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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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Being informed of the “bad news” may be the most stressful period a patient experiences during the course of treatment for a life-threatening medical diagnosis. The fact that a patient has entered the end stage of their illness also is a difficult time for staff. The task of delivering difficult information is one of the most challenging responsibilities a doctor has to perform. Recognizing the limitation put on doctors by time constraints and lack of counseling training, physicians are increasing advocating for staff who are trained in transitioning patients from curative treatment modalities to quality-of-life care planning and lending supportive care counseling.
We identified several issues in managing our patients with pulmonary conditions. These included extended ICU stays, long length of stay, frequent readmissions, frequent emergency department visits and emergency medical services (EMS) calls. We wanted a way to manage this population at the hospital as well as in the outpatient setting. We wanted to create a program for our chronic lung disease patients that spans the continuum of care. Education and communication may begin in the hospital setting; however, consistency in messaging is an integral part of caring for patients in transitions.
In 2012, the hospital’s heart failure readmission rate exceeded 22.6 percent, compared to the American Hospital Association’s Hospital Engagement Network (HEN) national rate of 18 percent. Despite the fact that Critical Access Hospitals are not penalized for readmissions, heart failure readmissions became an area of focus for the hospital’s HEN team. Keeping patients with a chronic disease in their home is the right thing to do for the patients and their families.
Initially, our team implemented discharge teaching with “teach back,” made follow up appointments for patients before discharge, completed electronic medication reconciliation and provided written home care instructions including daily weight monitoring using a scale. Despite these interventions, patients were still presenting to the Emergency Department with large, unrecognized weight gain and distress.
Improving bidirectional communication between the emergency department and post-acute care facilities
Lack of standardized bidirectional verbal and written transition processes between post-acute care facilities and the emergency departments (ED) can cause delays in treatment, redundancy of testing and potentially poor quality of care. The lack of critical clinical information exchange can also be very time consuming and frustrating for the clinical staff resulting in inefficiency of care processes. Standardized verbal and written processes can ensure that the necessary clinical information is exchanged each and every time a patient transitions between settings.
Anecdotal evidence has revealed issues related to inadequate written and verbal communication between settings along with a lack of standardized tools and processes. The Skilled Nursing Facility-Acute Care coalition was created as a venue to enable hospital and skilled nursing facility (SNF) staff to personally meet and discuss issues both sides were facing as SNF residents were being transitioned between settings.