As part of its safe transitions program, Swedish Edmonds Hospital in Edmonds, WA, has partnered with two local fire departments to enhance follow-up care for patients being discharged to home from the emergency department.

“This is a collaborative approach to try to meet the needs of the patient. We want to reduce readmissions and we recognize that care doesn’t stop when the patient leaves the hospital. We have a short period of time to educate patients about their disease and medication regimen, and often they need follow-up assistance,” says Deb Dukleth, RN, director of case management for the 217-bed hospital.

Patients who are reluctant to accept home health services often are agreeable to have someone from the fire department come by the check on them, Dukleth says.

“Patients have a variety of reasons for refusing home health, but in many cases it’s a concern about costs. Many times, they say yes to a visit from the fire department when they won’t say yes to other things,” she says.

When patients agree to visits from fire department personnel, the hospital faxes the fire department basic information about the patients including demographic and clinical information. Paramedics from either the Snohomish County Fire District or the Community Resource Specialists at Lynnwood Fire Department make the visits, depending on the location. The fire department representatives also visit patients who have frequent falls or other issues that land them in the emergency department.

During the visit the paramedics take the patient’s vital signs, make sure patients understand their treatment plan, check the patients’ homes for safety issues, and alert the hospital or the patient’s primary care physician if there is an issue or if patients have questions about their treatment plan. They may make follow-up visits to patients to make sure they are doing well and have everything they need, she says.

The fire department partnership is part of Swedish Edmond’s safe transition program, Dukleth says. As part of its efforts to cut down on readmission, a coalition of Snohomish County healthcare providers meets regularly to discuss ways to improve discharge transitions. The coalition includes representatives from community hospitals, skilled nursing facilities, assisted living centers, adult family homes association, home health, hospice and palliative care, specialty and primary care clinics, and representatives from two fire departments that serve the area.

“Our goal is to reduce readmissions, not just for the hospitals but also for the skilled nursing facilities, and to improve patient satisfaction at the same time. Our meetings are an open forum where participants identify reasons for readmissions and discuss barriers to discharge and potential communication issues,” Dukleth says.

For instance, the group discusses ways the hospital can provide an accurate and complete handoff to the next level of care as well as how the skilled nursing facilities can improve their handoffs. Representatives from the other two hospitals share information about their readmission reduction programs, what has been successful, and what has not worked as well.

“The physicians who see patients after discharge have identified potential communications issues that we also are assisting with,” Dukleth says.

Initially, the safe transitions program focused on reducing heart failure readmissions. The coalition has expanded the program to include any patients who are at high risk for readmission, Dukleth says.

At Swedish Edmonds, the case management staff assess all inpatients within 48 hours of admission using a high-risk screening tool to identify patients who may need assistance after discharge. In some cases, patients who are receiving observation services also are assessed for discharge planning needs and resources. Physicians and nurses also identify patients who may need follow-up after discharge.

“Swedish Edmonds staff members make follow-up calls to patients within three days of discharge. If they don’t answer the phone, it might be another indication that they need additional support,” she says.

When at-risk patients are identified, the case management team determines the patient’s level of functionality before the hospital admission, his or her living situation, social support, and anticipated discharge needs. They work with the patient and family to identify needed resources and develop a discharge plan.

“Our healthcare team works with the patient and family to develop a safe discharge plan that may include medical equipment, home health, transportation and lower cost medication, if needed. Many people don’t know what resources are available to them. They want to stay independent but need support to stay safe,” Dukleth says.

Patients often need assistance with transportation or help with meals or housekeeping. Sometimes they can’t afford their medication.

“It’s sometimes a challenge to identify the issues in the home and the resources patients need. We try to cover all resources needed, but people in the hospital have an acute illness that affects them and their loved ones and they may not always provide accurate information,” Dukleth says.

Having someone visit at-risk patients at home, whether it’s a home health nurse or a paramedic, often alerts the treatment team to patient needs, she adds. “What they see in the home may be very different from what the patients and family members have told us. They identify problems and needs that we otherwise would never know about,” she says.

The fire departments also work collaboratively with the emergency department and alert them when patients they transport to the hospital have issues in the home and additional needs, she says.

The case managers also refer patients to the Center for Healthy Living, which has a care transition coach who can follow patients after discharge, Dukleth says. The center is part of the county’s senior services.

Sometimes a representative from the center visits the patients before discharge to explain the program and find out what the patient needs.

When patients are readmitted, the case managers work with the treatment team in the hospital to identify the reasons. “We try to identify the real issues in the home and what resources we can provide. We may reach out to family members, members of their church, and neighbors for help in developing a successful treatment plan,” she says.