Health System Improves Patient Care and Transitions Through Outreach
September 1, 2022
By Melinda Young
EXECUTIVE SUMMARY
Case managers can improve patient transitions when health systems focus on population health and partner with community-based organizations, including groups that address food insecurity.
- Case managers can follow patients across the continuum, meeting weekly to address gaps and opportunities for care.
- Simple, magnet-style discharge instructions will work better for patients who may have trouble finding and understanding a discharge brochure.
- Patients might need simple or repetitive training on taking medication or using devices as part of their improved safety in self-management.
The typical fast-paced discharge process can leave case managers feeling discouraged. They see patients barely absorbing the self-management education — and often returning soon to the hospital when their symptoms flare.
It can be frustrating to send home patients with overwhelming discharge instructions, says Billie Lynn Allard, MS, RN, FAAN, a consultant with Southwestern Vermont Health Care (SVHC). In her previous career as a chief nursing officer, Allard researched novel and successful ways to deliver care.1,2 She embraced the concept of value-based care and focusing on keeping high-cost, complex patients out of the hospital.
“We partnered with primary care providers to smooth that transition from primary care to the hospital or to the emergency department,” Allard says.
Soon, connections between the health system and community providers expanded to include skilled nursing facilities, nursing homes, and home care organizations. “It all blossomed into so much more than we anticipated,” Allard notes.
Within three to six months, SVHC reduced readmissions of high-need patients by almost half. That has remained constant for eight years.
SVHC also connected with community organizations to bring fresh and healthy foods to communities, food banks, shelters, and soup kitchens, says Tiffany Tobin, MS, director of hospitality services at Southwestern Vermont Medical Center.
“Bringing everyone together is what makes these programs successful,” Tobin says. “It’s all about being a link in the chain of wellness for the community, and each one of us doing our part.”
This is how the outreach programs work:
• Address food insecurity in the community. As health systems come up with more ways to improve population health, one important area to address is food insecurity. (For more information, see related story in this issue.)
“We didn’t understand how huge the issue was,” Allard says. The health system began to produce enough food to give casseroles, soups, and stews to local shelters and soup kitchens.
The food insecurity program pulled back temporarily due to COVID-19, but the program will resume when the pandemic ends. “But we’re anxious to get back into the swing of partnering with our community, and we have many strong ties in which multiple organizations are partnering with us,” Tobin adds. “We each have a different role we play to keep these conversations moving forward for the betterment of our community.”
• Nurses follow patients across the continuum. “They observe how care is delivered in our community, going to the doctor’s office with patients,” Allard says.
Nurse navigators accompany patients on visits to rehabilitation and specialists. They also visit patients in nursing homes. “We’d meet on a weekly basis and download all the gaps and opportunities we were finding,” Allard says. “We saw that half of patients were not taking their meds correctly, and some had really scary situations where they were taking aspirin while on coumadin.”
The patients had not thought to tell doctors they were taking aspirin. In other cases, patients were not taking their prescribed thyroid pills or potassium.
“It was a total mess,” Allard notes. “Some patients had two or three doctors who were not talking with each other, and so the patients would keep getting new prescriptions with new names. They had no clue about what to do.”
The solution was to give patients medication boxes and talk with their physicians. “A lot of people were sent home with a big list of medications, and they had no way to get them,” Allard says. “Transitional care nurses went into the home to start straightening it out.”
Once a nurse put patients on track with taking the correct medications and doses, patients no longer struggled, she adds.
• Make discharge instructions easier to access and understand. “We also changed the discharge instructions,” Allard says. “Previously, the nurse specialist had created the instructions, but they were in the trash, not being used, and hardly anyone found them helpful.”
That needed to change, so they created refrigerator magnets of red, yellow, and green, reading, “If you get up in the morning and are having trouble breathing, this is what you need to do,” Allard says.
“That was on the fridge, so they didn’t have to look for it. It helped them manage better,” she adds.
• Help patients improve safety in self-management. Some patients had trouble using their inhalers. They were trained on certain inhalers in the hospital but did not know how to use the inhalers from the pharmacy after they were discharged.
“Some were trying to use their inhaler with the cap on and were wondering why they were readmitted,” Allard explains. “Some people lived in unsafe situations and needed safety items put in place.”
The hospital began a pilot project for an occupational therapist to visit patients’ homes to identify their safety issues. Then, high school students installed bars on their shower or toilet. This is a solution that could be expanded with funding, and it could help reduce falls and hip fractures, Allard notes.
• Reduce acute care transfers. SVHC created a program called Interactions to Reduce Acute Care Transfers (INTERACT).
“We did work in the nursing home setting because we saw there was poor communication between the hospital and nursing home,” Allard says. “[Because of that], we implemented INTERACT.”
The goal was to reduce readmissions by asking hospital staff to listen to nursing assistants about patients’ conditions and changes in symptoms.
“Once they say there’s a change in condition, there needs to be more frequent assessment of vital signs and chest X-rays to nip any problems in the bud so they can prevent hospitalization,” Allard explains. “That worked very well.”
The program started with an affiliated nursing home and expanded to all nursing homes in the community. “Nursing assistants often had their finger on the pulse of what was happening with patients,” Allard says. “But [before the program], no one was paying attention to it.”
INTERACT brought nursing home leadership teams to learn how this could work to everyone’s benefit. “We educated all nursing and nursing assistants about their role, and the system was set up,” Allard says. “Once there was a change in the patient’s condition, they immediately implemented a whole new care plan that included more frequent assessments, talking with a nurse practitioner or physician who was in charge of ordering things and getting things done.”
The health system also educated nursing home staff on warning signs in a patient with COPD or congestive heart failure. “Once they saw how it worked, a strong nursing home administrator hardwired it into their system. Most in our community have continued to use it,” Allard says.
REFERENCES
- Allard BL, Conroy CA. Our nursing profession at a crossroads: Time to chart a course for the future. Nurse Adm Q 2022;46:208-217.
- Allard BL. INSPIREd Healthcare: Revolutionizing Care Coordination Delivery to Achieve Success. Sigma. 1st edition: Jan. 31, 2020.
Case managers can improve patient transitions when health systems focus on population health and partner with community-based organizations, including groups that address food insecurity.
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