Before Montefiore Medical Center in New York City began collaborating with five skilled nursing facilities on ways to improve transitions, the 30-day readmission rates at those five facilities averaged from 25% to 27%. For the last eight months, those facilities have had average 30-day readmission rates of less than 15%.
Montefiore began working to establish a more formalized relationship with the skilled nursing facilities in the area several years ago. "We wanted to change the way patients were being managed around the triple aim of reducing cost, increasing quality, and improving the patient experience," says Alex Alvarez, RN, senior director of Network Care Management, Montefiore’s care management organization.
Montefiore was one of the original Pioneer Accountable Care Organizations, the Centers for Medicare & Medicaid Services initiative to provide coordinated care to patients with the goal of reducing healthcare expenses. Participating organizations share in any savings. "We were sharing savings with Medicare for about 25,000 lives, so we have an incentive to see that the patients get the best care possible in a cost-effective way," he says. Montefiore transfers between 220 and 250 patients to skilled nursing facilities each month.
Before starting the program, a multidisciplinary team from Montefiore visited the facilities in the area, talked to the staff, reviewed the information on the Nursing Home Compare website, and looked at each nursing facility’s readmission rates for Montefiore and their overall readmission rates. Using that information, the team chose five nursing homes to work with, taking into account the volume of patients Montefiore already was discharging to the facilities and the convenience of the location for patients from Montefiore.
In the beginning, the team met individually with each of the five facilities.
"When we visited these facilities, we told them we weren’t there to tell them how to take care of patients, but to help them change the culture of their organization so everybody would understand when patients first start to get in trouble so they could intervene early, and avoid patients having to go to the hospital," he says.
For instance, when patients with chronic diseases needed a transfusion, the facilities would send the patient to the emergency department where they would receive blood and be admitted. The Montefiore team educated the nursing homes on how to set up an elective transfusion so patients can get the blood they need but avoid a hospital admission.
Recognizing that a large percentage of patients who are readmitted have heart failure, the team arranged for Ileana Pina, MD, MPH, associated chief of academic affairs in the division of cardiology, to educate the physicians and nursing staff at the skilled nursing facilities on how to manage heart failure patients with specific protocols.
For instance, she recommended that the nursing facilities weigh patients every day and intervene earlier when a patient’s weight changes.
The skilled nursing facilities welcomed the education, Alvarez says.
"One of the things that has helped us be successful is that the nursing facilities are aware that their readmission rates are going to be measured in the future and our incentives are aligned," Alvarez says.
Montefiore and the skilled nursing facilities adopted the INTERACT program (Interventions to Reduce Acute Care Transfers), a quality improvement program designed to improve care and reduce potentially avoidable readmissions.
"We worked with them individually to incorporate the INTERACT program into their culture," Alvarez says.
One component, SBAR (Situation Background Assessment Recommendation), is a document that provides a structured format for the nurse to use when calling a physician about a patient. "In the past, the nurse wouldn’t always give details but would say the patient was looking bad and the doctor would send the patient to the emergency department. Now, they give the full clinical picture of the patient and the physician has vital information to act upon," Alvarez says.
The hospital team also helped the certified nurse assistants use the Stop and Watch tool to observe changes in the patients and notify the clinical staff to intervene. "The bottom line is that the CNAs are the people who spend the most time with the patients. They often will notice patterns of change earlier than the clinical staff," he says. For instance, if a patient usually wolfs down his pudding and he hasn’t eaten pudding for a couple of days, the certified nurse assistant fills out a form that goes to the patient’s nurse, who conducts an examination to find the cause.
When a patient is likely to be discharged to a skilled nursing facility, Montefiore’s Care Management Resource Unit sends information to three to five facilities to find out if they have a bed available to meet the patient’s needs.
In addition to sending written information on the patient being transferred, the case manager on the unit calls the nurse at the receiving facility to discuss patients the case manager believes are at risk for interventions and what can be done to manage the patient.
A staff of three RNs follow patients after discharge and work with all the skilled nursing facilities in the Bronx on managing the care of patients transferred from Montefiore who are part of the risk/shared savings population.
The nurses have weekly conference calls with the skilled nursing facilities that have a large volume of transfers from Montefiore. They talk about the patients’ issues, their goals for the week, and what progress is being made. "They make sure that the nursing home staff consistently and constantly identifies patient challenges and are working to get patients back to the baseline," Alvarez says.
The nurses work with the families to educate them on the patients’ skilled nursing benefits. "Patients tend to think that if they have Medicare that they can stay in a nursing home forever. The nurses engage the family early on to educate them on the patient’s benefits and help them make choices," he says.
The nurses make suggestions for interventions when patients are not progressing. For instance, if a joint replacement patient is not participating in physical therapy because of pain, the nurse may suggest a pain consultation or a visit with the surgeon who replaced the joint.
"It’s a very collaborative endeavor. It’s not about cutting off benefits. It’s about what we need to do to get the patient to the next level of care. If Montefiore is penalized when patients are readmitted from the nursing home, it’s imperative that we collaborate with the nursing home to help the patient progress. We can’t afford to send patients to facilities that aren’t on board," he says.
Now, Montefiore’s care management team meets monthly with representatives of five skilled nursing facilities and discusses trends and areas for improvement, Alvarez says.
"The hospital team and the nursing facility representatives are identifying populations and collaborating on treating them all the same, whether they are patients from Montefiore or other hospitals," he says.
For instance, in August, the meeting focused on dialysis readmissions. "In the first quarter of 2014, we had 97 readmissions from these five nursing facilities, and 33% were dialysis patients. We are now working on how to treat dialysis patients with a higher level of surveillance to avoid readmissions," he says.
A team that includes the hospital’s director of nephrology, representatives from dialysis centers, and the hospital’s medicine service are looking at clinical data to determine how to improve treatment of these patients.
The team is working on developing a capabilities matrix that identifies all of the interventions that skilled nursing facilities can perform. "Our goal is to make sure all five can do the same things. This will standardize the level of care available at all of them and make it easy to get our patients to these care settings," he says.