Transdisciplinary collaborative helps New York hospital system reduce readmissions

Like many acute care facilities across the country, Greater Hudson Valley Health System has struggled with reducing readmissions for the past seven years. But it wasn't until two years ago, when it launched a multi-pronged readmissions reduction initiative, that the not-for-profit Middletown, New York-based health system began to see its rates drop.

The system, which includes Catskill Regional Medical Center in Sullivan County and Orange Regional Medical Center in Orange County, previously attempted a few "best practice" initiatives in the early years of the project--with the mistaken belief it would fix all their troubles, Rose Baczewski, R.N., (pictured) vice president of patient safety, quality & health information management for the system, told FierceHealthcare during an exclusive interview.

But in August 2012 the organization held a readmission reduction summit with physician groups and the community to talk about the problems and find potential solutions.

The result of that summit is what Baczewski describes as a "transdisciplinary collaborative," which so far has led to a 29 percent decrease in readmissions, regardless of diagnosis.

The approach focuses on three areas:

1. Emergency department and skilled nursing facilities

The organization learned during the summit that patients from skilled nursing facilities (SNF) who go to the emergency department don't necessarily have to be admitted. The collaboration allows facilities to share information via the electronic medical record (EMR) so the data on the patient is accessible when the patient arrives at the ED.

"We also include flags in the EMR so when a patient does come back, and may potentially be admitted through the ED, providers are alerted to the fact the patient may have been hospitalized recently and can access what their condition was. It actually puts a patient-flow process in place that provides for provider-provider communication through the emergency department and the skilled nursing facility," she said.

Pharmacist reconciliation in the ED is also a big piece of the puzzle across all three buckets to make sure patients' medication lists are accurate, according to Baczewski.

2. Inpatient hospitalizations and discharges

Instead of trying to give patients a crash-course on their treatment plans in the last few hours of their stay, the organization strengthen its patient education by having clinicians provide instructions throughout  their hospitalization.

"The teaching is ongoing and the patient should verbalize the instructions that we are giving them," she explained.

To make sure SNFs receive the proper information about the patient's discharge instructions, the organization created a universal transfer form that hospitals and SNFs can use to exchange patient information. Nurses also conduct post-discharge calls to make sure patients are following instructions and doing well.

The system also started a palliative care program to work with patients and families to make sure they have a good quality of life.

"They don't necessarily have to keep coming back to the hospital. These aren't necessarily people in hospice or end-of-life treatment. These are patients with chronic conditions that need to be better managed in a more sensitive way," she said.

This year Orange Regional Medical Center began work with Nexus Health Resources, a Middletown-based healthcare coordination company, to coordinate care after discharge for patients with congestive heart failure (CHF) or pneumonia.

Nexus Health's care coordinators schedule follow-up doctor appointments for patients, have pharmacy deliver medications to the patients' homes and keep in touch with patients for 30 days after discharge to make sure the treatment plan is working and there are no gaps in care.

"Nexus makes sure the pharmacy delivers medication to the bedside and this is such an important piece, Many times, patients go home with a prescription and they may not fill it for three to five days, or they may never fill it, even if it's a new medication or a different dosage," Baczewski said.

"This medication reconciliation process ensures they are taking the medications right away."

Since the partnership began in January, readmission rates for monitored patients with CHF and pneumonia improved dramatically, according to Baczewski. The readmission rate for monitored CHF patients is 11 percent (based on data from January through March). The overall hospital rate for that patient population during the same three-month period was 20 percent.

No monitored pneumonia patients returned to the hospital in January and February, but in March the readmission rate was 10 percent. During that same timeframe, the overall hospital readmission rate for pneumonia patients was 17 percent in January, 29 percent in February and 32 percent in March.

3. SNFs and home care

In addition to the universal transfer form, the organizations works collaboratively with SNFs and home care facilities to develop a standardized process for transferring patients from SNFs back to their homes. They also work to engage patient families in the process and provide community education to try to prevent patients from boomeranging back to the hospital.

"These examples are just a handful of what we are doing with our various programs," she said. "We are making progress but we have a lot more work to do.

Next steps for the organization include adding more resources and staff to the transdisciplinary team, and focusing on other diagnoses and long-term care residents. The organization also wants to identify hospital frequent flyers or "super users," who continue to bounce between home and hospitals.

"This takes time. We are starting to see a benefit from the multi-prong approach but it's going to probably take another year to see the trend spike down more dramatically," Baczewski said. In the meantime, "we know we are doing things better for the patient."

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