Hospitals, providers collaborate on transitions

Goal is to reduce readmissions

In order to facilitate smooth transitions between levels of care and ensure that patients continue to recover after they are discharged from the hospital, Baystate Health, with headquarters in Springfield, MA, is partnering with post-acute providers and meeting regularly to discuss opportunities for improved patient care and partnership.

Baystate Health is a three-hospital system in western Massachusetts. The flagship facility, Baystate Medical Center is the only major tertiary center in a 60-mile radius.

"Our patients come here very sick. In today's healthcare environment, hospitals save people's lives but patients no longer stay in the acute care hospital long enough to fully recover. We need to make sure that when patients no longer meet the criteria for an inpatient stay that they go to a facility that can continue the plan of care and will incorporate additional focus on the recovery components of a patient's care," says Susanna Hall, RN, BSN, MBA, director of post-acute services at the three-hospital system in western Massachusetts.

The health system assembled a multidisciplinary post-acute performance team that began meeting with post-acute providers in the area. (For details on how the partnership works, see related article, below). The hospitals in the system and post-acute providers are working together to determine why patients are readmitted to the hospital and to work on ways to keep them in the appropriate level of care.

The team used the INTERACT (Interventions to Reduce Acute Care Transfers) Readmission assessment tool to collect information on hospital readmissions from skilled nursing facilities. INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in status of residents of skilled nursing facilities. The assessment showed that the biggest spike in readmissions occurred on Thursday and that the fewest patients were readmitted on Wednesdays. The data also showed that the majority of readmissions occur during the day shift.

The team drilled down to look for reasons and determined that readmissions are affected by the physician coverage model at the skilled facilities, reports Hall. We found that most of the readmissions are made telephonically by a physician, a physician assistant or nurse practitioner. The readmissions are lower on Wednesday because that is the day that community physicians make their rounds in the skilled nursing facilities," she says.

The team asked representatives at the post-acute facilities to review the readmissions and determine what could have prevented each individual readmission. "We are working within the structure of each organization to determine how they can improve and reduce admissions. We have asked them to look back and see if there was something they could have changed in the days before the readmission to avoid sending the patient back to the hospital," she says.

In some cases, the physicians said they weren't comfortable that the nurse who called them was aware of exactly what was happening with the patient. For instance, the nurse might see that the patient's condition was deteriorating, and talk to a physician who had never seen the patient and wasn't comfortable in adjusting the medication over the telephone.

The team encourages the post-acute providers to take proactive steps to avoid readmissions. As a result, one facility has contracted with a telemedicine program so if there is not a physician in the house during certain hours, the on-call physician can see the patient via tele-monitor and has access to the patient's medical record from the acute stay as well as the rehab period.

In some situations, the skilled nursing staff reported that heart failure patients were being readmitted because the patient and family didn't understand the goals of care and the family had brought in a pizza or other salty food for a heart failure patient who was on a low-salt diet.

"We saw that each side could learn by sharing and developing collegial relationships. Jodi Koshouh, RN, the hospital's heart failure coordinator needed to learn about the constraints of a skilled nursing facility," Hall says. She arranged a roundtable discussion at the skilled nursing facility so both sides could learn and exchange best practices in heart failure management. Koshouh says: "The learning was a two-way street. We learned that skilled nursing facilities are a much different environment from the acute care hospital, in terms of the patient's right to choose. Acute hospitals can be very autocratic and vigilantly oversee every step, but when a patient leaves and is in a skilled nursing facility, it is more like their homes."

For instance, in a skilled nursing facility, patients have the option to refuse to be weighed if they want. Their diet is not as regimented as it is in the acute care hospital and if they want a salt-laden meal, they can have it. Hall says: "This was a big eye-opener for the hospital team. We have standardized the education patients and families receive at all levels of care. The more everybody gives patients the same education, the more likely they are to follow the recommendations."

Hall also works with post-acute providers to make sure that patients are not readmitted when they could receive the care they need at the skilled facility. The group talks a great deal about goals of care. For instance, a frail elder with dementia who is declining and is sent back to the acute care hospital is a common type of case. "When this patient is readmitted and ends up in the intensive care unit, the acute care practitioner often asks 'why did this need to happen,' " Hall adds. Often, the goals of care had not been clearly discussed with the family and there is a high potential that a patient could have received palliative care or hospice care at the skilled nursing facility, and experience a peaceful death, not one filled with machines and noises," Hall says. She suggests that a better solution would be to educate the family about a disease's progression and what can be done in a skilled setting long before the patient's situation starts to deteriorate.

"For some of these patients, the best care is to keep them comfortable and let them live as best they can, rather than admitting them to the ICU and putting them on a ventilator. We want to take steps in advance to help the family come to terms with their loved one's condition and not wait until there is a crisis," she says.

Alzheimer's patients are a difficult population to place, Hall points out. "It's a challenge to find the right post-acute provider," she says. As a result of the post-acute transition initiative, one of the organizations with which Hall works has opened a geriatric psychiatry unit in a local hospital. "If there is a patient with dementia in the hospital that we can't settle down, we can send him to the specialized unit. We have worked with the skilled facilities with dementia units not to send patients back to us if they have problems, but to send them to the geriatric psychiatric unit so they can receive the medication adjustment and focused clinical management they need," she says.

For instance, if a dementia patient is hospitalized, the intensity of the inpatient experience causes a lot of confusion and they may become very aggressive, creating patient safety issues. The staff at the geriatric psychiatric unit have the expertise and the resources to handle the patients' medical problems and keep their behavioral problems under control. In some cases, Hall has negotiated to have Baystate Health assist with the cost of one-on-one services for Alzheimer's patients until they settle into the new location, rather than having the patient readmitted to the acute care hospital.

Initiative creates a bridge to post-acute providers

Improving transitions is the goal

In her role as director of post-acute services for Baystate Health in Springfield, MA, Susanna Hall, RN, BSN, MBA acts as the bridge between the health system and post-acute providers to make sure that the post-acute providers share Baystate Health's vision of quality, to improve communication as patients transition between facilities, with the ultimate goal of ensuring that patients receive the care they need to reduce hospital readmissions.

"My role is to walk this line between the hospital and the post-acute providers and be the person who understands the need to move patients out of the hospital effectively and what the receiving providers need so we can support them. The health system created my role in 2006 to concentrate on establishing strategic initiatives to improve transitions," Hall says.

When Hall became the healthcare system's director of post-acute care, the hospital already had a relationship with a skilled nursing facility but not every patient wanted to go to that particular facility, and it didn't have the capacity to handle every patient who needed post-acute care.

"We reached out to other providers in the area, including skilled nursing facilities, inpatient rehabilitation hospitals, the Baystate Visiting Nurse Association & Hospice, and long-term acute care hospitals (LTACHs). We wanted to work together to make transfers a seamless process," she says.

Initially, Hall held strategic planning sessions with representatives of the area's post-acute providers at each level of care but determined that the process would work better if the hospital system worked with just one post-acute provider at a time.

"Everybody along the continuum is at a different place in terms of how they deliver care. They have to comply with different regulations and many have different nursing models. We had to meet each level of care at each facility where they are and work together to develop smooth transitions," she says.

The team has met with representatives of three corporations that own the bulk of post-acute facilities where Baystate Health patients receive care. "By meeting with representatives of individual corporations, rather than representatives from multiple corporations, we were able to be direct and talk frankly about our specific concerns. We talked about best practices and program outcomes and brainstormed on how to improve transitions," she says.

The hospitals and post-acute providers worked together to determine the strengths of each organization and identify opportunities for each facility. "We wanted to avoid a situation where many facilities were concentrating on accommodating the total joint patients or stroke patients," she says.

The team collaborated with the post-acute providers to determine what information providers need as patients transition from one level of care to another. "We asked our partners what information they need, how detailed it should be, and in what order. We're now in the fifth or sixth version and are still working on it," she says.

Now instead of meeting with individual corporations and providers, Baystate Health has moved the meetings with the post-acute providers into their State Action on Avoidable Rehospitalizations (STAAR) meetings. STAAR is a multi-state project sponsored by the Institute for Healthcare Improvement that aims to reduce readmissions.

The team discusses difficult cases and how they might be handled better, Hall says. "We talk about the patients who have been a challenge for everyone and learn from each other," Hall says.

The hospital system is monitoring readmissions but doesn't have any firm data to share.

"The best outcome for this initiative is that everyone is on the same team. They call me if they have a problem and I call them as well. We support each other in caring for patients and discuss what we need to do to work together for a comprehensive plan. In the end we are all working towards the same goal: helping people recover to their optimum wellness and return to living," Hall says.


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