Readmission project aims to smooth transitions
Hospital collaborates with post-acute providers
As part of its efforts to reduce readmissions, WellStar Health System, based in suburban Atlanta, is meeting with post-acute providers to collaborate on ways to make transitions between levels of care smoother. It is piloting a program in which a transition coach works with heart failure patients in the hospital and follows them for four weeks following discharge. (For details on the transition coach program, see related article, below.)
WellStar conducted a systemwide, root cause analysis of readmissions, reviewing charts and interviewing patients to determine the reasons patients were coming back to the hospital, and used the data from the analysis to develop performance improvement initiatives.
"We saw an opportunity to work with post-acute providers to improve transitions of care," says Kamela Sooknanan, RN, assistant vice president, medical management for the five-hospital health system.
One of the first steps was to set up a series of community-wide meetings with representatives from skilled nursing facilities, assisted living facilities, home health agencies, hospice agencies, and ambulance companies to discuss improving transitions. The meetings are held every other month and are well-attended. "The post-acute providers say they find them very helpful. These providers rely on the hospitals for patient volume and are interested in working with us to improve patient care. The post-acute providers understand that consequences to the patients when they are readmitted to the hospital, and are partnering with us very well to prevent unnecessary readmissions," Sooknanan says.
At the meetings, the providers discuss glitches that occur in the transition process and brainstorm on ways to overcome them. "The hospital system was the first to acknowledge that there are issues with transferring patients and we were the first to be transparent. We acknowledged that there was some lack of coordinated care and asked for the post-acute providers' help in fixing it," she says.
Based on input from the post-acute providers, the hospitals in the system have developed a single point-of-contact at each hospital so representatives of the post-acute facilities know who to call if they have questions about a patient. The case management directors of each facility attend the meeting so the facility representatives can put a face with the name.
They have standardized the information the hospital sends with the patient and made sure it's always in the same order. The health system sends a survey to post-acute providers at the time patients are discharged from the hospital, asking for feedback on how the transfer went. "They understand that we want to know when something works and when it doesn't," she says.
The group developed a uniform process of transferring the patient from the hospital to the post-acute facility and is developing a standardized transfer form that all facilities can utilize when they transfer patients back to the hospital. The form includes information about what has been happening with the patient, including medication and vaccinations, so the hospital team won't duplicate something that has already been done. In addition, the form will allow the emergency room physicians and nurses to become very familiar with obtaining the same level of information on all skilled nursing facilities.
The health system's emergency department case managers are working with post-acute providers when patients come back to the hospital to determine if they can be discharged from the emergency department after they are evaluated and treated, and continue the treatment they need in the skilled nursing facility. For instance, if a patient comes back to the hospital with a urinary tract infection, the case managers ask the transferring facility to take the patient back after he or she is assessed and treated by the emergency department physician.
"The post-acute facilities understand what we're doing and anticipate that we may be calling them to take patients back. They're very open and willing to work with us," Sooknanan says.
Pilot aims to cut readmissions Transition coaches follow up after discharge WellStar Health System, in suburban Atlanta, is piloting a program in which a care transition coach provides oversight to ensure a high quality discharge including extensive education to heart failure patients in the hospital. The coach follows them after discharge to ensure that they are following their treatment plan and keeping their condition under control. The health system bases its care transition coaching program on Project RED (Re-engineered Discharge) and recommendations from the Agency for Healthcare Research and Quality and the Joint Commission, according to Kamela Sooknanan, RN, assistant vice president, medical management for the five-hospital health system. (For more information on Project RED, see resource, below.) "Heart failure is a complex disease and has one of the highest readmission rates. We started with heart failure on one unit, and when we know the process is working well, we will roll it out to other diagnoses and other parts of the hospital," she says. Because of the slow economy, the health system has not been able to add FTEs, requiring the system to be creative in using staff for the program. Instead, one case manager has been trained as a transition coach/discharge advocate. The transition coach makes rounds with the treatment team on the telemetry unit every day. The coach develops a discharge plan for the heart failure patients and focuses on making sure they get the education they need to manage their condition after discharge. "The care transition coach model is designed to make sure that patients being discharged have the knowledge they need to manage their disease at home. We make sure they understand the disease and their medication and how to take it. We educate them to weigh themselves daily, and recognize symptoms and what to do when they occur," Sooknanan says. The coach uses the teach-back method to educate patients on what symptoms to watch for when they go home, and how to manage any red flags. The coach follows the patients for 30 days after discharge, usually calling patients four times during that period, but increasing the frequency when needed. The goal is to call the patients the first time within 24 hours of discharge and make sure they have filled their prescriptions and understand how to take their medication. Before discharge, the transition coach gives patients a two-sided sheet that includes a 30-day calendar listing their appointments on one side and the Heart Failure Zones, which shows what symptoms and sign to watch for and what to do when they occur. "We began with heart failure and are now putting together a program for care transition coaches for patients with other complex diseases. The program is appropriate for all chronic illness. The only thing that changes is the education about the specific disease, Sooknanan says. Resource For more information on Project RED, visit: http://www.bu.edu/fammed/projectred. |
As part of its efforts to reduce readmissions, WellStar Health System, based in suburban Atlanta, is meeting with post-acute providers to collaborate on ways to make transitions between levels of care smoother. It is piloting a program in which a transition coach works with heart failure patients in the hospital and follows them for four weeks following discharge.
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