Do I do or Do I don't
You would not remove the patient from the Epic RR Patient list when you see this type of change
What would I do if I see the DRG/Principal problem has changed on the RR Patient list
All RN's can "Balance" this
What is the call schedule?
The .Phrase for populating RR HF flags.
What is .RRHFPathwayFlag?
How the "Days to Readmit Date" is calculated in the Readmission Spreadsheet
What is the number of days from the ANCHOR date to readmission?
An attempt is made in the morning and again in the afternoon.
What is the process for Readmission Reduction 1st calls to help prevent calls from being rolled to the next day?
What are BPCI visits in the hospital?
The cadence to follow when an RR patient is admitted to the hospital for a problem not associated with heart failure
What is Continue the call cadence on discharge?
The .phrase to enter the HF zone tool into Epic AVS
What is .HFZoneTool?
"RX#1/RRHF"
What is the process for altering a RX call note to show that Pharmacy should make the call a priority for the day?
The 3 Home health companies TTCC will begin sending emails to during 1st call
What are VNA (TGH Home Care), Centerwell, and Pinnacle?
Hospice Refusals, Deceased patients, Patients that fall off of bundle
What are patient types that do not need to be added to the Refusal Spreadsheet?
When a patient receives a VAD implant
What is exclude a patient from the Readmission Reduction Patient List?
The .phrase to use when conducting Readmission Reduction DC evaluations
What is .RRHFGREETINGCOMPLETED
"Nicole to review readmission"
What do you update the TC Sticky Note to say if Nicole or Kristy are not available to review a readmission not related to HF?
Attempt to speak to the patient. If you are not able to speak to the patient and assess the ideations, provide the person you are speaking to with the hotlines for help and advise them that they can also call the police for assistance as well.
What are the beginning steps for dealing with a patient with suicidal ideations?
Update the flag and TC Note stating the patient is going to a facility/Hospice
What you should do when you see a CM note stating the patient is going to a facility/Hospice
When filtering the Readmission Reduction Patient List, these are the 3 primary groups we will follow
1. They have a RED HF severity score (no matter the diagnosis
2. They have a HF DRG or HF primary problem
3. A previous nurse documented in the TC sticky that they added the flag
The .phrase for all RR HF calls.
What is .TTCCHeartFailure
At readmission you message Nicole or Kristy
Who do you contact if a patient readmits for something other than HF s/s or Complications of HF?
This appears in the Patient information tile when a patient is being followed by USF Care Management
What is "Caravan MSSP ACO Roster"?
This appears in the Patient information tile when a patient is being followed by TGMG Population Health
What is "This patient is enrolled in CCM"?
These are the 5 exclusions from Readmission Reduction
DC anywhere but home or home with HH, VAD, HD, Actively Managed by Transplant, previous nurse has documented "will not follow"
When assisting Pharmacy, the .Phrase used to conduct an Rx RRHF call.
.TTCCHFRRrxEducationCall
The cadence when an RR patient is admitted to the hospital and discharges during the 30 day follow period
What is Restart call cadence at day 1?
Epic "Primary Problems" related to HF DRG
What are A. fib with RVR, Hypertensive Urgency and Acute CHF