Through patient, caregiver, community and team collaboration, Calvert Memorial Hospital created a program to educate, engage and empower patients.
CMH 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, CMH 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.
What We Tried
CMH created Calvert CARES, a free community benefit program that takes a multifaceted approach to meet the post-discharge needs of patients by assisting patients at moderate to high risk for readmission or emergency department overuse. CARES stands for Collaborative Activation of Resources and Empowerment Services.
CARES bridges the gap for patients who:
- Are unable to schedule a follow-up physician appointment within five days post-discharge from the ED, observation stay or inpatient admission.
- Lack a primary care provider.
- Can’t afford essential medications and/or need assistance managing multiple medications.
- Need assistance securing transportation to health care appointments.
- Can benefit from access to an array of post-acute care resources.
Calvert CARES consists of several components and interventions:
Partners in Accountable Care Collaboration and Transitions (PACCT)
Since October 2013, PACCT members have created a forum for sharing best practices, increasing awareness of housing options for seniors and creating solutions to improve patient outcomes and patient experience.
- Community coalition of over 30 local agencies and health care providers.
- Focused on optimizing patient outcomes through improved care coordination, collaboration and communication.
- Targeted improvement of transitions between the hospital and home (medical home, skilled nursing or retirement community).
Discharge CARES Clinic (DCC)
The clinic focuses on care management coaching, health status assessment, goals building, intervention planning, medication therapy management, psychosocial support and resource access.
- Structured to allow patients extended time with the care team.
- Facilitate information processing and dialogue between the patient and the care provider.
- Survey patients on service provision to gain real-time feedback, to address needs as they arise and to identify gaps in services that can be filled by using the network of partners in Calvert CARES.
Transitions to Home (T2H)
T2H provides health management coaching and medication management guidance via phone calls and home visits. Pharmacist medication therapy management home visits are a significant part of the program. Target population is patients with somatic health challenges.
- Target high utilizers with a focus on patients with heart failure, chronic obstructive pulmonary disease, diabetes, pneumonia or multiple comorbidities.
- Readmission root cause analysis (RCA) patient interviews and chart reviews.
- Potentially avoidable admission RCA patient interviews and chart reviews.
In August 2015, CMH and the Calvert County Health Department partnered to target patients needing mental health and substance abuse services.
- Provides care management coaching and medication management guidance via phone calls and in-person coaching sessions with a social work case manager.
- Readmission RCA patient interviews and chart reviews.
Medication Assistance Program (MAP) and Transportation Assistance Program (TAP)
CMH utilizes hospital funded financial assistance programs to help patients pay for essential medications, medical supplies or transportation to medical appointments.
CARES Grand Rounds
This community-focused committee serves in an advisory capacity to facilitate identification of potential solutions to care challenges and gaps for high utilization group patients.
- Provision of safe, quality patient care in an optimal setting.
- Awareness, education and accessibility of Calvert health system and community-based programs and resources.
- Community support and guidance in developing and implementing multifaceted care plans.
Calvert CARES has greatly contributed to CMH’s lowered readmission rate. CMH ended 2016 with an average risk-adjusted readmission rate of 8.83 percent, one of the lowest readmission rates in Maryland.
All-Cause, Intrahospital, Non-Risk Adjusted Readmission Reduction Trends FY 2014 – FYTD 2017
CMH’s all-cause aggregate, nursing home and Medicare readmissions have significantly trended down over the past three years, with the most recent decrease occurring when they opened their second CARES Clinic.
Risk-Adjusted Aggregated Inter- and Intrahospital Readmissions for CY 2016
CMH not only met their targets for 2016, they also ranked as one of the best hospitals in Maryland for readmissions avoidance.
The CARES clinic team saw 165 patients last year. Less than 4 percent of them returned to the hospital within 30 days of discharge.
- January to June 2016 readmission rate = 3.74 percent
- July to December 2016 readmission rate = 3.60 percent
- CY 2016 readmission rate = 3.67 percent
CMH recently added palliative care, using a contracted hospice physician as a consultant, and a CMH Palliative Care Coordinator, who is a certified Palliative Care social worker on the Case Management Team. This has improved the quality of life for terminally ill patients as well as reducing readmissions.
- Slow down the pace – give patients time to listen, process and formulate questions.
- Identify the patient’s goal(s) and then build the plan upon them.
- See the patient fresh each time. Don’t give up – you never know when a patient is ready or activated to make the necessary lifestyle changes.
- Consider implementing Medication Therapy Management, a group of services provided by a trained pharmacist, to gain the best medication outcomes for your patients.
- Remember, programs are tools. Make sure your tools fit your patients’ needs, not your needs or what you think patients need.
- Decrease handoffs and enhance the strength of the relationship between the patient and your post-acute tools by crossing over staff between programs.