Improving transitions cuts HF readmissions

Post-acute providers, hospital team up

A series of initiatives by Cooley Dickinson Hospital in Northampton, MA, has improved patients transitions, which has resulted in a 50% reduction in readmissions for heart failure patients.

Key components of the initiatives include forging an alliance with post-acute providers, transition coaching for at-risk patients during the hospital stay and after discharge, and teaching patients to use their personal health record to track their care and list questions for providers, according to Tammy Cole-Poklewski, RN, MS, director of quality, patient safety, and care management at the 142-bed facility.

The hospital started its readmission reduction program in 2008 by leading the development of the Hampshire County Continuum of Care, an organization of hospital staff, including case managers, social workers, nurses, and physicians; skilled nursing facility administrators; and representatives from the Visiting Nurse Association and elder services agencies. The organization focuses on improving communication between levels of care. (For details on how the consortium was organized and what it does, see related article, below.)

"In the fall of 2010, we realized that we were making improvements in heart failure, but the overall readmission rate wasn't going down as much as we had hoped," Cole-Poklewski says. The team reviewed the charts of a group of patients who had been readmitted, and determined that the majority were readmitted within 24-48 hours of discharge. A large population of patients readmitted within 24 hours had secondary psychological diagnoses, or were uninsured, underinsured, or homeless, she says.

"We knew that if we didn't address the underserved population, we'd never decrease the readmission rate," Cole-Poklewski says. "We also knew that the readmission reduction techniques we used with the rest of the population wouldn't work with this group because there are so many other things going on in their lives."

The hospital received a grant from the Massachusetts attorney general's office to focus on decreasing emergency department visits and readmissions for the high risk population. The hospital adopted the Care Transitions Intervention model, developed by researchers at the University of Colorado in Boulder, CO, led by Eric A. Coleman, MD, MPH, a geriatrician who is director of the Care Transitions Program and a professor of medicine at the University of Colorado School of Medicine in Denver, CO. (To learn more about the Care Transitions, follow the link in the Resource, below.) In the model, a transitions coach who is a case manager or a social worker follows the patients for a month after discharge. Trainers from the University of Colorado trained case managers and social workers to become transition coaches.

The hospital determined that the patients who were being readmitted shortly after discharge generally fell into two categories. One group had complex psycho-social needs, were uninsured, homeless, and had a secondary psychiatric diagnosis, and other needs that make them appropriate for coaching by a social worker. The other group of patients had multiple chronic diseases, was discharged on eight or more medications, had limited services at home or refused post-acute services, and had limited social support. In addition to heart failure patients, the second group includes patients with coronary artery disease, chronic obstructive pulmonary disease, diabetes, pneumonia, those who have had a stroke, and those who are being coached by RN case managers.

As part of the assessment process, the hospital case managers screen every patient admitted to the hospital if they have one of the diagnoses covered in the coaching program, to identify those who are eligible for the interventions. The care transition coaches pull up a report each morning, divide the list according to patient needs and set priorities on whom to see first, depending on the number of risk categories determined by the screen.

The coaches talk to the staff on the unit to get more details about the patients, then visit the patients, explain the program, and ask the patient to agree to the coaching process. The social worker coach also determines what community resources the patient may need and starts getting the resources in place.

"One of the biggest pieces was to give patients a personal health record and teach them how to fill it out," Cole-Poklewski says. The 24-page booklet has space for the patients to enter basic health information including names and phone number of providers, hospitalizations, allergies, and medications. It has a place for the patient to enter personal goals and list of questions for providers.

The transition coaches visit the patients within 3-4 days after discharge. They work in conjunction with other clinicians providing post-acute care to the patients. "The transition coaching doesn't replace other services, such as the Visiting Nurse Association visits, or follow-up doctor visits," Cole-Poklewski says. "The coaching supplements any other services the patients may get and helps improve the patient's self-management skills."

During the home visit, the coaches typically focus on use of the personal health record and medication review. The coach doesn't conduct the medication reconciliation, but talks the patient through it. Patients bring in all the medications they are taking, explain to the coach what they are for, and write it in their personal health record.

If the patient is experiencing symptoms or problems, the coach has them write down the symptoms, decide what questions to ask, and coaches the patient through calling the doctor.

"A key to the success of the personal health record is to have the patient or family member fill in the information, rather than having the coach do it," Cole-Poklewski says. "The coach is on hand when they fill it out to help them with the information and to help them identify their healthcare goals."

The overall hospital readmission rate has decreased every month since the program began in February 2011. Three patients enrolled in the program have stayed out of the hospital for more than 30 days after previously being admitted every 2-3 weeks, Cole-Poklewski says.

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Good communication smoothes transitions

Hospitals and SNF collaborate

By getting feedback from its post-acute providers, Cooley Dickinson Hospital in Northampton, MA, is improving communication between facilities and, as a result, facilitating smoother patient transitions.

The hospital led the development of the Hampshire County Continuum of Care Consortium in 2008 by inviting the lead people at local nursing facilities and the Visiting Nurse Association (VNA) to come to a breakfast and discuss how to work together better. Tammy Cole-Poklewski, RN, MS, director of quality, patient safety, and care management at the hospital explains: "Early on, we wanted to make sure the organization wasn't just a committee that met periodically but truly was an effort on the part of all participants to improve the way we work together," she says.

The 25-30 members of the Hampshire County Continuum of Care Consortium include hospital case managers, social workers, nurses, and primary care physicians, nurse practitioners who work in the community, nursing home administrators, representatives from the Visiting Nurse Association and elder service agencies, and retired healthcare professionals. Cole-Poklewski and the executive director of the VNA are co-chairs.

The entire group meets monthly and discusses improving patient care across the continuum. Smaller groups meet weekly and discuss specific activities to improve the transition.

"We started the consortium to improve communication between levels of care. We wanted to know how we were doing as a hospital to ensure a smooth transition and what we could do better," she says.

The first suggestion from the post-acute providers was for the hospital to improve the information provided to the receiving providers when a patient is transferred. A committee of hospital discharge staff and representatives from the nursing facilities and VNA worked together for a month to standardize and streamline the information provided by the hospital.

The biggest complaint the post-acute hospitals and agencies had was inconsistency in the information they were receiving through the hospital's electronic discharge product. "At the time, whichever nurse or social worker was handling the discharge pulled together what they thought the nursing home wanted," Cole-Poklewski says. "There were as many different ways the documents were organized as there were clinicians sending them. The nursing facilities told us that sometimes they didn't know where to begin."

The nursing facilities reported that they wanted the discharge summary, laboratory work, and progress notes in an easy-to-read format and for the information to be the same and in the same order for every patient. "We actually reduced the discharge paperwork from hundreds of pages to 8-10 key documents," Cole-Poklewski says.

The following month, the hospital began looking at how other hospitals facilitate transitions between levels of care and decided to hire a non-clinical support person to handle transmission of the discharge information. "The post-acute agencies loved it," Cole-Poklewski says. "In the past, eight or nine individuals were sending them information. This way they knew that every time, they were going to get the same information in the same place."

The consortium also focused on coordination of care and reducing readmissions for heart failure patients, identifying areas that needed improvement, and developing best practices in communication as heart failure patients transitioned through levels of care. For example, the consortium realized that each level of care was giving patients different materials to educate them about heart failure and how to manage it. The consortium developed a one-page educational sheet on heart failure that providers use across the continuum of care.

As a result of her involvement with the consortium, Cole-Poklewski was one of three healthcare professionals in Massachusetts who was trained as an improvement advisor for Massachusetts's State Action on Avoidable Readmission (STAAR) project that focuses on improving transitions among levels of care. STAAR is a collaborative project between the Institute for Healthcare Improvement (IHI) and the Commonwealth Fund.

"The STAAR initiative builds on what we already were doing and has helped us continue to improve the services for our patients as they go from one level of care to the next," Cole-Poklewski says.