Implementing Safeguards in the Patient Care Home Environment

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Implementing Safeguards in the Patient Care Home Environment

< 1 minute read

Community Hospital of Anaconda implemented safeguards within the patient care environment to assure safe transitions for patients and ultimately reduce readmissions.

The Issue

CHA (Community Hospital of Anaconda) had been compiling data related to readmissions. Data gathered was submitted to the Quality and Safety Networks: Performance Improvement Network (PIN), and Hospital Improvement Innovation Network (HIIN) with Health Research & Educational Trust (HRET). As a result of data submission, (CHA) was provided an opportunity to review national and local benchmarking parameters related to readmissions with a goal to reduce readmissions by 12%. CHA was at an 8.5% readmission rate on average with a goal to reduce the rate to 7.5%.

What We Tried

Opportunities to improve were guided by External Regulatory Groups and the foresight of CHA’s Administrative team to expand into services that would improve the overall health of our community.

Further efforts are aimed at ongoing implementation and understanding of quality measure rules, as well revamping of our patient management meetings. After daily rounding had been implemented, the group, including the hospitalist and ancillary departments, concluded that the meeting could be improved with the addition of the ACO nurse case manager and the home health nursing director.

The  development, design, and implementation of this intervention took 12 months.


It is apparent from the data below that there was significant improvement in patient falls from the activities in 1st quarter 2018.


Make Care Safer by Reducing Harm Caused in Delivery of Care.
Assistant Director of Nursing continues to lead education on fall prevention, policy and procedure review and revision for Adverse Drug Events; hypoglycemic medications have occurred, reduce avoidable readmissions related to care coordination, implement safeguards within the patient care home environment to assure a safe transition from acute care including home health, hospice, outpatient services, home health aides, medication management.

Strengthen Person and Family Engagement
Patient Experience Coordinator position was created in late 2017.

Promote Effective Communication and Coordination of Care
Bringing together Patient care team weekly and consistently with our ACO Nurse, Home Health Nurse, and Nursing Home Representative for discharge planning with a goal to prevent readmission. ACO Care Coordinator attends daily hospital rounds and weekly Home Health Meetings to ensure comprehensive care for our patients during hospital discharge and when
they need more care.

Promote Effective Prevention and Treatment of Chronic Disease
ACO & PCMH – Transitional Care Management (working with the hospital to get Medicare discharged patients to their appropriately timed follow up appointment with needed medications and services, working on a process for phone calls to be made to all of our ER and Convenient Care patients within 2 days of the visit). In the makings of Care Coordination Management program to work with Medicare patients with 2 or more chronic conditions, to help them better manage their conditions (arthritis, asthma, diabetes, hypertension, heart disease and osteoporosis) through support, education, coordinating of care to specialists, primary care, 24/7 emergency care medication review, and phone call check- ins.

Work with Communities to Promote Best Practices of Healthy Living
Brought in multiple services to this area, Care-a-Van use for medical needs. One process in the works is to include tracking our patients that were transferred out for services and ensure that they are getting appropriate follow up care. Medicare Annual Wellness Visits is our Care Coordinators main project at this time.

Make Care Affordable and Accessible 
More specialties have been brought in for local outpatient services including telemedicine, and continue with Convenient Care as well as Emergency room open 24 hours a day. Wellness visits and follow up visits remain vital in decreasing inpatient stays.

Organizational Background

Organization Name: AHA/HRET

Location: American Hospital Association, North Upper Wacker Drive, Chicago, IL, United States

Organization Type: Hospital

Organization Model: Not Set