Figure 4. Care Everywhere Participants; Connection to Other Vendors (Epic System Corporation, 2014)
HFHS utilizes both Allscripts and Epic for their EHR systems. In order to create a meaningful readmission report, information must be collected and collated manually. This results in questionable accuracy of the report as provided in feedback from various department. This project revolves around creating the electronic interfaces that would result in an automatically generated readmission report. It will involve and benefit stakeholders from administration, information technology, and providers/hospitalists. “System interfaces require physical equipment (e.g., hardware such as plugs, cables, and cards), software that controls the data and information that is exchanged, and concepts (e.g., data protocols and controlled vocabularies) that control the interactions between systems.” (www.healthit.gov, 2014) In addition, this involves social and organizational aspects, such as agreements to stipulate data in a reliable format (www.healthit.gov, 2014).
The readmissions report project will help reduce the readmission rate of HFWBH. This report will track readmission daily and alarm the providers for the next plan. In FY2016 we were penalized by CMS because we were above the national average rate. We were at 19% in January 2015 and at the end of December 2015 we were at the highest of 21% when the national average is at 16%. HFWBH target for next year is to reduce the readmissions to national average. Creating a better report will help track the frequent flyers in the organization to prevent them from coming back in the future, and to avoid CMS penalty. Creating a daily report in the hospital will b...
... middle of paper ...
...t made it easy to determine with whom to communicate (either SNFs, HHC organization) why the patient came back in the hospital. Homecare nurses respond to the report that was created via email that is communicated throughout the case management team, chief of the hospitalist, advance practice or mid-level provider manager, and to the medical director. Example of response from the readmission report, when the home care nurse came by to evaluate the patient, patient refused the service, or patient came back to the hospital prior to the services. With that said, communication has improved between HFHHC and hospital care team. Finally, in December 2015, the CMO approved the piloting of the 24-hour readmission report and distributed it to the chief of hospitalist, quality improvement, partnered SNFs, the director of the advance practitioners and mid-level providers.
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