Executive Summary
UnityPoint-St. Luke’s Hospital’s Transitions Home program has slashed all-cause readmissions to an average of 10% by focusing on making sure patients’ needs are met while they are in the hospital and after discharge.
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An Advanced Medical Team of RN care navigators and social workers works in the outpatient clinic and coordinates care for patients with multiple comorbidities who take multiple medications and are being treated by multiple physicians.
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The Consistent Care program, overseen by a social worker, links patients who use the emergency department for primary care with a primary care physician.
Dedicated care coordinators on each unit have cubicles in the nurses’ stations and meet daily with the charge nurse, social worker, and bedside nurse caring for the patient to discuss the goals of care and goals for discharge of each patient on the unit.
Readmissions drop to an average of 10%
The Transitions Home program at UnityPoint Health-St. Luke’s Hospital has reduced the all-cause readmission rate for the 532-bed Cedar Rapids, IA, hospital from 11.4% to an average of 10%.
The Transitions Home staff embrace and operationalized in their work, the hospital’s mission statement of giving “the care we would like our loved ones to receive,” says Peg Bradke, RN, MA, vice president of post-acute services.
Initially, the Transitions Home program focused on three measures: myocardial infarction, pneumonia, and heart failure. “We merged them into all-cause readmissions. With value-based purchasing, we have to look at the entire population and work on ways to better coordinate care,” Bradke says.
The program was developed by a multidisciplinary team that conducted a root-cause analysis on readmissions for myocardial infarction, pneumonia, and heart failure, looking for opportunities for improvement. The team later added total joint replacement, stroke, and chronic obstructive pulmonary disease to the program.
“We looked at those six diagnoses to find out why patients are coming back to the hospital. We found that a lot of readmissions occur because of social issues and lack of support,” Bradke says.
When the hospital began working on population health, it implemented an Advanced Medical Team of RN care navigators and social workers located in the hospital’s outpatient clinic who manage the care of patients at high risk. “The goal is to break down barriers, triage, and keep patients safe in their homes and out of our hospital,” Bradke says. The care navigator manages a population of around 100 patients.
Patients are referred to the Advanced Medical Team based on their risks, and discussions between the care navigators and the physicians about who would best benefit from the service. The typical patient in the program has multiple comorbidities, takes multiple medications, and is being treated by multiple specialists, according to Bradke.
The RN care navigators make frequent phone calls to the patients, complete medication reconciliation, and make sure patients are following their treatment. Outpatient social workers work very closely with the care navigators on managing the care of patients who have social needs. They meet with the patients when they come into the clinic, visit them at home, and follow up by phone to make sure services are in place, Bradke says.
When patients are admitted to the hospital, the Advanced Medical Team works with the inpatient case managers to ensure continuity. When patients are ready for discharge, the inpatient team hands them over to the outpatient team, she says.
The hospital has developed an emergency department Consistent Care program which is overseen by a social worker, she says.
“Many of the patients are using the emergency department for primary care because they don’t have a primary care physician. The social worker sets the patient up with a primary care physician and works with them to follow through on the care plan,” Bradke says. The care plan is on file in the medical records so if the patient comes back, the emergency department or clinic providers have the same plan to follow and reference, she says.
At St. Luke’s Hospital, patient assessments are a team effort, not just the responsibility of case management, Bradke says. The hospital has a dedicated care coordinator on all units. Social workers may cover up to two units.
“The bedside nurses have a key role in assessment. As they spend time with the patients, they build a connection and the patients may feel comfortable sharing information about their support system and any social needs,” she says.
The nurses share the information with the case manager during daily huddles attended by the charge nurse, unit care coordinator, social worker, and bedside nurse caring for the patient, Bradke says. The team discusses goals of care and goals for discharge and the patient’s progress. They re-evaluate the discharge needs and anticipated date each day, adjust the plan of care and adjust discharge preparations when needed.
The case management department has been decentralized, and now the care coordinators are housed on the unit and are part of the unit. “They have cubicles in the nurses’ station and are very visible to the physicians and other staff who take the opportunity to alert the care coordinators to patient concerns,” she says.
In the last few years, the administration at St. Luke’s has been pushing the idea that everybody in the hospital is a care coordinator and should share any information they have that can result in better patient care, Bradke says.
“Sometimes the radiology transporter or the housekeeper may hear something that would help the care coordinators develop a discharge plan,” she says. For instance, the patient care technicians spend a lot of time with patients, and they may notice a patient safety issue and report it to the nurse.
“Everybody knows everyone else and everyone is valued for the services they provide. We all work as a team for better patient care,” she says.
From Day 1, the team tries to involve family members and caregivers in the patient’s care, Bradke says. Each patient room has a 24” x 36” white board that the staff and family use to share information. At the beginning of each shift, the nurse writes the goals for the day and the goals the patient must meet in order to go home. Family members are encouraged to write questions on the board. The treatment team also does bedside reports as a way of engaging patients and family members.
When patients are admitted to the unit, they are asked to identify an accountable caregiver who will be involved with the discharge care planning and education, she says.
The team uses the white board to make sure the right person is present when the nurse gives the discharge instructions, she says.
Discharge planning is a team effort. The care coordinator and frontline nurses handle the discharge if patients are being discharged to home. The social workers get involved if patients are going to a different level of care. The staff nurse is in charge of patient education and discharge teaching, using the teach-back method to engage patients, she says.
The team recognizes that patients are overwhelmed at discharge, are ready to go home, and often don’t pay attention to the discharge, she says.
“When we do discharge teaching, we also teach them how to use the discharge instructions, and what information they contain,” Bradke says. The discharge instructions are written in simple language and include information about where the patient is going, how to take their medication, information on their follow-up appointment, instructions for self-care, and contact information in case of emergency. The nurse prints two copies of the instructions — one for the patient and one for the caregiver.
