process easier, faster and more complete via automation, yet preserving human
interaction; and incorporating end-users’ needs all contribute to success.
Existing barriers: Ensuring the transition / discharge summary completed within 24 hours
Wrap Up: Roll out the format in EPIC to the entire medical staff

21. ACMQ – March 2015 21

22. ACMQ – March 2015
MHS Contact Information
Dan Westphal, M.D. Jennifer Kadis, RN
Director of Medical Affairs Administrative Director,
Memorial Hospital Pembroke Clinical Effectiveness
dwestphal@mhs.net Memorial Healthcare System
954-883-8401 jkadis@mhs.net
954-265-5449
Scott Oxenhandler, M.D.
Chief Medical Information Officer
Memorial Healthcare System
soxenhandler@mhs.net
954-987-2000
22

23. ACMQ – March 2015
APPENDIX
23

24. ACMQ – March 2015
South Broward Community Coalition Work Groups
24

25. ACMQ – March 2015
Work Group #1: Nursing and Case Management Communication
25
Goal Statement Team
Ensure safe transitions of care through advanced planning of
discharges and enhanced communications between hospitals,
SNFs and HHAs
Lead: ____________________
MHS:
Home Health:
SNF:
Opportunities Potential Solutions
 Lack of communication at time of discharge between case
manager, HHAs and SNFs (e.g., patient’s behavioral health
status, challenging family members)
 Enhance verbal communication
 Access to hospital records
 Improve post-discharge follow up
 Involve post-acute care agencies earlier in the stay  Earlier discharge planning
 Earlier communication with post-acute service
 Insurance case management involvement

26. ACMQ – March 2015
Nursing / Case Management Communications: Wrap Up
Goal Statement: Ensure safe transitions of care through enhanced
communications between hospitals, SNFs, Long-Term Acute Facilities,
HHA’s, Assisted Living and Hospice
26
In Scope Deliverables Status
•Discharge Communications
• AMI / CHF / PN / COPD Patients
• Pilot at 1-2 hospitals
• All Payers
• All Community Partners
•Inter-Organizational Transitions of
Care
Team developed Transition of Care Form for implementation Completed
Implement use of form
At-Risk
(Delayed)
Wrap-up Plan: EPIC is currently developing a report that can be sent via EPIC to the
provider.

27. ACMQ – March 2015
Work Group #2: Physician to Physician Communication
27
Goal Statement Team
Improve communication between providers by ensuring open
dialogue, adequate hand offs and delineation of responsibilities
Lead: Dr. Dan Westphal
MHS:
Community:
Home Health:
SNF:
Opportunities Potential Solutions
 Breakdown in communication and lack of handoffs between
hospitalists and primary care physicians
 Shared information with PCPs
 Delineation of responsibilities post discharge
 Post-discharge call center
 Late discharges due to lack of adequate communication  Early identification of patient disposition
 Early initiation of discharge planning

28. ACMQ – March 2015
Physician to Physician Communications: Wrap Up
Goal Statement: Improve communications between providers and post discharge care
takers by ensuring open dialogue, adequate handoffs and delineation of
responsibilities by defining and enhancing what, when and how information should be
communicated.
28
In Scope Deliverables Status
• Admit Notifications between MHS
facilities and PCP’s
•Discharge Communications
between MHS facilities and PCP’s,
Long Term Care Facilities, Rehab,
Skilled Nursing Facilities, Home Health
/ Alternate Living Facilities, Hospice
Completed ‘best’ practice discharges summary research Completed
Enhanced transition document with input of SBCC stakeholders Completed
Captured PCP office telephone numbers in EPIC with ongoing updates Completed
Implemented discharge fax notification with IT Completed
Completed random telephone interview with physician office managers to confirm transition
care document delivery -
Completed
Lessons Learned: The process of how to develop physician communications by means of the discharge
summary format and ensure it meets the needs of patients, physicians and other
stakeholders.
Existing barriers: Ensuring the transition / discharge summary completed within 24 hours
Wrap Up: Roll out the format in EPIC to the entire medical staff

29. ACMQ – March 2015
Work Group #3: Medication Reconciliation
29
Goal Statement Team
Ensure accurate and consistent delivery of medication information
and necessary scripts to the patient/family and/or facilities
Lead: _________________
MHS:
Community:
Home Health:
SNF:
Opportunities Potential Solutions
 Inconsistent medication reconciliation and lack of prescriptions  Patient medication refill instructions
 Concise and accessible medication reconciliation
 Better management of prescriptions
 Educate physicians

30. ACMQ – March 2015
Medication Reconciliation: Wrap Up
Goal Statement: Ensure accurate and consistent delivery of medication
information and necessary scripts to the patient / family and / or facilities
30
In Scope Deliverables Status
• Inter-facility Medication Reconciliation
Process
 MHS to SNF
 MHS to HHA / ALF
 SNF to HHA / ALF
 SNF to MHS
 HHA / ALF to MHS
• Transitions of Care
• Tools and Technologies
• Education / Communication to Patients /
Families
• Needs Assessment
• Gap Assessment Between Current State and Defined Needs
• Daily Report
Completed
• Key Performance Indicator(s) Baseline and Methodology
• Process and Enabling Tools / Technology Opportunities
Assessment
On-Track
Lessons Learned / Wrap Up: Subject matter experts need to be a part of the team (pharmacy);
Competing initiatives can interfere with team commitments; Goal needs
to be very specific and manageable; Receiving entity needs point of
contact from sender for real time resolution of questions

31. ACMQ – March 2015
Work Group #4: Palliative Care
31
Goal Statement Team
Ensure appropriate use of palliative care services Lead:
Assistant Leads:
MHS:
Community:
Home Health:
SNF:
Opportunities Potential Solutions
 Lack of palliative care/end-of-life care discussions
 Limited accessibility and availability of palliative care physicians
 Establish a Palliative Care program
 Provider training and awareness

32. ACMQ – March 2015
Palliative Care: Wrap Up
Goal Statement: Provide goal directed, comforting care for patient and family through the
appropriate, timely use of palliative care services within the South Broward Community
32
In Scope Deliverables Status
• Palliative Care
• All Community Partners
• General Awareness Communication
• Education for Clinical and Non-Clinical
Educated emergency department nurses and physicians on
palliative care
Completed
Lessons Learned: Many misconceptions about what palliative care is amongst health care team
Existing Barriers: Lack of coverage for outpatients in need of palliative care; inconsistent
communication about plan of care; reluctance of families to discuss plan of care,
advanced directives and end of life
Wrap Up: 1. Strategic Education plan for community
2. Formal education content for new employee orientation
3. Consistent education content for new employee orientation

33. ACMQ – March 2015
South Broward Community Coalition
33
Hollywood Rehab
Medcare Home
Health
Presidential Home
Health