Name
#44 Building capacity to reduce military treatment facility (MTF) plan all-cause readmissions
Content Presented on Behalf of
DHA
Services/Agencies represented
Defense Health Agency (DHA)
Session Type
Posters
Room#/Location
Prince Georges Exhibit Hall A/B
Focus Areas/Topics
Clinical Care, Medical Technology, Policy/Management/Administrative
Learning Outcomes
Following this session, the attendee will be able to:

1. Identify the four selected AHRQ RED interventions that are expected to reduce unnecessary hospital readmissions
2. Describe project management, dissemination, implementation, and assessment activities utilized during the project’s lifecycle.
3. Define future improvement and scale-up efforts.
Session Currently Live
Description
Prevention of Plan All-Cause Readmissions (PCR) is a Defense Health Agency (DHA) priority. Ineffective and poorly coordinated care transitions, discharge planning, and follow-up care often result in avoidable readmissions. DHA’s PCR initiative incorporates Agency for Healthcare Research and Quality (AHRQ) Re-Engineered Discharge (RED) Toolkit interventions. The DHA’s Medical Management team partnered with the Research & Engineering Implementation Science Branch (ISB) to develop an implementation infrastructure for PCR interventions including: (1) Post-Discharge Follow-up Phone Call; (2) Discharge Medication Reconciliation; (3) Multidisciplinary Discharge Rounding; (4) Post-Discharge Follow-Up Appointing. Stakeholder informational interviews uncovered PCR barriers and facilitators which were addressed through project management, dissemination, implementation, and assessment activities: 1) Project Management: conducted informational interviews with stakeholders at multiple facilities. 2) Dissemination: created materials cultivating leadership buy-in, and enhanced provider and patient/caregiver PCR awareness. 3) Implementation: developed implementation resources, including detailed workflows across interventions. 4) Assessment: developed a logic model and comprehensive metrics table, supporting an organized and systematic approach to measures prioritization. Detailed process maps reflected intersections and gaps between AHRQ RED interventions and DHA policy, supporting a targeted implementation effort. At an organizational level, implementation materials were aligned by clarifying required electronic health record workflows. Efforts to improve DHA compliance with the four selected AHRQ RED interventions, benchmarked against AHRQ’s PCR HEDIS metrics, are expected to reduce unnecessary hospital readmissions by improving and standardizing DHA discharge processes. Current enhancements underway within the new electronic health record system to improve and standardize inpatient to outpatient transitions. Future steps include establishing a consistent feedback loop between PCR Champions and DHA. Plans are in place to improve scale-up efforts by providing standardized and comprehensive resources to healthcare personnel who implement PCR interventions and establishing a unified data plan which provides consistent data tracking of compliance targets.