For efficiency and impact, SF General focused their efforts on patients who were open to coaching and able to change.
Collaborator (Non-Members)Larissa Thomas, Michelle Schneidermann
When we first started, we saw almost everybody. We enrolled anyone 55 and older with COPD, pneumonia, or MI and we didn’t see any changes in our readmissions rates. We realized it was because we couldn’t work effectively with that many patients at once—we were trying to see ten patients a day. That’s the same as being a floor nurse, and there’s no way to develop a therapeutic alliance when you’re seeing that many patients.
San Francisco General is a non-profit hospital and level 1 trauma center in San Francisco, CA. It has 598 beds and serves a diverse population, the majority of whom are lower income and do not speak English as their first language. Many are also illiterate in English as well as their preferred language. The hospital also serves individuals who may not have health coverage, housing or access to food. They enroll the most difficult to engage patients who have a history of substance abuse and poor health outcomes. Their transitions program began in 2009 and is influenced by the Care Transitions Program and Project RED.
What We Tried
We decided to focus on the low-hanging fruit, meaning patients who are ripe to be motivated and able to change. We looked at which patients we were most successful with to decide where to focus. We realized we can’t help someone who’s on their fifth readmission in the last 6 months—they need chronic care management. It also doesn’t make sense to coach a homeless person on dietary changes because they’re going to eat whatever they can get their hands on. Other patients suffer from psychosocial issues and refuse to talk with us or share their barriers. We didn’t ignore any of these patients—we gave them educational materials and opened the warm line up to them—but we didn’t focus on them for our coaching. Instead of spending 20 minutes with them, we spent 10 and looked for their caregiver to speak with next time. We focused our bedside coaching time on patients who we could legitimately help.
Our readmission rates have dropped significantly since focusing our efforts. The drop is due to many reasons, but a large one is that we’re using our resources more effectively.
After working with patients for a while, it was easy to see which patients could benefit from our coaching very quickly. We gave our frontline nurses the freedom to decide which patients to work with rather than forcing them to follow specific criteria.
The hardest part for us was telling physicians or staff nurses that a patient they referred to us was being screened out. On the surface, those patients seemed like perfect candidates because they were at high risk for readmission, but we had to explain to them that there are some patients that we just can’t help with our limited resources.