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CM redesign, home visits are among initiatives
After the Holzer Health System in Gallipolis, OH, embarked on a comprehensive readmission reduction program involving the entire health system, all-cause readmissions dropped by 20% in just two years.
"It was a team effort across the continuum. Representatives from every setting helped design the initiative, and we still work together on strategies for preventing readmissions," says Teresa Remy-Detty, DSC, MHA, LNHA, BSN, RN, vice president of post-acute care services for Holzer Health System.
The health system’s readmission reduction team includes nurses, case managers, pharmacists, and physicians from the health system’s acute care hospitals, skilled nursing facilities, home health agencies, hospice providers, and assisted living centers.
The team has come up with initiatives that range from increasing the hours and days that case managers cover the hospital to arranging home health visits, and sometimes physician visits, for patients at high risk for readmission to telephoning the charge nurse at skilled nursing facilities to discuss patients being transferred.
The health system also partnered with the Area Agency on Aging and developed a Community-based Care Transition Program with a grant from the Centers for Medicare & Medicaid Services (CMS). The Area Agency on Aging has placed its care transition coaches in the same department with the case managers and social workers. They work with patients who are identified for the program based on CMS criteria, go on multidisciplinary rounds, and work with the case management team on transition issues. The Agency on Aging’s transition coaches who work in the hospital hand off patients to the home transition coaches who work in the community, she says.
One of the early steps in the process was the redesign of the case management system, Remy-Detty says.
At the time, the case management department and the social work department were separate and reported to different people. Now, the departments have been combined and report to the chief medical officer.
Case management staff, either RN care managers or social workers, are in the emergency department to assess and work with patients who come back after discharge. Many of the patients were coming back in because of lack of medication or lack of support at home.
"In the past, these patients would have been admitted or placed in observation. Many times, the case management staff can work with the emergency department staff to get them stabilized and send them home with a home health referral or to a skilled nursing facility," Remy-Detty says.
Before the initiative, the case management team worked only Monday through Friday. Now they work seven days a week including holidays and evenings. They discuss what puts the patient at risk and what needs to be done and goes over readmissions to find the cause, she says.
When patients are identified as high risk for readmission, the case management team talks to the patient and family members about the importance of home health as a care transitions intervention. Some still decline the visit, she says.
The goal is for every patient at risk for readmissions to have at least one home health visit after discharge to home from the hospital or from a skilled nursing facility. One Holzer physician who is active on the readmission reduction team visits patients at high risk in their homes, she says.
The case management team makes follow-up appointments with the primary care provider before patients leave the hospital. The home health nurse is alerted and encourages the patient to keep the appointment, she says.
The home health case managers make frequent phone calls to patients to see how they are feeling and answer any questions or concerns. "We looked into telehealth, but although our high-touch approach takes longer, we’ve found that talking to patients and getting to know them is more effective," Remy-Detty says.
Recognizing that medication issues often are responsible for readmissions, the team came up with an initiative to deter patients from taking their old medication when it has been replaced with new prescriptions, she says.
When home health nurses make the first visit after discharge from the hospital or a skilled nursing facility to at-risk patients, they gather all of the patients’ medications and conduct medication reconciliation. They take all of the old medications and put them in a brown paper bag emblazoned with a big red stop sign and the message "Talk to your doctor before taking any of these medications."
"It works beautifully. The nurse staples the bag shut and the patient knows not to go in the bag. We started with our own home health agency and are working with others to get them to do it as well," she says.
When patients have multiple comorbidities, are frail, or have a complex condition, the hospital arranges for home health visits several times in the first week, sometimes every day, rather than spacing them out over a series of weeks. "The first week, and especially the first weekend, are the most crucial time for patients and the time that they are most at risk for problems," she says.
When at-risk patients are going home with home health, Remy-Detty calls the director of nursing at the home health agency, even if it’s not part of the health system. "I let them know that the patient is being referred, tell them what we have been doing in the hospital and what issues have been identified. Many times, the home health agency nurse will call me back with an issue and we will work on it together," she says.
She follows the same procedure when patients are going to a skilled nursing facility or an assisted living center. "It’s very time-consuming but it works. I’ve been doing this myself but am making plans to hand it off," she says.
In some situations, the health system sends a physician to see a patient in the skilled nursing facility. The physician may be a Holzer medical director or may be the attending physician. They check on the patients and work with the skilled nursing facility’s physicians to make sure that the patient’s needs are being met. When patients are being discharged to a skilled nursing facility, their physician writes orders for three days of medication to go with them.
The hospital hosts lunch-and-learn sessions every quarter and invites administrators, nurses, social workers, and admissions staff from skilled nursing facilities, assisted living centers, home health agencies, and hospice providers. The hospital brings in speakers and has arranged for participants to receive continuing education credits for each session. During lunch, participants at each table brainstorm to solve situations related to care transitions. After the meal, the tables share ideas and solutions they have developed.