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Using ‘gut feelings’ to identify the right patients for enrollment

3 minute read

Peninsula Circle of Care at Mills Peninsula asks nurses for their gut predictions of which patients are at risk for readmission.

The Issue

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.

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.

Impact

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.

Tips

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.

Yvonne Chan

Profession:

Organization Background

Organization Name: Mills Peninsula Hospital

Location: 1501 Trousdale Drive, Burlingame, CA 94010, United States

Organization Type: Hospital

Organization Model: ctp

2 Comments
  1. Casie Kichler 2 years ago

    When you round with nurses is it integrated into bedside shift report or a similar format?

    • Author
      Yvonne Chan 2 years ago

      HI Casie,

      Sorry for the delay in replying to you. When we round with the nurses it would be a consistent time each morning when we would approach each staff nurse and ask them to give us a response; it was not integrated into bedside shift report (but your suggestion is a great one).

      Thanks,
      Yvonne

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