Executive Summary
Our Lady of the Lake Regional Medical Center has avoided readmission penalties for Medicare patients by launching a series of initiatives that tailor interventions to the individual patient.
- Members of the multidisciplinary team communicate throughout the day during morning rounds and daily huddles, and share information on patients and their caregivers that the case manager can use to develop a discharge plan.
- Care navigators in some areas provide extra assistance and post-discharge follow-up for patients who need it.
- Every patient gets at least one follow-up phone call after discharge.
Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, takes a team approach to reducing readmissions as well as tailoring interventions to each individual patient.
The hospital had no penalties for readmissions in the first three years of the CMS readmission reduction program.
“Our physicians and clinicians are the superstars of our readmission reduction efforts because they work together as a team. We wouldn’t be successful if just one discipline was responsible for reducing readmissions. Having everyone on the team take ownership has enabled us to succeed,” says Christi Pierce, MBA, MSHA, vice president for quality and safety at the 800-bed hospital.
The hospital was working on reducing readmissions before CMS launched its readmission reduction program, beginning with a project with its Quality Improvement Organization (QIO).
“We have developed a wide range of initiatives from care navigation for some populations to ensuring access to post-discharge care for patients who are at high risk for readmissions. We developed a number of strategies because we realize that when it comes to patients, one size doesn’t fit all. We treat patients as individuals and get to know them, understand their potential needs once they get back to their home environment, and meet them where they are,” she says.
At Our Lady of the Lake, assessment is a team effort that starts at discharge. “Physicians, nurses, case managers, and social workers all assess the patients’ discharge needs from the beginning of the stay and whenever they see the patient,” she says.
Throughout the stay, the multidisciplinary team contributes information that helps the case manager develop an appropriate discharge plan.
“You don’t learn everything you need to know about a patient by having one person go in with a clipboard. You learn by talking to patients and to their families. Our team spends a lot of time understanding the patients and making sure the care we give and the discharge we plan is the right thing for that individual patient,” she says.
Physicians, nurses, case managers, and social workers have multidisciplinary rounds on many units each day and discuss the patient’s condition, treatment plan for the day, potential discharge needs, risk for readmission, and anticipated discharge date. Physicians and the clinical staff work closely together, she says.
Each unit has a daily huddle attended by the nurses, the case manager, the social worker, and therapists as needed. Physicians attend when they are on the unit. “The team builds on the information in the morning meeting and addresses the issues in the huddle. We focus on open communication across all disciplines,” she says.
The hospital has developed best practice protocols for complex conditions like heart failure, but the team may modify the process depending on patient needs. For instance, a patient with a chronic condition who has been readmitted multiple times may receive extra education and the case manager may meet with family members to make sure they understand the discharge plan and the importance of following it.
“We recognize that each patient is unique and that a cookie-cutter approach won’t work. Some patients may need more support after discharge and others with a strong, stable home environment may not need as much follow-up,” she says.
The team focuses on patient and family education, beginning before admission when patients are scheduled for elective procedures, and during post-discharge follow-up calls. “We spend a lot of time on patient and family education. We recognize that the hospital is a stressful place to go and patients aren’t able to remember everything they are supposed to do,” she says.
Every patient gets a follow-up call from the nursing team within 24 hours after discharge. The nurses make sure the patients got home safely, have everything they need, and understand their discharge plan. They answer any questions or concerns that patients or family members have.
The hospital has added the position of care navigators in some areas to provide extra assistance and post-discharge phone calls to patients who need it. “The navigators work with the whole patient, not just the condition that brought them to the hospital. It’s really powerful,” Pierce says.
Patients who are scheduled for total joint replacement surgery attend pre-admission classes taught by a RN navigator, called the joint coordinator. “This way, they know what to expect before, during, and after surgery,” Pierce says. The joint coordinator visits the patient the first day after surgery and throughout the stay and works with the primary nurse, the social worker, and case managers to make sure the patient is ready for discharge and that the patient and family can follow the discharge instructions.
He makes follow-up calls shortly after discharge, at 14 days, and 30, 60, and 90 days after discharge. “We want to make sure the patient is recovering well and isn’t having any problems,” she says.
Navigators in the cardiovascular program are nurses and follow patients who have had open heart surgery. Cancer care navigators are either nurses or social workers.
The newly implemented Meds to Beds program fills patients’ discharge prescriptions and delivers them to the bedside prior to discharge. “This eliminates the transportation issues that some patients have with getting to the pharmacy after discharge. It’s a convenience for the patients and it also helps us ensure that patients have the medications they need,” she says.
The hospital has developed a close working relationship with post-acute providers and transitions are generally smooth, Pierce says. Before patients are discharged, a liaison for the post-acute provider who will be caring for them visits patients and family members.
“When patients arrive at the facility or home health services start, they are well known to the providers because of all the work up front. This is supplemented with the discharge summary and other information the receiving providers need to care for the patient,” she says.
Our Lady of the Lake Regional Medical Center has avoided readmission penalties for Medicare patients by launching a series of initiatives that tailor interventions to the individual patient.
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