Peninsula Circle of Care at Mills Peninsula asks nurses for their gut predictions of which patients are at risk for readmission.
Our program wasn’t condition-specific, we were focused on all elderly patients. At the same time, we wanted to identify the high-risk patients to enroll to have the greatest impact. The challenge at that time was that our risk assessment tool wasn’t automated, so to find the “right” patients we essentially had to speak to every single patient. That just wasn’t possible.
Mills Peninsula is a non-profit hospital in Burlingame, CA that has partnered with the Palo Alto Medical Foundation and Peninsula Family Services to develop the Peninsula Circle of Care program. The hospital has 241 beds and serves a primarily elderly population (average age of 81) living alone with 90% on Medicare. Peninsula Circle of Care, their transitions program, began in 2012 and is influenced by the Care Transitions Program and a community based model.
What We Tried
We ran a small experiment to see if referrals could help us narrow down our pool of patients to screen. We went to hospitalists, case managers, and staff nurses and asked them a very simple question: “Would you be surprised if your patient ____returns within the next 30 days?” We didn’t ask for any justification, just a simple yes or no. Thirty days later we looked back to see how they did. It turned out that bedside nurses were really good at predicting whether a patient would get readmitted, so we started going to them regularly for referrals. We went on rounds with nurses and also sent out emails reminding case managers to send referrals our way. Do not underestimate the bedside nurses’ ability to ‘predict’ if a patient will be likely to return to the hospital. They may not be able to state “why,” but their gut feelings are valuable in identifying the right patients.
Referrals are only the first step. We still screen patients that have been referred to us, but referrals have helped speed up the process by surfacing likely candidates for our program. Our readmission rates have gone down significantly and we believe a large part of that is due to the fact that we’re working with the right patients. Even though our risk assessment tool is ready to be automated, we’re still going to request referrals because a tool can never pick up as many subtleties as a person talking to the patient can. This is especially true for social determinants like home situations or relationships with family members.
The quality of referrals depends on how well people understand your program and the services you offer. It took awhile for our nurses and case managers to understand what made us different from home health.
Since it’s a new step in their workflow, we had to remind people in different ways to keep sending referrals to us. Now it has become ingrained in their workflow, so we regularly get the right referrals.