Three sentences summarizing the document: The document outlines St. Joseph's/Candler Health System and describes their efforts to establish an outpatient discharge clinic to help reduce preventable hospital readmissions. It provides background on hospital readmission penalties, describes the clinic's methods and services, and presents initial positive results showing a lower readmission rate for patients who utilized the clinic compared to those who did not. The document also reviews limitations and best practices from other successful transition of care programs aimed at further reducing readmissions.

1. ST. JOSEPH’S/CANDLER
OUTPATIENT DISCHARGE
CLINIC
Capstone Project  Ambra R. Brown  Fall 2015

2. ST. JOSEPH’S/CANDLER HEALTH SYSTEM (SJC)
• The region's only faith-based, not-for-profit health system
• Two locations:
• Located on Savannah's south side, St. Joseph's Hospital is a 330-bed acute care hospital
founded in 1875 by the Sisters of Mercy.
• Located in Savannah's Midtown, Candler Hospital is Georgia's first hospital (1804) and
the second oldest continuously operating hospital in the United States, 384-bed facility.

3. READMSSIONS
• According to CMS, historically about one in five Medicare patients discharged from a hospital are
readmitted within 30 days.
• Rates vary substantially by:
• Hospital
• Geographic Area
• Type Of Disease
• Severity Level Of The Patient’s Condition
• Medicare Payment Advisory Commission (MedPAC) concluded that about three-quarters of
readmissions within 30 days were potentially preventable, representing an estimated $12 billion in
Medicare spending.

4. HOSPITAL READMISSION REDUCTION
PROGRAM (HRRP)
• Reduce Inpatient Prospective Payment System (IPPS) payments to hospitals for
excess readmissions beginning October 1, 2012 (FY 2013)
• Payment adjustment occurs for hospitals with an excess readmissions ratio
• Excess readmission ratio = actual readmissions/expected readmissions
• Goal: Improve healthcare by linking payment to the quality of hospital care.

5. PENALTIES
READMISSION MEASURES
FY2013 & FY2014 FY2015 FY2016 FY2017
ACUTE MI COPD - CABG SURGERY
HEART FAILURE THA -
PNEUMONIA TKA -

6. PENALTIES
Name
FY2013
Readmission
Penalty
FY2014
Readmission
Penalty
FY2015
Readmission
Penalty
FY2016
Readmission
Adjustment Factors
Candler Hospital 0.06% 0.19% 0.07% 0.9999
St Joseph's Hospital 0.00% 0.00% 0.05% 0.9994
Memorial Health 0.02% 0.12% 0.73% 0.9925
Readmissions Adjustment Factors (RAF)
RAF = 1.000  No penalty
Any Number between .9999 - .9700 = penalty

7. Diagnosis: Kidney Failure
Normal reimbursement = $15,000
1.5% Penalty = $225 deduction
New Reimbursement after penalty = $14,775

8. ST. JOSEPH’S/CANDLER'S OUTPATIENT
DISCHARGE CLINIC
Center for Medication Management

9. PURPOSE
• “To determine if patients seen in a pharmacist-managed outpatient clinic post
discharge from the hospital are less likely to be readmitted within 30 days of
discharge.”

10. THE CLINIC
• Outpatient pharmacist-managed, hospital based clinic
• Focuses on
• Medication management
• Coordination of care among healthcare disciplines
• Patient compliance
• Disease education
• Staff
• Three pharmacists, two NPs, clerical
• Hours of Operation
• Monday – Friday
• 8am – 5pm
• Clinical on-call answering service afterhours & weekends

11. METHODS
INPATIENT
Patient
Admitted
Screened for
Readmission
Risk
Risk Score >
4
Discharge RN
calls DC Clinic
Initial
Appointment
Scheduled
Patient
Discharged
from Hospital

12. READMISSION RISK
ASSESSMENT TOOL
Name Account Number Admit Date Location Room Chief Complaint TRRS DCC?
PATIENT NAME J # 9/25/2015 C 2N C 211 5 N
PATIENT NAME J # 10/17/2015 C 2N C 214 CHF 5 N
PATIENT NAME J # 10/13/2015 C ICU C 282 COPD 5 N
PATIENT NAME J # 10/18/2015 C 6N C 609 RESPFAIL 5 N
PATIENT NAME J # 10/20/2015 C 6N C 632 NEURO 3 Y
PATIENT NAME J # 10/19/2015 C 6S C 663 CARDIO 3 Y
PATIENT NAME J # 10/18/2015 C 6S C 688 PNA 4 Y

13. METHODS
OUTPATIENT
Patient
contacted by
Pharmacist
within 48 hrs.
Verifies
medication
and
appointment
Patient seen
by NP for
disease
management
Follow-up
appointment
scheduled
with PCP
DC Clinic
makes follow
up call to
patient in 2
weeks
DC Clinic
makes
another
follow up call
in 30 days

14. MEASUREMENTS
• 2 sets of patients
• Group 1 – 28 patients
• Met criteria
• Attended DC clinic appointments
• Group 2 – 33 patients
• Met criteria
• Chose not to attend DC clinic appointments

15. RESULTS
• Group 1
• 33 patients
• Risk scores > 4
• Did NOT use DC Clinic
• 9 patients readmitted in 30 days
• Group 2
• 28 patients
• Risk scores > 4
• Used DC Clinic
• 3 patients readmitted in 30 days

16. RESULTS
Candler Hospital Readmission Rates
Disease 2014 2015
Heart Failure 27.50% 20.50%
Pneumonia 18.37% 17.90%
COPD 22.41% 18.60%
Sources: QIO/CMS

17. LIMITATIONS
• Patient participation
• No contact
• No transportation
• Inpatient discharge nurses

18. MARKETING
• Informational brochures and flyers
• Patient and family
• Physician
• Case management
• DC Nurse
• Pharmacy Students

19. SUCCESSFUL PROGRAMS
Best practices

20. PROJECT BOOST
BETTER OUTCOMES BY OPTIMIZING SAFE TRANSITIONS
• Developed in 2008 by the Society of Hospital Medicine
• $1.4 million grant from The John A. Hartford Foundation
• Uses mentors/coaches for a year on how to use data and integrate BOOST tools into
their own organizations
• Tuition fee $19,000 per hospital (if accepted)
• Participating hospitals in Georgia
• Piedmont Hospital
• Emory Crawford Long Hospital
• Saint Joseph's Hospital of Atlanta

21. PROJECT BOOST
ST. MARY'S MEDICAL CENTER
• 582 bed teaching hospital in St. Louis
• July 2009, implemented BOOST
• 30 bed hospitalist unit
• Within 3 months, 30 day readmission rates were reduced from 12% to 7% and patient
satisfaction increased from 52% to 68%

22. PROJECT RED
PROJECT RE-ENGINEERED DISCHARGED
• Developed by a research group at Boston University Medical Center
• Relies on 12 components that have been proven to reduce readmissions.
• Meet Louise
• Animated DC character
• Set up specifically for patient
• Toolkits are free to download

23. CARE TRANSITIONS INTERVENTION
• Developed by Eric Coleman, MD, MPH & University of Colorado
• 4 weeks program
• Coach – patient – clinician relationship
• Patients, family & caregivers receive tools and work with transitions coach
• Disease education & management
• Adopted by 750 organizations
• Facilities can expect 20-50% reduction in readmissions

24. STORIES FROM PATIENTS AND HEALTH
CARE PROVIDERS
ROBERT WOOD JOHNSON FOUNDATION
Patients
• Patients did not necessarily see hospital
readmissions as a problem
• Many patients felt they were
discharged too soon
• Many did not understand their
discharge instructions
• Some had only limited or no support
once home
Health Care Providers
• Readmissions are complicated.
• There are financial pressures to
discharge as soon as possible
• The quality and training of the
providers can make a difference.

25. ANY QUESTIONS?