EXECUTIVE SUMMARY
A Care Transitional Task Force at San Francisco General Hospital created a cross-continuum program that has reduced readmissions and increased timely primary care visits for discharged patients.
- A basic bundle of services includes communication between inpatient and outpatient providers, providing the right information to the next level of providers, and giving patients and family members the right level of education.
- Transitional care nurses work with heart failure patients of any age and patients over 55 with chronic obstructive pulmonary disease, diabetes, renal failure, or who are recovering from a myocardial infarction.
- The nurses work closely with patients and family members during the hospital stay and follow up weekly for 30 days after discharge.
A multi-pronged, cross-continuum program to improve care transitions at San Francisco General Hospital has reduced readmissions and increased the percentage of patients who see a primary care provider within seven days of discharge.
When CMS announced its readmission reduction program in 2012, the hospital appointed a multidisciplinary Care Transitions Task Force to develop initiatives to improve care transitions, says Michelle Schneidermann, MD, clinical professor of medicine at the University of California San Francisco/San Francisco General Hospital and medical director of the San Francisco Department of Public Health Medical Respite and Sobering Center. In addition to clinicians and staff from the hospital’s inpatient and outpatient settings, the task force included representatives from primary care clinics and skilled nursing facilities.
When the task force started, 34% of patients were seen in the primary care clinic within seven days. Now, it’s upward of 50%. About 70% to 80% of patients leave the hospital with a primary care appointment, Schneidermann says. “Shortly after the push for timely post-acute follow-up, the hospital’s all-cause 30-day readmission rate decreased from 13% to 10.5% and has remained there. Patients seen within seven days of discharge have a readmission rate of about 6%,” Schneidermann says.
San Francisco General Hospital is a trauma center and the only public safety net hospital in the city and serves a diverse, young, and underinsured population. About 30% of patients are uninsured, 40% are covered by MediCal, California’s Medicaid program, and 8% to 10% are homeless.
“As a safety net hospital, we have limited resources and we need to be smart about how we deploy resources, whether it is personnel or financial resources. That was our challenge as we worked on ways to improve transitions and reduce readmissions,” Schneidermann says.
The goal of the task force is to improve transitions for all patients, regardless of risk. The team developed a basic bundle of interventions for all patients. It includes appropriate communication between inpatient and outpatient providers, appropriate transfers including information needed by the next level of providers, and the right level of education for patients and caregivers.
“Whenever possible, we use materials that target patients with lower health literacy and limited proficiency in English,” she says.
All patients, regardless of risk, get the basic bundle. Patients identified as high risk are referred to the SFGH transitional care nurses, the task force initiative staffed by three nurses whose backgrounds correspond with the racial, cultural, and language identities of many patients served by the hospital.
One nurse is African American, was born at the hospital, and has ties to the community served by San Francisco General. The others are a bicultural and bilingual Latino nurse and a bicultural and bilingual Chinese nurse.
The nurses work with heart failure patients of any age, and patients over 55 with chronic obstructive pulmonary disease, diabetes, or renal failure, or who are recovering from a myocardial infarction.
When they see patients in the hospital, the nurses use motivational interviewing to determine how to focus their bedside teaching with the patient and caregiver. They conduct extensive medication reconciliation and education about the patient’s medication regimen and print out an enhanced post-discharge care plan. The nurses use software purchased with grant funding to create medication instructions at a fifth-grade reading level that can be translated into 18 different languages.
The nurses make sure patients have a follow-up appointment with a primary care provider and coordinate with outpatient and community providers. They call patients within 72 hours of discharge to reinforce the education and answer questions and concerns. Then they make follow-up calls to the patients every week for a month.
At-risk patients who receive the transitional care nursing intermissions have a readmission rate of 10% compared with 18% for similar patients who aren’t able to receive the interventions for various reasons, Schneidermann reports.
“It’s been a very effective program for a relatively small number of patients,” she says. “We are trying to figure out how to scale this up and develop similar interventions. We are also still learning how to best identify patients at risk for readmission. We know that readmission risk is more than just a diagnosis and that psychosocial issues contribute a lot to the risk. We want to develop a standardized, systematic approach to identifying which patients have both medical and non-medical issues that put them at risk.”
The team is concentrating much of its efforts on transitions from the hospital to the community and a primary care provider.
“We learned early on from our analysis that our hospital is different from many. Only 6% of total discharges and 9% of Medicare patients go to a skilled nursing facility. Most of our patients receive their immediate post-acute care in outpatient clinics. We also found that there were gaps in communication between the inpatient team and outpatient providers, so we are focusing our energy on improving transitions to outpatient care,” she says.
Getting patients to see a primary care provider for post-acute follow-up is a struggle for many hospitals and it’s particularly difficult at San Francisco General, Schneidermann says. “Most of our patients live in poverty and have a lot of stressors and competing priorities, and making their clinic appointment may not be at the top of their list. We have to meet patients where they are and work from there,” she says.
The team analyzed data from the 12 public health clinics in the hospital’s network to determine the proportion of patients who went to follow-up appointments in the clinic within seven days of discharge. They are partnering with the leadership in the clinics to increase the number of patients who are able to get timely follow-up appointments and set performance goals to increase the number of patients who are seen in the clinic within seven days.
When representatives from the primary care clinics reported that they often didn’t have the information they needed about their patients’ hospital stay, the task force developed a discharge database that everyone in the network can access.
They began a pilot project to determine if it is feasible to have a health worker or medical assistant in the clinics make post-discharge follow-up calls and created a program to educate patients to see their primary care provider if they have post-discharge problems rather than coming back to the hospital.
Members of the task force are working with the leadership of local skilled nursing facilities to improve transitions and to standardize the handoff between the hospital and the skilled facility.
“Reducing readmissions and improving care transitions is a priority for the hospital. We are beginning to understand the problem and share the information to providers in the health network,” she says.
The multidisciplinary task force, which meets bi-weekly, includes clinicians and staff across the health services including the inpatient team, representatives from the hospital’s primary care and ambulatory clinic, and skilled nursing facility. It includes representatives from the physician and nursing staffs in inpatient and outpatient settings, case management, social services, utilization management, physical therapy, palliative care, and the hospital and primary care administration. The team added a data analyst who routinely collects metrics related to care transitions.
“We wanted to be able to tell the story of care transitions and readmissions with data as well as anecdotal experiences and chart review,” Schneidermann says.
The first year the team developed its mission and vision, set goals, and identified metrics to follow, then began to address the gaps that occurred when patients transition from one level of care to another. The team created three subgroups who were charged with developing initiatives in the inpatient setting, the primary and ambulatory care settings, and pharmacy-related initiatives.
“When we started, we didn’t have an approach to assessing risk for poor transitions of care and we didn’t have information on the types of patients that were being readmitted. We now have an ongoing process to help us understand which patients are at highest risk. From a human perspective, just focusing reducing readmissions is not compelling. What is more compelling is improving the way we provide both acute and post-acute care and to ensure that patients and caregivers have a positive experience and a safe transition,” she says.
A Care Transitional Task Force at San Francisco General Hospital created a cross-continuum program that has reduced readmissions and increased timely primary care visits for discharged patients.
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