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Connecting with Families: Turning Interest into Action

University of Illinois at Chicago’s Division of Specialized Care for Children (DSCC) has a regional office in Peoria, a city that is home to a well-known children’s hospital that cares for many children eligible for DSCC’s programs. Many of these children are referred to DSCC for assistance but often not until the child is older. DSCC’s care coordination teams believe it is vital that these children are referred to our programs as soon as soon after birth as possible, especially those with critical cardiac conditions. DSCC’s Peoria staff had developed relationships with the hospital’s nurses and social workers and presented about our programs numerous times. However, they recognized that hospital staff members are busy with their own heavy workloads; therefore, we cannot rely on them as the primary referral source for these families. Our staff also recognized the need for families’ privacy during the emotional time following the birth of a child with special health care needs.


Huddling to Improve Teamwork

In DSCC’s Mokena Regional Office, each Care Coordinator is paired with a Program Coordinator Assistant to work as a team to meet a child and family’s needs. A Care Coordinator is a DSCC staff person who is a nurse, social worker, speech pathologist or audiologist. A Program Coordinator Assistant (PCA) is often a family’s first contact with DSCC. The PCA takes referrals, discusses the child’s needs and sends the application to families. The PCA also determines financial eligibility and updates this information periodically.

The Care Coordinator and PCAs’ individual responsibilities often are contingent upon the completion of specific activities from their respective partner. Upon my arrival as manager, several employees expressed multiple issues related to the lack of communication between team members. This lack of communication resulted in missed deadlines or lapses in other pertinent information required to complete a task.


Meds to Bed Program: A Medication Concierge Service

Tamblyn and colleagues found that nearly a third of patients fail to fill first-time prescriptions.1 Other studies have found that e-prescriptions are 65% more likely to be left abandoned at a retail pharmacy by patients than hand-written prescriptions. 3 Mount Sinai Hospital (MSH) recognizes that the issue of medication adherence is challenging. MSH strives to become the national model for the delivery of urban healthcare and develops innovative and effective ways to accomplish its mission.

In the communities served by MSH, the percentage of citizens living below the poverty line ranges from 14% to 45%. Ten of the 13 communities MSH serves have a poverty rate higher than the Chicago average of 22%. Three communities (East Garfield Park, North Lawndale, and West Garfield Park) have a poverty rate two times higher than the city average.

The literacy rate for MSH’s community served is another barrier to medication adherence. Nineteen percent of Chicago adults over age 25 do not have a high school diploma. In 12 of the 13 communities, the percentage of adults without a high school diploma is higher than the city average. In two communities (Gage Park and South Lawndale), over half of adults lack a high school diploma.

Another limitation of MSH’s patient population is the lack of transportation. Patients depend on family members, neighbors and friends to commute. Financial concerns and long wait times are other barriers that patients voice as concerns for filling outpatient medications.


Calvert CARES Program Reducing Readmissions: It’s All About Relationship

CHMC was challenged with developing an innovative plan to address high utilizer recidivism in the ED and inpatient settings. Early success with the Transitions to Home Program resulted in readmission targets being significantly decreased. To identify resource access gaps, CHMC called on its “village” (local health care coalition and their case management team of acute care and emergency department nurses and social workers) to identify opportunities for program enhancement by using a SWOT analysis. Medication and medical supply affordability, transportation access and other social determinant-related opportunities were identified.


Building a Care Coordination Program: Addressing Determinants of Health and Well-being

In 2013, Medical Center Health System, located in Odessa, Texas, embarked on a journey to create a healthier community. We knew we had a long way to go. Our county health rankings weren’t favorable according to the County Health Rankings from the Robert Wood Johnson Foundation, and we didn’t yet have a department at our hospital to address our community’s many health needs. We knew we wanted to approach the issues from the community angle but also from the hospital perspective. Our hospital understood that to build a “Culture of Health” we needed to be innovative and think beyond the traditional four hospital walls. We wanted to design a program that centered on the medical well-being of the patient but also addressed the determinants affecting our residents’ health. We also appreciated the fact that we needed to be creative to make best use of our existing resources and available health care providers.


Tackling Pneumonia Readmissions through Standardizing Processes

We, at Baptist Memorial Hospital, have been focusing on readmissions for quite some time but for the last two years, we received the readmissions penalty. We’re higher than the national average for pneumonia readmissions rates.


State Policy as an Opportunity to Evaluate Current Discharge Processes

Effective Jan. 1, 2016, Indiana enacted the Caregiver Advise, Record, and Enable Act, or the CARE Act. The CARE Act requires hospitals to offer each admitted patient who will be discharged home an opportunity to: (1) identify a lay caregiver, (2) communicate with the lay caregiver regarding discharge and (3) offer education and training to the lay caregiver to ensure he or she understands how to care for the patient post-discharge, among other things. This required Riverview Health to evaluate its current processes and implement strategies to ensure compliance with the CARE Act.


Heart Failure Readmissions: Pinpoint the Problem, Improve the Process

In 2008, Mary Washington Hospital (MWH) was ranked first in the state for having the worst 30-day Heart Failure (HF) All-Cause readmission rate. Inconsistent with our mission for improving the health status of the people in our community, MWH undertook efforts to reduce HF readmissions. With administrative support, a registered nurse (now the HF Program Coordinator) began taking steps to identify opportunities surrounding HF readmissions. From detailed chart review, it was discovered that the opportunities were multi-faceted and required an organized, comprehensive approach.


Commitment to Warm Hand-Offs Amongst a Complex System

It can be difficult to ensure patients receive a warm hand-off when there are many moving parts in a complex system. Sakakawea Medical Center and Coal Country Community Health Center worked to improve their continuous care model. This model transitioned patients from the medical center to the clinic with a warm hand-off to allow for continuity of care.


Identify and prioritize transitional care program patients

Illinois Valley Community Hospital set a goal to reduce its readmissions rate for patients diagnosed with congestive heart failure, COPD and pneumonia. This rate tends to run slightly higher than the overall hospital readmissions rate (1 percent). Medicare also focuses on congestive heart failure, COPD and pneumonia for reimbursement.


Make changes to routine practices

Saline Memorial Hospital (SMH) has been a part of the Arkansas Hospital Association Hospital Engagement Network (HEN) since the network’s inception in 2012. Although our hospital’s multidisciplinary team has grown and changed over the years, we pride ourselves on working together to improve the safety of our patients and community. When the HEN presented readmissions as one of its quality improvement initiatives, it was an area we hadn’t thought about or believed we could make an impact. Although we didn’t think readmissions was a problem, we asked our IT department to create and send a report each morning, showing the number of readmissions from the day before. That’s when our eyes were opened! When we first started collecting readmissions data, the numbers seemed overwhelming and too big to overcome. But we remembered the story about “how to eat an elephant … just one bite at a time” and that’s how we proceeded for this initiative.


Implement admission, discharge, and transfer notifications in real time

While emergency departments (ED) and hospitals are an integral part of the health care system, unnecessary ED and hospital utilization, as well as avoidable hospital readmissions, are significant challenges. As the foundation of an efficient and effective health care system, comprehensive care coordination by primary care physicians (PCPs) can help reduce excessive care, repeated tests and procedures and high rates of ED and hospital utilization. However, to do so, the primary care practices in the ACO need to be informed of the full spectrum of their patients’ care. This includes care delivered outside of their practice, and particularly when patients are admitted to or discharged from a care facility.



Medicare beneficiaries take control of diabetes self-management

More than 700,000 people in Georgia and North Carolina have been diagnosed with diabetes, which is the seventh leading cause of death in both states. Alliant Quality’s goal is to increase our reach and depth in both states, empowering and educating people to make lasting behavior changes that will improve health outcomes and quality of life.

We want to decrease the risk of complications related to diabetes; these complications may include lower leg amputations, stroke, heart attack, blindness, and kidney failure. We are working to help people with diabetes take control of their condition so they can live longer, healthier, productive lives.



Reverse adverse drug events by establishing processes

Medicare patients on anticoagulant therapy are at increased risk for adverse drug events (ADEs). Recognizing an opportunity to improve care coordination for this vulnerable patient population, Telligen, the Centers for Medicare & Medicaid Services Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Colorado, Illinois and Iowa worked with Porter Anticoagulation Center in Denver, Colorado, to identify Medicare patients at high risk for ADEs and to establish care coordination processes between the inpatient and clinic pharmacists.
The Porter Anticoagulation Center is run by a staff of pharmacists who see up to 90 Medicare patients at least once a month. Many Medicare patients were not making appointments for follow-up visits at the outpatient anticoagulation clinic after hospitalizations, putting them at greater risk for ADEs. The clinic staff sought a way to identify patients at high risk for ADEs and tailor their interventions accordingly. In addition, clinic staff saw an opportunity to improve care coordination for non-anticoagulant-related issues due to the frequency of their patients’ visits.


Drive facility interventions from data

In 2015, the hospital readmission rate for all payers was more than 28 percent, higher than the adjusted national average of 18.4 percent reported by Centers for Medicare and Medicaid Services. Greenbriar Community Care Center began working closely with one of its primary referral partners on improving communication across settings and established a designated unit for the short-stay skilled population.

Greenbriar had introduced the use of ‘stop and watch’ and SBAR from the INTERACT tools but noted there was inconsistent use. Additionally, the center added a registered nurse to its transitional care unit to alter the skill mix with residents’ growing acuity. Although Greenbriar was responding to these challenges, the response was not impacting the readmission rate.


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