Community collaboration helps cut readmits

Rural hospital partners with post-acute providers

By improving processes within the hospital and collaborating with post-acute providers in the community, Charles Cole Memorial Hospital in Coudersport, PA, decreased its 30-day readmission rate for all patients by 15.9% in a one-year period.

The critical access hospital, located in a rural area in North Central Pennsylvania, is licensed for 49 beds and has an average daily census of around 25 patients. Cole Memorial and its ten community health care centers serve more than 60,000 residents within a 65-mile service area including Potter, Cameron, McKean, and Tioga Counties in Pennsylvania and New York's Southern Tier.

The hospital originally planned to collaborate with the Pennsylvania Area Agencies on the Aging to apply for a Community-Based Care Transitions grant from the Centers for Medicare & Medicaid Services' (CMS) Partnership for Patients but determined that the collaboration did not qualify because grant funds are not available to benefit patients discharged from critical access hospitals.

"We decided to move forward anyway because we knew a partnership with community agencies would be beneficial to the community residents we serve and every organization involved," says Cynthia Hardesty, RN, vice president and chief nurse executive.

The hospital had been working on ways to reduce readmissions and meet patient needs throughout the continuum for some time, reports Kris Zitnik, RN, BSN, CIC, director of quality management. "We were working on improving processes within the hospital, but we also knew that because hospital stays are very short and patients typically are not fully recovered when they are discharged, we had to involve other providers in the community as well," she adds.

The hospital put together a community transitions team led by Bonnie Kratzer, RN, director of care management, home health and hospice, and began having monthly meetings with other community providers to discuss ways to improve transitions and prevent readmissions. Representatives from the hospital's own skilled nursing facility and home health agency participated, along with other skilled nursing facilities, personal care homes, pharmacies, home health agencies, and representatives from the Pennsylvania Area Agencies on the Aging in the hospital's service area.

The communitywide transitions task force had its first meeting in July 2011 and continues to meet monthly. "At the first meeting, we realized that the community partners had no knowledge of what we were doing as a hospital to prevent readmissions and that we needed to be educated about the role of the post-acute providers and what happens when they take over care of the patients," Kratzer says.

In the beginning, the participants took turns presenting information and education about their organization and how it works. "Along with learning about each other, we cut down the silos and became friends. Some of us were still competitors but we started to work together and put patients first," Kratzer says.

In the early meetings, the group worked together to develop a standardized transition form that the hospital uses when patients are transferred to a skilled nursing facility or referred for home health services. The team also created a form for the skilled nursing facilities to use when patients are discharged with home care.

"When we started, everybody had their own form and their own needs. We worked together to mesh all of the information everybody needs into one form. It makes the discharge process simpler and we know that the next provider has the information they need to immediately start providing care for the patient," Kratzer says.

When the nurse case managers from the Agencies on the Aging reported that the medication lists they received from the hospital were hard to read, they worked with the hospital case managers to improve them. They reported on what problem areas they found when they visited the patient homes and brainstormed on how the hospital could improve the discharge plan. The Agency on the Aging shared educational materials from other hospitals and worked with the Cole Memorial staff to standardize patient education.

"We work closely with the Pennsylvania Area Agencies on Aging to enroll eligible patients who need additional support after discharge in their program. In addition, if our hospice or home care staff report an issue in the home such as a frail patient living alone, someone with no food in the home or disconnected utilities, they refer the patient to the Agency on the Aging in that area for assistance," Kratzer says.

When some patients reported during follow-up calls that they couldn't get their prescriptions filled because the pharmacy was closed when they were discharged or that the medication they were prescribed wasn't in stock, the hospital pharmacists and representatives from the retail pharmacists on the task force worked together on changing the medication formularies.

Internally, the hospital staff reviewed the charts of patients who were readmitted and looked for opportunities to improve processes. For instance, the team improved the education the nurses were giving the patients and tweaked its medication reconciliation process.

When data showed that patients who went home with a follow-up appointment two weeks later often returned to the hospital before their primary care visit, the hospital made sure that patients got follow-up appointments in a short time period after discharge. To make sure patients don't experience difficulties in getting a timely follow-up appointment with a primary care physician, the nursing staff arranges the appointments while the patients are still in the hospital. "It's more effective if an appointment is made before the patient leaves. Hospital personnel can make a point with the physician office staff that the patient needs to be seen within a few days," Kratzer says. The surgical services began making follow-up appointments for patients at the same time they scheduled elective surgery.

The major key to the success of the program is to keep trying different ways to make the processes work, Hardesty says. One example is the initiative to make follow-up calls to patients after discharge to make sure they have everything they need and understand their discharge plan. Initially, the case managers made the calls, but when they were busy the calls fell through the cracks. Then, the quality management nurse and the director of acute care tried making the calls, but sometimes they were too busy. Now the supervisors make the calls as they are close to the point of care.

"We felt this was important, so we kept plugging away. It takes persistence to get the right processes in place. The more you keep talking about it, the more everybody understands the big picture. Just bringing the community providers together has helped put improving patient care and preventing readmissions on everybody's radar," Hardesty says.