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NCD Pacing Event: Part Two of Two: Improving Readmissions Through a Comprehensive Approach to Discharge Planning and Care Transitions

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Thursday, August 22, 2019, 10:00 a.m. to 11:00 a.m. PT.

This HIIN and Hospital Pacing Event will build on the 8/15 session to provide additional examples of comprehensive discharge planning and care transitions programs that are resulting in reduced readmissions. This session will feature the Cleveland Clinic’s recent addition to its care transitions program: an improved discharge summary and medication reconciliation process as part of its handoff to post-acute care partners. The session will also feature Penn Medicine’s Supporting Older Adults at Risk (SOAR) program, which is an adaptation of the “flipped discharge” model to “discharge to plan” for the patient’s needs, its components, and the outcomes achieved. Each program will share lessons learned and recommendations that can be applied to hospitals of varying types and sizes.

Summary from 8/22 Pacing Event: “Part 2 of 2: Improving Readmissions through a Comprehensive Approach to Discharge Planning and Care Transitions”

This “part 2” webinar built on the August 15th session to provide additional perspectives and best-in-class examples to help HIINs and hospitals generate new or enhanced actions targeted to reduce readmissions. Specifically, this session featured two additional hospital-based programs that are impacting readmissions by focusing on thoughtful approaches to discharge planning and care transitions.

A team from the Cleveland Clinic discussed its work to augment its discharge planning process by adding an improved discharge summary and medication reconciliation process as part of its handoff to post-acute care partners. They discussed the improved process, the feedback loop to providers, and the input from post-acute care settings. A team from Penn Medicine shared its work to design and implement its SOAR (Supporting Older Adults at Risk) program, which is based on an adaptation of the “flipped discharge” model that focuses on a “discharge to assess” approach that addresses patients’ needs at home. The team discussed the model’s three phases and outcomes achieved. Presenters from both teams highlighted lessons learned and recommendations for hospitals of all types and sizes and discussed their work to spread their models.

The guest presenters for this event were:

  • Amy O’Linn, DO, FHM, FACP, hospitalist and physician lead for readmission reductions efforts at Cleveland Clinic.
  • Fran Hober, MBA, CPHQ, HACP, Senior Director, Quality Reform and Reporting at Cleveland Clinic, who provided an overview of their readmission reduction efforts and then described the development and implementation of an improved process around quality discharge summaries and medication reconciliation, as well as its impact thus far and plans for spread.

Representatives from the Penn Medicine SOAR program, who shared their program’s components, outcomes, and plans for spread:

  • Rebecca Trotta, PhD, RN, Director, Nursing Research and Science, and Director, Geriatric Nursing Program at the Hospital of the University of Pennsylvania
  • David Resnick, MEd, MPH, Innovation Manager at the Penn Medicine Center for Health Care Innovation
  • Anita McGinn-Natali, a co-chair of the Patient and Family Advisory Council at the Hospital of the University of Pennsylvania.

The session was moderated by Kendall Hall, MD (NCD).

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