Non-clinical care coordination process improves discharge process, reduces readmission

In case you missed it, this week FierceHealthcare ran a story about the success of a pilot program at three Pennsylvania hospitals that had non-clinical patient navigators help patients gain access to essential healthcare services after discharge. Their work--which included connecting patients to local care services and scheduling physician appointments--directly led to a significant reduction in hospital readmissions.

As hospitals across the country face increased risk of Medicare penalties for excess readmissions, many organizations look to improve the discharge planning process. Those that use patient navigators may be on to something.

Orange Regional Medical Center in Middletown, New York, has had success this year with a similar program that addressed gaps in the care coordination process for patients admitted to the facility with a diagnosis of either congestive heart failure or pneumonia.  

The program began last January and already boasts a 30 percent reduction in readmissions for those two patient populations, according to Rose Baczewski, R.N., vice president of patient safety, quality & health information management for the Greater Hudson Valley Health System, the parent company of Orange Regional Medical Center. This year the program will expand to include chronic obstructive pulmonary disease (COPD).

"It really is remarkable," Baczewski (pictured right) told me during an exclusive interview. "What's interesting is that it was part of a long dialogue and development period. It was an evolution of a thoughtful discussion about the landscape and challenges," she said.

Baczewski worked with Virginia Feldman, M.D., an ENT surgeon who had admitting privileges at the hospital, to discuss and identify the gaps in the organization's current process and which patients were falling through the cracks. Feldman was inspired, realized she could make a difference and established Nexus Health Resources to assist Orange County Regional by engaging with patients early in the admission process to prevent readmissions.


Feldman (pictured left) said hospital staff do what they can to provide safe discharge plans but once the patients return home they frequently fail to make follow-up appointments with their physicians or neglect to fill their prescribed medications. And that's when they end up returning to the hospital, often within 30 days.

Feldman's plan uses care coordinators who meet with patients and their family members within the first two days of admission to explain the process and form a relationship with them. They also arrange to have their prescribed medication delivered at their bedside prior to their release from the hospital or directly to their homes and make follow-up appointments for the patients within five business days of discharge.

The care coordinators also go over their discharge instructions before the patients leave the hospital and ask patients to repeat them back to ensure they understand. Coordinators record the conversation through an audio software program so patients and their family members can listen to the instructions again once they get home.

"We have the nurse on our care coordination team review the clinical signs and symptoms with the patient so they know the early warning signs [and] understand when they need to reach out to the appropriate doctor" to avoid readmissions, Feldman said during the exclusive interview.

The recordings are a vital piece that was missing in the old discharge process, Baczewski said, adding that "When people are stressed or medicated, they often don't remember what was said, even if they take a pad and pencil and write everything down."


Within 24 hours of their discharge, the care coordinators from Nexus contact the patients to make sure they have their medications and, if they don't, arrange for them to receive it and make sure they know when they are set to meet with their doctors for follow-up care. Care coordinators continue to check on patients every five to seven days after discharge. "By the third and fourth week, they usually and hopefully feel better," Feldman said.

When Feldman and Baczewski first discussed the plan, many in the organization were skeptical. But the data on the hospital's readmission rates for the two patient groups has now made believers out of them.

"Many physicians, case managers and nurses didn't think it would work because it's not a clinical model," Baczweski said. "People were skeptical because Dr. Feldman doesn't provide clinical support. It's environmental support. They aren't making the discharge instructions or administering the medications. They are making sure people get their medications and make sure they get their appointments and check up on them like a family member would.

We felt strongly that was the missing piece of the puzzle and it's that non-clinical piece that is pushing us forward."--Ilene (@FierceHealth)