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Recognizing that case management alone can’t ensure smooth transitions in care, OSF Saint Francis Medical Center in Peoria, IL, developed a series of initiatives to engage the entire hospital staff as well as attending physicians in the importance of safely transitioning patients across the continuum.
As a result of the initiatives, the hospital achieved a decrease in the 30-day all-cause readmission rate and a significant reduction in length of stay, says Jane Counterman, RN, manager of care management.
"It took a culture change to implement this program. As a department, case management changed first, but we knew it couldn’t end there. We can do our best to create safe transitions, but it won’t work as well unless the administration is on board and bedside nursing, providers and everybody else on the team are engaged," Counterman says. For what it calls its Best Care initiative, the hospital put together a multidisciplinary team to develop a series of projects aimed at improving transitions.
"We didn’t just want to throw a lot of new ideas at the frontline staff and expect it to make sense. Instead, we developed an infrastructure and a plan to roll out a new initiative every quarter," says Leslie Foti, supervisor of transitions and outcomes.
The team initially focused on reducing readmissions and piloted Project BOOST on two units. Every nurse and every case manager went through four hours of classroom training and simulations on navigation and other readmission prevention strategies and how to engage with physicians, pharmacists, and ancillary department staff. For two weeks, a supervisor supported them on the unit to help them navigate.
Project BOOST lists 8 P’s that indicate a patient is at risk for readmission. They are: presentation of the patient, problem medications, psychological, principal diagnosis, polypharmacy, poor health literacy, patient support, and prior hospitalization. The OSF Saint Francis team added a ninth predictor: the need for palliative care.
The bedside RN assesses patients for risk of readmission, using Project BOOST guidelines within four hours of admission. Then the bedside nurse on every shift reviews and updates the assessment. If the patient meets any of the risk factors, the electronic medical record has a check-off box that triggers an alert to the appropriate care team member for an intervention. For instance, if the patient has polypharmacy issues, the alert goes to a pharmacist. If the patient needs financial assistance, social work is alerted.
"After the initial assessment, the subsequent shifts review the patient to make sure there are no new risks. We know that things can happen through the hospital stay to make risk factors go from negative to positive, and we didn’t want anything to fall through the cracks," Foti says.
In another initiative, the Care Partner Program, patients are asked to choose a partner to be engaged in their care. Participation in the program is voluntary. The hospital gives each patient’s partner a wrist band that identifies him or her, offers the partner employee discounts in the cafeteria, and involves him or her in the day-to-day care for the patient.
"We engage this person in caring for the patient from Day 1. The Care Partner may take the patient for a walk or learn to change the dressing. This doesn’t take the place of nursing but enhances the patient experience and helps the caregiver learn to care for the patient after discharge," Counterman says.
To reduce the risk of readmission because patients don’t get their prescriptions filled, the hospital partnered with an onsite commercial pharmacy to bring medications to the bedside. "This program enhances the patient experience, prevents readmissions, and results in a financial gain for the commercial pharmacy," Foti says.
The team on every shift assesses patients for delirium using the Confusion Assessment Method. If the patient is positive, it prompts a set of interventions that includes a consultation from the pharmacist to review medications and a phone call to notify the patient’s physician of the change.
Each day, the multidisciplinary treatment team develops SMART (Specific, Measurable, Attainable, Realistic, Timely) goals for each patient and enters them on the SMART board in the patient room. "We make sure the goals are legible and that the patients understand what they are to do that day," she says.
The team instituted the teach-back method for patient education. Whoever does the teaching documents it in the patient record.
All patient care managers round every day on every patient, ask a standard set of questions, and feed the answers into a dashboard that is available to the entire hospital. For instance, they ask: Do you have a care partner? Were you told about the medication to bedside program? Do you have a goal?
The team created a discharge readiness report, a discharge needs checklist that is filled out by nursing and case management. "It’s an easy way for the team to look quickly and double-check that all of the items on the list have been done," Foti says.
A key to the success of the Best Care initiative is real time measurement and daily, weekly, and monthly dashboards that show how compliant the staff are with the components of the initiative, Counterman says. The data is on a spreadsheet and can be drilled down to the patient level and how individual staff members are performing on the metrics. If one unit is struggling on a measure, the manager can call on the manager of a unit that is more successful to see what that unit is doing.
"Now the entire hospital is focused on care transitions and the providers understand how the decisions they make affect outcomes. Everybody speaks the same language and understands what the goals are, and that makes a huge difference," she says.