This Project RED (Re-Engineered Discharge) webinar was held December 13, 2011.
Joint Commission Resources, Inc.
Moderator: Kathy Lauwers
January 6, 2012
11:13 a.m. ET
Operator:
Good afternoon. My name is Britney, and I'll be your conference operator today. At this time, I would like to welcome everyone to the Project RED All-Site Webinar.
All lines have been placed on mute to prevent any background noise. After the speakers' remarks there will be a question-and-answer session. If you would like to ask a question during this time, simply press star, then the number 1 on your telephone keypad. If you would like to withdraw your question, please press the pound key. Thank you.
Ms. Lauwers, you may begin your conference.
Kathy Lauwers:
Thank you, Britney. And welcome to all of you on our Project RED Webinar. It is my pleasure to welcome you all and extend an additional welcome from my JCR colleagues; Debbie Nadzam and Susan Whitehouse, Susan Pasario, and Gina LaMantia as we have all been actively working together with you today. We also have received our executive support from Anne Rooney and Ann Sunnis who are incredibly committed to patient solutions and excellence in care delivery.
And we also want to acknowledge all our State Hospital Associations who have been supportive and all of your participation with Project RED, and then especially acknowledge the Agency for Healthcare Research and Quality for their support and guidance on RED.
In terms of today, and our agenda today, we have 11 sites that are presenting on various topics, and it will be exciting. This Webinar is so exciting because you are all going to be learning from sites that are already implementing RED, so it is sort of like people that are walking the talk, and that makes it really exciting for us.
We have a very compressed agenda with, unfortunately, minimal time for Q&A, but as Britney had suggested, you can submit questions through that question box on your screens. And our goal for this webinar was to provide as many site examples as possible in a very limited timeframe.
So our agenda has four major sections. We are going to start out with making the business case for spreading RED beyond the pilot. Then we are going to have some conversation about creative solutions and engaging external organizations. We will hear some lessons learned from followups with those phone calls to patients, and then we will get into our innovative ideas.
And so with that as a welcome and an opening, I would like to invite Vicki Gardner to begin discussion on the business case at Euclid Hospital. Thank you, Vicki.
Vicki Gardner:
Thanks, Kathy. I'd like to welcome everyone and wish you the best on your journey with Project RED.
I work at Euclid Hospital. It's a 206 licensed bed, acute care hospital located on Lake Erie, just outside of Cleveland, Ohio.
Project RED was piloted here in June of 2010. We were initially one of the 50 hospitals to pilot Project RED, and it's one of the best decisions that we've ever made here. I followed one physician and all his CHF patients. We provided education, individual health care plans, follow-up phone calls to these patients, and I do that on a part-time basis.
During that time we saw a decrease in our readmissions from 19 percent to under 5 percent and we sustained that for 9 months. We were able to take that information back to our administration and to make a business case, and we were able to expand Project RED with that. On the graphic you can see here, our rates for readmission for CHF have dropped significantly.
We did have a bounce back after the holiday, which is something that we always see with our CHF patients, and even then, the bounce back was still lower that what we had seen in previous years. But if you follow all the way to the end of that graph you can see a large increase, and it was a good thing for administration to see because I had to take a leave, unexpectedly, and during that time there wasn't anyone to replace me, and we had an increase of readmissions by 25 percent.
So taking all this information and showing this graph and providing all the education that we have done and telling administration our successes, we've been able have a full-time advocate starting in January of 2012. We've been able to increase it to not just CHF patients but also pneumonia, AMI, and COPD patients. We've started a Readmission Committee and that includes pharmacy and case management, lots of other disciplines from the hospital that can really help out with your project.
We've also started rounding at nursing homes because what we found when we were doing it, a lesson learned for us was that we were having a lot of readmissions from nursing homes, and so now the CHF clinic nurse practitioner and myself round in our area of nursing homes, and we provide CEUs to their staff. We go in and talk with them, and we have a great working relationship now with those nursing homes and we have very few readmits from the nursing homes now. So it was a great lesson learned for us.
Also our hospital is part of a larger system, part of the Cleveland Clinic system, and the Cleveland Clinic system was so impressed with our decrease in readmissions that there is a care advocate, which is very similar to a discharge advocate, at every hospital in the Cleveland Clinic system and it is based on everything that we've done here at Euclid Hospital.
They've managed to make a system-wide database for us to use.They have system-wide standardized education materials that we are able to use, and we are working on this as a group now, and again, we are adding more and more diagnoses every day and we are going to start rounding on as a Project RED project.
We've definitely had some lessons learned. As I mentioned, the nursing home readmissions was a trend that we weren't expecting to see and we found, so we are working with that. A lot of patients tell us that they can't afford scales at home, so we've had 100 scales donated to us that we're able to give out to patients that need them. It's a team effort. You definitely need to have a backup discharge advocate, as we've found, for those times when someone is not here.
You will also need to utilize the departments that are available to you. Pharmacy has been a huge help in educating our CHF patients about medications, so that's really important to take advantage of those.
And finally, it's important to celebrate your successes and your lessons learned. You know, everyone on the team is working so hard, and you need to recognize their work and have a party about it because it's a great achievement that we are doing here. We are really making a difference in patients' lives.
Our hospital recently received an excellence award which is an award given out through the Cleveland Clinic system, and a monetary value is attached to it. It's a very prestigious award, so we were really proud to be able to share that and celebrate together.
And again, please free to call me or contact me via email if you have any questions. I'd be more than willing to answer anything you have. Thank you.
Kathy Lauwers:
Thank you, Vicki, for a very nice highlight of all your accomplishments, and I do want to thank all our presenters. As you will notice on all of their title slides, they've provided contact information. As you move through this very quickly, you will have the opportunity if you want to follow back at a later point in time for more information.
So with that, I would like to invite Dr. Palermo from Health First, to give us business case.
Dr. Palermo:
Thank you very much, Kathy. It's a pleasure for us to be a participant this afternoon, and we are delighted to have the opportunity to share our experience related to really one of the most successful quality improvement initiatives that we've ever embarked upon.
Our experience is very much like Vicki's at Euclid. Health First is an integrated delivery system in Brevard County, Florida, and we are located on the Central Atlantic Coast of Florida, and our primary claim to fame is that the Kennedy Space Center is here.
We have all of the essential components for a highly functional, integrated delivery system. Four hospitals, 120-member Health First physician group. We also have a health plan, which is very integral to our overall continuum of care management. And we also have a fairly broad scope of community health services.
Our number one strategic priority has been to break down whatever silos we have in our organization. As you know, integrated delivery systems are oftentimes siloed, and we certainly recognize that and understand that we must be more tightly integrated so that we can better meet the needs of our patients.
Our patients are always the center of our focus. We've been very fortunate that we've been able to collaborate in many ways with the Florida Hospital Association, as well as AHRQ and also Joint Commission Resources.
We have two pillars of our clinical integration strategy. One is a physician alignment initiative and the other, and what we are talking about today, is our transitional and post acute care management. Our T-PAC Committee consists of interdepartmental members representing all facilities and entities. Each one of those members has been a very, very productive member of our committee as we set our goals and have, of course, strived to meet those goals.
Those primary goals are aligning our clinical practice with strategic goals, utilizing a patient-centered systems approach. We've also been able to identify the gaps and the redundancies in care delivery, and that was one of the first things that we noticed, that we had a lot of redundancies throughout our organization in terms of managing transitional care, and, of course, the transitional care piece is what we've been able to focus on with Project RED.
We've also had the opportunity to evaluate the impact of health care reform and develop what we think are best practice interventions across the continuum. So you might ask yourself, you know, why should we be focusing on readmissions? There is a laser-focus right now on the health care value equation, and I think everybody understands that's quality over cost. And what we are striving to do is deliver superior quality and patient-centered care but in the most cost-effective way.
The readmission piece in terms of cost, it's estimated about a $15 billion bogey in Medicare cost per year, secondary to readmissions. And just in Florida, congestive heart failure, we spend about $280 million, AMI about $60, and pneumonia about $130 million.
We've been a very active participant in a very comprehensive Florida Hospital Association Readmission Collaborative for about 2 years. Project RED was one of the programs offered through the collaborative, and, after a very comprehensive evaluation of the different national readmission programs, we identified Project RED as really being the most amenable for our specific organization, and that was basically based on the fact that the outcomes were so compelling and also that the project itself was supported by Joint Commission Resources and the Agency for Healthcare Research and Quality.
We started our pilot in October of 2010, and it ran through May of 2011. Our target population was congestive heart failure, and we basically targeted congestive heart failures on a floor at each one of our three hospitals. Now at the time that we started our pilot, we only had three hospitals in the system because our fourth hospital actually opened up a brand new hospital in April of this year.
So we targeted one specific floor where there was the highest volume of congestive heart failure patients. The project itself was funded by our Health First health plans, they obviously recognized the value to them to decrease readmissions. So the 6-month demonstration project, we allowed it one full FTE at Homes Regional Medical Center which is our regional tertiary medical center, it has 514 beds and we allowed it the half in FTE to two community hospitals, Cape Canaveral Hospital and Palm Bay Hospital.
The keys to Project RED intervention were of course, the discharge advocate. The discharge advocate is really the linchpin and unifies the patient care experience, and some of the primary keys to success were the patient teachback, the care plan discharge instruction which was in the patient's language, and was very, very carefully presented to each patient and their family. The follow-up physician appointments as well testing, of course, was managed by the discharge advocate.
And one thing that we did was we engaged Pharmacy. We had actually Pharmacy in the emergency room as well as Pharmacy at the time of discharge to manage what we found to be one of the most compelling issues and that was medication reconciliation. And, of course, the last, but certainly not least, is a post-discharge followup with electronic transfer of discharge summary and care plans to the primary care physicians and the follow-up phone call to the patients within 72 hours.
Our overall results were, again, quite compelling. What we did is we actually compared our all cause 30-day readmissions for congestive heart failure in the same period one year prior, and also looked at, as a comparative group, at those patients that had congestive heart failure during the time of the pilot, but we could not include them into the pilot just because of volume.
What we saw was an overall decrease in readmissions by about 30 percent. In the system, we went from about between 29 and 30 percent readmissions during the comparative periods down to 19.6 percent. So there certainly were some opportunities. There were some opportunities, and there were also some threats.
We saw the opportunity, obviously, for better management of the continuum of care and improved patient safety, especially in terms of their medication reconciliation and med management at home, opportunity to improve our standings on Hospital Compare and also the patient experience in the hospital, and also to increase the marketability of our system to third party payers. And our Finance Department, they still identify, or they see admissions as an admission. They see that as revenue so there certainly was the perception of a loss of income and profit margin in hospitals because we are still on a fee-for-service model. There has also has been some lack of clarity from at least our perspective in terms of the CMS penalty algorithm, which I'll talk a little bit about in a minute.
Obviously the financial ramifications and what's happening across the health care industry, in terms of Medicare and Medicaid reimbursement has really put some restraint, or put some constraints on us in terms of being able to make sure that we have the appropriate resources in place.
Just to one mention about the CMS penalties, which you're going to hit in October 2013, I think everybody is pretty much laser-focused on this readmission issue, and we know that we've got to have something in place. So as we looked at what we might do from our system perspective, we were a little bit different than some organizations because there is a significant benefit of having a health plan.
We collect premium, we manage medical expenses, we make a profit, hopefully, but of course with the health plan we also support the Health First delivery system. There is a cost to the health plan of each congestive heart failure readmission of about $4,100 in terms of variable cost which drops right down to the far right bottom line. And, over the past year, we had 47 readmissions for congestive heart failure, which cost us almost $200,000.
As we look at health plan cost-avoidance opportunity moving forward, we are going to be looking at not just heart failure, but also AMI, pneumonia, and COPD, and as you can see, we are going into that $500,000 range, half a million dollars, going down the drain unless we are doing something actively and managing net transitional care, a period for that patient.
So what's the risk of doing nothing? You know, now that we know what the benefits of RED are, can we really ignore them? And what would it mean for our patients if we did? And what would it mean for our bottom line, and really, it's coming down – there has been the adage of "no margin, no mission," but really it's really, "ugly outcomes, no income" basically.
So best practice recommendations from Health First, you know, we are looking at an estimated 3,600 patients, about 700 of those are going to be health plan patients, that are going to be admitted on an annualized basis with one or more of the four chronic conditions that we mentioned above.
So what we are looking at is we are evaluating what we can do with Project RED in terms of making sure that we are all inclusive for not only our Health First Health Plan patients, but also our private-pay patients. And we are also looking at risk stratification for the fee-for-service Medicare patients and our commercial members within the health plan.
So our recommended staffing, after this we went to the senior leadership, we had obviously, the compelling results and outcomes of Project RED during our 6-month pilot period and our recommendation was for 5-1/2 FTEs to expand the program and to manage as best we can all four of those specific chronic conditions that we know are of the highest readmission rate. And we were very successful in doing that; in fact, we've expanded even more.
We are looking at Holmes Regional Medical Center for 4 FTEs and also expanding in our three now community hospitals, originally we were hoping for ½ of an FTE, but I think we are going to expand that to probably to 1 full FTE to each one of those hospitals. So I think that what we are doing is very similar to what Vicki is doing at Euclid. Project RED has been, from our perspective, widely successful. Actually our project manager has traveled around the country and has been sort of an ambassador for Project RED and has been received very, very well throughout the country.
Kathy Lauwers:
Thank you so much, Dr. Palermo. That was a really pretty comprehensive and in a very short period of time, and I really appreciate the fact that you were able to help us focus in on some of the metrics and the return on investment. So, again, thank you.
And I would like now to invite Heidi Nelson to talk about the business case at University Hospital.
Heidi Nelson:
Good afternoon. My apologies in advance, I've been fighting laryngitis and bronchitis, and I promise; this is not how I sound ordinarily. I hope I can last 5 minutes, so I'm going to run through this.
The University Hospital is a not-for-profit health system, very well received within the community, and it has been around since 1818, approximately average daily census of 360, we are running right about 400 hundred right now. Bottom line, we touch about 400,000 lives annually through various mechanisms. We have about 3,000 hospital employees, 600 medical staff and 300 volunteers.
We have been awarded the National Research Corporation Consumer Choice Awards 13 years in a row, and we are very, very proud of that. We are, basically, 2 hours east of Atlanta, so we are in a large community area with a lot of medical centers, we do have an academic medical center in our area as well, but we are not the Academic Medical Center, although there was an affiliation some time back.
The University Hospital Cardiovascular Institute, and this was opened in January 2009, and this is where the majority of our heart failure patients, about 70 percent with primary diagnosis, go to this tower, as we call it. It is a four-storey tower, we have 72 universal beds, and you can see the – I'm not going to spend a lot of time on this, this is the universal bed concept, so they are cared for in one room, whether they're critical and they can be transferred over to a lower level of care.
In talking about Project RED, we are very, very excited about participating in Project RED. You know, as director of quality, trying to get quick wins can be a big challenge. This project was supported organizationally from the get-go, and is one of our strategic goals, and our goals are to reduce organization readmissions over the years as they come forward.
University has a long history of excellence and focus on quality, actually, I attended the university about 10 years ago and the reason was because I believed that the senior leadership and Board really supported quality. Project RED went live here March 21st, 2011, and actually you can see the picture of Nancy Rayburn in there. This was sort of the flyer that went out, so they're educating staff, we do all the little introductions. We went to all medical staff meetings. We've got a lot buy-in from a lot of the physician champions.
We had a cardiologist who is very supportive and also the medical side as well. You can see our Project RED team, there was a lot of enthusiasm, huge spirit from this group, and I'm not going to read in detail all about this.
We are very, very lucky at University Hospital to have a continuum of care. We do have a Disease Management Clinic that supports heart failure. We also have a telemonitoring piece, a call center that they can be tapped into, and we also have in the Disease Management Program medication assistance, and so it is very, very comprehensive post acute care, and we are very, very grateful for that.
We do look at which patients were we going to include in Project RED, we started out with a discharge advocate, one FTE, and that's where we are today. So we not only had to use her very, very wisely, we had to focus on the patients where we can get our bang for our buck.
We did focus on the tower, which is our Cardiovascular Institute where about 70 percent of our heart failure patients are housed. She does see approximately 45 percent of those admissions, and we are focusing on our systolic and diastolic, and we have a very aggressive management protocol post-discharge.
Our heart failure, they've got to be an admitting diagnosis, and as you can see; the exclusion criteria that we have listed there. Patients, so they are stenosis and (inaudible) cognitively, and then those that are discharged with skilled nursing facility. I like the idea I heard the previous conversations about focusing on our skilled nursing facilities, I think we are also looking at that too with the Interact Program and operationalizing protocols for that.
You can see about 238 patients have gone into Project RED, and as I've mentioned, 45 percent. Our original three Project RED readmission rate, we have – we actually have in the past been a better performer in the Hospital Compare Web site right now, we are like national with readmissions on the Hospital Compare Web sites. However, we are on the lower side of the confidence intervals.
We have done post-enrollment and the patients that have been enrolled in Project RED have a readmission rate of 9.5 percent, which is a 61 percent reduction of readmissions. Now there are some caveats on all of this. You do have to make some assumptions. The challenge with some of these that we find, and we drill down on each readmission, is a lot of the readmissions are due to non-heart-failure issues.
So they could come in with something else, whether it be they're on dialysis, and we have a huge dialysis population in this area. So there are some components, you know, they get coded with heart failure versus renal dialysis or fluid overload challenges. So that is one area that we are really trying to target, we are working with a nephrologist on that.
I know one of the things that's hard to quantify, performance improvement efforts, and I work very, very closely with financial and you know, there are hard dollars in there as well as soft dollars, and so often PI will really targets the soft dollars and that's really more in terms of cost avoidance.
So if we were looking at the 238 patients, just to give you some idea how I calculated this, if you use the readmission of 9.5 versus 22, this translates to about 29 patients coming back, and so our actual length of stay for those that are readmissions is longer for those patients who come back as a readmission for heart failure.
So if you look at the 6.75 days, I'm probably a little embarrassed to share that that's our length of stay for those readmitted patients, but I'm sure some of you have, equally, those days, too. If you multiply that out, you've got 195 days saved and in terms of cost avoidance, if you look at $5,000 you know, for those patients your avoidance is about $145,000. And that's from your March date timeframe to pretty well current. Now if you look into the future, as we won't get paid and we don't really know the details of what we will taking away financially, but if you look at our length of stay it is around 4.95 days, and I just took 5 days, and you bring in additional patients that are, hopefully, revenue-producing, and you would bring in 39 more patients to our door, and therefore generate approximately $6,000, $10,000, whatever your revenue is for each patient, you could add in approximately $174,000 in additional revenue; which translates, if you add the two together, about $319,000 of soft and hard dollars.
I don't want to run too long. I wanted to just sort of mention some of the key actions, and the two previous speakers have mentioned some of the same things. So one of the things is hiring the right person as a discharge advocate. We were very, very blessed to hire Nancy, who actually was in telemonitoring and has had a relationship with many of these heart failure patients over the last 10 years, so while she may not have been able to see them, though she talked to them on the phone. Plus, she's also pursuing her NP, nurse practitioner. So she loves these patients; she has a passion for what she does, and I think that's the right person. Self-motivated, self-directed. You have to create a sense of urgency. And early on, prior to the go-live date, we met frequently and established a very passionate team. We had great support from palliative care and disease management and see financial and so forth.
One of the other key pieces is train the trainer. Nancy as a single FTE is very challenging. She is doing the train the trainer with other nurses on the floor. Education is key. I think you've heard that, and we took it down to a fourth-grade level.
Lessons learned: Many of the same things, ensuring that you get the right person; you've got to have buy-in and support from leadership. One of the things that I think I haven't heard is we have built a focus study in MIDAS, and you can't manage what you don't measure, so we have a very detailed data collection process that we can run numbers on where we stand; again, we've got three scales and education is key.
The road to excellence is always under construction. We're continuing to look at ways to spread the learnings from this, and all learnings from our Project RED are taken to our stay out of the hospital organizational readmission team.
With that I'll close. We actually did win an I Care Award. In terms of celebrating, we will be celebrating that McKessen Technology, and using our telehealth we have just won the top award, Pinnacle award.
Kathy Lauwers:
Congratulations, Heidi, and thank you so much for your enlightening presentation. I'm going to move us right along to St. Mary's Hospital, and I believe we have Carol and Bill. Hello?
Operator:
Carol, please un-mute your line.
Kathy Lauwers:
Gina?
Gina LaMantina:
Yes.
Kathy Lauwers:
I'm going to do these slides, and if they come on, we will certainly welcome them.
Gina LaMantina:
Thank you.
Kathy Lauwers:
And I would like to say, everyone, if you indeed encounter any type of hospital emergency or code red, or code pink, whatever, of course that is your first priority, and we would expect that you would abort the call and go and tend to your emergent patient care needs. So I will try to cover Carol's and Bill's slides. They started their Project RED in May of this year, but they're focused on heart failure patients, and you can see their criteria there.
They've had 36 patients in their pilot, and they've had quite a significant drop in their readmission rates that they're quite proud of. They think or they claim their most important strategies in how they have accomplished this was the ability to have CHF nurses 7 days a week, with the enhanced teaching materials and the teach-back, very formalized order sets that they've developed in collaboration with their medical staff.
And how they were able to really get on their data management an early identification of patients was an initial challenge, but they conquered that. The feedback from their discharge calls, and then the collective wisdom of their interdisciplinary team, really were the catalyst that they described for their success. Having their leadership support, and their committed Project RED champion, certainly having their chief nurse being an executive sponsor, and then they coalesced around all their infrastructure at St. Mary's.
So the Med Exec Committee, their administrative council where their senior leaders reside, and even involving their Quality Care Committee as the sub-committee of the Board, were all engaged in every part of RED, so it was from the initial definition of what it is to the support execution and results of their pilot.
So on the next slide you can see their baseline data that they had prior to their pilot, and I'm not going to go over these because I know you all have them in front of you and can study them, but we are very proud of the results that they've had, and I'm trying to make up for a little bit of time here. So, again, this just speaks to the tremendous support they've had from senior leadership and medical staff oversight.
The lessons learned that they wanted to highlight was how important their team approach has been. The fact that you have all those interdisciplinary people doing the process map, doing the swim-lane diagram, being able to close their gaps and reduce some of the redundancies was extremely important to them. Obviously the senior leadership support throughout the course of RED and the ability to early identify those patients when they come into the organization, and how important the followup is to prevent those readmissions.
So they are also committed to spreading the knowledge, and their COO, Teresa Rutherford, continues to challenge them with the fact that if they do not set a goal, how could they ever achieve anything? So they are very goal-focused, and they're really focused on safe, effective care along with the fact that readmissions are dissatisfiers not only in terms of some of the business implications, but really in terms of the patients.
Their next focus will be to look at their cardiac PCI patients, their new service lines for them and, again, it is also an outpatient service, so they are going to be satisfying their high-risk populations as they now have organizational support to go beyond their initial pilot and spread the RED.
Female:
Kathy?
Kathy Lauwers:
That was a very rapid summary for that facility, and that will get us into the questions and answers. So if we could, Gina?
Gina LaMantina:
Britney, if you could please let the participants know how to queue up for questions on the phone line.
Operator:
At this time I would like to remind everyone, in order to ask a question, press star then the number one your telephone keypads. We'll pause for just a moment to compile the Q&A roster.
Gina LaMantina:
Thanks, Britney. And to all of you that are participating in today's Webinar, if you are sitting at your computer and you are interested in submitting a question online through the Webinar, there is a Q&A tab at the very top of your screen. If you click on that and type in your question we will manage that, and pass that to our presenters to respond to. Thank you.
Operator:
You have a comment from Carol Donaldson.
Carol:
Kathy, this is Carol and Bill. Our apologies, from St. Mary's; our apologies, we had some technical difficulties.
Bill:
We couldn't get our phone off mute for some reason.
Kathy Lauwers:
Apologies accepted, and my apologies to you. I went through your slides very rapidly, and I now need to catch us up with a little bit of time so that we can sure we get all our presenters on live. So thank you.
Carol:
That's quite all right, thank you.
Gina LaMantina:
We do have a question on the Webinar, just asking if the slides will be available following the Webinar. Please note that they will be sent out to all of the project managers as well as posted on the Blackboard site for download.
Kathy Lauwers:
And Gina, the audio will be available when?
Gina LaMantina:
There will be a streamed media file archived of today's Webinar, that will also be placed on Blackboard, and you should be able to access that tomorrow.
We do have one question coming in. Any good ideas for critical-access hospitals where people wear so many hats and adding additional FTEs is greatly discouraged?
Kathy Lauwers:
Any of our business case folks interested in responding to that question?
Vicki Gardner:
Hi, this is Vicki at Euclid. I can tell you that we face that challenge as well, because when I started doing it, I was part-time infection control and then picked this up on top of that. You know, definitely rolling it out to frontline staff and having them understand the process of what Project RED is and having each staff member take a little piece of it will help take the weight off of one individual person or hiring an FTE.
And, hopefully, as they see the results that many of us have seen, maybe that will encourage them to hire a part-time person, at least to get you started.
Kathy Lauwers:
Thank you, Vicki, and you for all of you, our critical-access hospitals are 25-bed hospitals and they wear multiple hats, and so I think, perhaps, another takeaway will be the focus on metrics and that objective story to tell. And we've got a couple of critical access hospital reports a little bit later on in the Webinar that I think will be helpful.
I'd like to move us along to the second part of our agenda, Gina, I think we need to catch a little time here.
Gina LaMantina:
All right, Kathy.
Kathy Lauwers:
This part of the agenda is about creative solutions to engage external organizations and internal staff, and there are three topics under this part of the agenda, the first topic is community resources, homecare, long-term care, and agencies. And what we wanted to do was to stretch those Project RED boundaries beyond acute care and to begin to hear how some of our sites are doing that. So I would like to invite Evan Landvik from Platte Valley to share his experience.
Evan Landvik:
Thanks. So my name is Evan Landvik and I'm the Care Coordination Manager at Platte Valley Medical Center.
Platte Valley is an 88-bed hospital. We are sort of on the fringe of the Metro area, I guess we are ex-urban, but we do have a lot of rural areas to the north and east of us, and we are an independent hospital, we report to a local Board. We are not part of any larger organization and our Board, and our leadership is very committed to this particular project.
In addition to the internal processes that we have for Project RED, we have a really great collaborative going on with this local community health center, so we actually have a co-presenter today, and her name is Rachel Wolfe, and so Rachel, go ahead.
Rachel Wolfe:
Hi, there. My name is Rachel Wolfe, and I am here from Salud Family Health Centers. We are a Federal qualified call center with nine clinics, and I'm the Transitions in Care Program Manager for our system.
And so a little background about our health center, we are a nonprofit, Federal-qualified health center, like I said. We serve low-income and vulnerable populations within our defined cachement of Northeastern Colorado. We have a sliding-scale fees and comprehensive care which includes behavioral health, dental, and we have our own pharmacy as well.
We also have AmeriCorps members that work for our clinic, and I don't know if you guys have heard about AmeriCorps, but it's a government organization that provides funds to local and national organizations which are committed to using their service to address critical community needs, and that's in health, among other things.
So our medical director decided to use these members for our transitions of care pilot, because, obviously, they are cost-effective for us, and we are hoping to show that we can reduce hospital readmissions with similar outcomes as other transitions of care models, but without using, you know, more expensive mid-levels. And so Salud, as an organization, was particularly invested in reducing our clinics' patient hospital readmission, because we are actively involved in an ACO; and Evan can touch on how our partnership came about.
Evan Landvik:
So, I literally got a phone call one day from the Medical Director at Salud, somebody that we know, and we've had a long-term relationship with Salud, but he called me up and said, Evan, you know that Project RED thing, I have some AmeriCorps volunteers that are on their way to your office. And they literally showed up 15 minutes later.
And so, it's been a process for us to figure out how to utilize those resources, but one of the key pieces that Rachel, who is co-presenting with me today, who is now a Salud employee was one of those initial volunteers, and so we started developing a relationship at that point.
Rachel Wolfe:
So, yes. And so we did our initial pilot last spring, we identified 99 Salud patients in just under 4 months. We visited in-home 28 of those patients. We had 13 total readmits, and only 1 was after our visit. So obviously they weren't huge numbers, but they are indicative of success. And I'll touch later on our current project that started in September, our protocol, about how we actually do our do.
Evan Landvik:
So, one the challenges for us is to figure out how to identify – two main challenges for Platte Valley, one is how to identify Salud patients so that they can intervene as soon as possible, and the second piece is how to get them information. And so, we did a lot of this manually, and it was very painful and time consuming, and there was lots of phone calling back and forth, and so fortunately we launched an EMR this July, and so we were able to run a query by provider.
Rachel, since she's a Salud employee, actually has access to our EMR as do all providers at Salud, so she's able to run a query and basically get an up-to-date report of who is in-house, and using that report gives instructions to the AmeriCorps volunteers.
And then we also have ID rounds that we've had going for quite some time, and that happens at 1:15 every day, so they show at 1:15 and get all the information they need about discharge at that point.
Rachel Wolfe:
So while the AmeriCorps are in the hospital, they meet our patients and introduce themselves and the transition of care programs. So for those patients who are open to it, and I should mention that we certainly get patients who decline, we aim to conduct a home visit within 1 week of discharge, and like, Evan, I'm talking about, we have access to the EMR, so I'm able to print med lists and discharge instructions and everything prior to the home visit.
We have a few other points of contact after the home visit. Pharmacy students make a phone call if there are med issues, and the AmeriCorps members make another phone 2 to 3 weeks post-discharge for followups.
And then our home visit focuses on five interventions. These are probably familiar to all of you, they are pretty standard in the transitions of care world. They are reconciling meds, reviewing discharge instructions, a little bit of education and we employ some motivational interviewing techniques. We make and just verify that they have a follow-up visit appointment made. We do a life structure screening, and we also do an environmental assessment. And we communicate all of the pertinent information that we find back to our Salud providers through our own EMR.
And so our current program, we're 2 1/2 months into it, and as of last week we've identified about the same number of patients Salud had in 4 months during our pilot. So, for 98 patients, we've completed 32 home visits. We've had only six readmits, and one was after a home visit.
And I should mention that, you know, there are various reasons that we won't conduct a home visit. Some, obviously, declined, but we also have to risk-stratify complex patients out and things of that nature. We are also in the process of hiring care managers, because what we've found is, the home visits are really effective and we've really had great feedback, but we oftentimes find to lots of other things that need to be dealt with in the house, and the AmeriCorps members are just at capacity, you know, between hospital duties and actually doing the home visit.
So we are hiring sort of a second line of contacts that can help coordinate medical and social needs, and we are still in the process of designing that plan.
Evan Landvik:
So lessons to be learned from the hospitals is to find out what your community health plan is doing and try to utilize those resources if they have them. AmeriCorps volunteers, I know, are probably in a lot of community health clinics at this time. And then also leverage your EMR capabilities to share information with appropriate partners. And it makes it a heck of a lot easier, I can tell you that.
And then also leverage your ID rounds if you have them. We use it here in-house as a sort of a clearinghouse of information and by attending that, once again, my team doesn't have to spend a whole lot of time communicating with the Salud folks about what's going on with patients.
And then lastly, there are a lot of legal implications here, and it took awhile for us to sort through it, so if you want to do any partnership with this, you know, take care of those legal issues before you move on. Thank you.
Kathy Lauwers:
I would like to throw that that's a creative use of expanding resources without expanding your budget, and the opportunity to look for volunteers and tap into them is pretty innovative, so thank you.
Our second subset now is around the pharmacy involvement. And I would like to welcome Dr. Aniwaa Owusu to the conference.
Aniwaa Owusu:
Hi, good afternoon, everyone. My name is Dr. Owusu. I'm from Bronx-Lebanon Hospital. I'm sorry, I'm battling an upper respiratory infection right now, so I've been coughing. But our hospital is a 964-bed hospital. We have three sites, Concorde, Fulton, and the special care center, and this is what we are doing here for Project RED. I'm just going to talk to you about the pharmacy perspective. Our program here is a multidisciplinary team; it consists of pharmacy, pharmacy residents, nutritionists, cardiologists, nurses, and Visiting Nurse Service of New York.
And during our discussion, we have an open-group discussion which is pharmacy-led, and the CHF patient gets to meet other CHF patients. We all sit together at a roundtable, and we discuss the heart conditions, they get to learn about the disease state and management, especially medication management.
The program actually began in May 2011, but Pharmacy didn't get involved until the latest days of August of this year. We target CHF patients, and we educated about 146 patients to date. Before this project began, we had approximately 18 percent readmission for CHF, but we haven't conducted a post-assessment yet. We will do that in a few months, so we will let you know about that.
The Pharmacy goals and objectives for this project, we hope to improve access to an understanding of medication instructions for all CHF patients. We also look to reduce readmissions that may have been prevented if they had this information earlier on. And also we are looking to improve patient and pharmacy communication so that patients will be more comfortable to speak to their pharmacist about their medication management for CHF.
For the education section, we normally get a computer-generated report of all inpatients with the diagnosis code for CHF. And the hospital staff, including nurses, PCTs, and the cardiologists, and the pharmacists, we all try to encourage all these patients to attend. And so far we've been very successful, most of the patients do attend these sessions.
And like I mentioned earlier, the pharmacy education part started late August, and we have educated 88 patients up to date. During the education session, we give information on lifestyle modifications, the daily weight monitoring medication adherence, especially to the therapies like ACE inhibitors and beta blockers. And also strike on the importance of taking charge of your health care from the patient's perspective.
And also, during the session we encourage a lot of questions and comments, it's more of a discussion and less of a lecture. We also provide weight scales to patients who do not have one already, and this actually being provided by the cardiology service of this hospital. We refer the patients to the Visiting Nurse Service of New York and also to our outpatient CHF Clinic for followup and also if they have any questions later on.
Pharmacy then collects all the patient information, the medical record number, any updated contact information. We keep all these in a binder in the pharmacy, but we also update the patient's electronic medical records to reflect this education that was provided. And cardiology service follows them up and calls the patient after discharge to remind them of their follow up with the clinic and also for the Visiting Nurse Service of New York.
For the lessons learned at the hospital, through the education program, we encourage patients mostly to have a baseline understanding of their condition and how to manage it, and we also stress on the importance of medication adherence, I cannot say that enough, it's so important.
We also encourage patients to improve their communication between them and other health care professionals, with your doctors, with your pharmacists, and the nursing service, and also we recommend that patients take charge of their health care and follow up with the team. We have also learned, and I believe it's been mentioned so many times during this webinar, that it's a team approach. You cannot do this on your own.
We realized that every discipline has their own unique skills which contributes to a better outcome for the patient, so it needs to be a team of approach involving the cardiologists, nurses, and the pharmacy team, and also getting patients together into a group discussion in an inpatient setting is challenging, but if you have a team approach you can help to improve this outcome and get better results overall, and reduce readmissions.
So, so far that's what we are doing here at Bronx-Lebanon Hospital. Thank you.
Kathy Lauwers:
Well, thank you, Dr. Owusu, that was really how important the pharmacy role is, particular in the enhancement of RED.
I'd like to move to Jen Shaffer and Grove City Medical Center.
Jen Shaffer:
Hi. Thank you for having us. Grove City Medical Center is a small not-for-profit hospital in Northwestern Pennsylvania. We have 90 acute care beds and 20 skilled beds. And I'm here today to talk about our Home with Meds program. This Home with Meds program was born out of our preventing readmissions quality improvement projects through the Highmark Blue Cross Blue Shield initiative, and we have since turned that preventive readmissions program into our Project RED group.
So this group has a lot of experience and a lot of knowledge on the methods that are needed to prevent unnecessary readmissions. One of the things we identified through all of our studies and practices and the initiatives that we instituted, which is the same theme nationwide, is that medications are a problem for patients when they leave the hospital.
Being a small hospital, we are not licensed to dispense medications for the patients as an outpatient setting, so we started to work collaboratively with a local retail pharmacy. Basically the simple overview of our program is that we help, using this retail pharmacy, we provide the patients with the next 30 days of their medications and very easy to understand blister packaging, or pillow packs. It's senior-friendly, and we've had a lot of positive feedback from the patients and the family members that help them manage their medications.
Like I said, we are working with one retail pharmacy at this time and we are hoping to expand that, and the program is not just giving the patients their medication, it also comes with some extra counseling. I am the Transition Coach in the hospital and one of my duties is to do follow-up phone calls on all of our patients that are discharged from the hospital.
Also, I still continue to do this. Also, for people who agree to do this program, they're receiving additional counseling from the pharmacist at this pharmacy and a couple days after the patient goes home to make sure that the packaging system works for them, if they have any questions. One question that comes up frequently in this program is what if the medications change. And the pharmacist does repackage the medication whenever any changes in their medication regimen come up.
Also, about week three, the pharmacist contacts the patient to see what they want to do for the next 30 days. Do they want to continue with the program, what refills do they need, what do they have at home? We did a pilot project, we started in February and we piloted this on our Transitional Care Department, and it was a very tightly-controlled pilot. We did 13 patients; of those 13, none of them were readmitted. Since the pilot program, we have had one patient readmitted that has done the Home with Meds program, and it had nothing to do with their medications. I believe it was related to a fall.
Our patient and family-size factions who have participated in this program have been very high. We've had incredible, positive comments and about how much this has helped them manage their medications at home. Some of our barriers that we have identified that we want to work on is that in our small community we only have one pharmacy that's participating, yet we have several other pharmacies.
Some of them are large-chain pharmacies, so we have to deal with the individual pharmacists would like to do it, but they have to get permission through the corporate people. We will find that patients are very loyal to their own pharmacies that they go to, and they're not willing to switch. And for medication safety reasons we don't want them pharmacy hopping anyway.
So we are really going to push and try to get these other pharmacies in the communities to participate, and hopefully when they see what a positive outcome it has been for the patients and for the community, they will be willing and able to do that.
Another obstacle is that patients use several sources to get their medications, such as mail-order meds. They like to get the 3-month supply, and we do have some veterans facilities close to us where the patients are able to get their medications through the VA system at a much lower cost than some of our other pharmacies.
So those are all extrinsic to the hospital. Barriers for in the hospital, when we did the pilot program, it was very tightly controlled. I, myself, did a lot of the counseling with the patients and communicated with the pharmacy. I wanted to work out all the kinks before I handed this over to the general nursing staff so they would have a better positive experience, but in doing that it's been dubbed as Jennifer's program, rather than a program for the patients or for the hospital. So the staff thought it was a great program so long as they didn't have to do it.
The Transitional Care Department has slowly progressed, and they are doing it themselves now, and I'm just used as a consult. And we are moving on, in the next couple weeks, to our Acute Care Department and we will be doing some education with them. So if anybody wants to do something like this, I would be careful in how you start the program out, so that it's not one-person dependent.
And I think that's about it. We've been able to identify with this program, too, some of our gaps and our medication management and reconciliation and discharge, which we are going to be working on as well.
Kathy Lauwers:
Thank you, Jen. That was very helpful and appreciate your lessons learned and the need to keep trying.
And I would now like to invite Dr. Carter to talk about medical staff involvement.
Gary Carter:
Hello. My name is Gary Carter. I'm the Medical Director of Quality at North Kansas City Hospital. We are a 450-bed hospital located on the north bank of the Missouri River in Kansas City. What follows is a picture of our hospital, which has grown considerably over the 20 years that I've been here.
We began Project RED in March of this year. We restricted it to CHF patients. Our n was lower than many of you, but we did not have a full-time equivalent. We had a Discharge Advocate who did this voluntarily because she had a passion for it, Michelle Lane, and she did an excellent job.
We had 20 patients enrolled, we just closed that enrollment and passed the 30-day mark for the last patients and had a readmission rate of 10 percent, which was less than half of what our previous readmission rate was for CHF patients. So, basically, we validated the principles of Project RED and what we are looking for now is how to super-size that process at this facility.
This next bullet point is one that they ask for some interesting tidbit, or something that you might have learned, post Project RED. We did a review of 30-day readmissions of Medicare patients and what we found was that, in a hospital that processes 25,000 admissions a year, we had 141 patients that accounted for 44 percent of our readmissions in that 6-month period.
So what we are doing now, we are trying to identify flags that would identify them in the EMR, so that we could use the resources from Project RED to kind of target these high-risk patients But a low number of patients accounted for a high percentage of our 30-day readmissions.
My topic actually is about the engagement of physicians, so this was an easy topic. I mean, it was an easy thing relatively speaking. And the way that we went about engaging the physicians was first by just educating them. We put flags on the chart, laminated red flags: This is a Project RED patient. And at first the doctors thought it was witness-protection or something so it created a little buzz in the hospital when they saw those flags. It also made those patients sort of important to them.
They did have questions, they had questions about – well, I educate my own patients -- how is this going to interfere? And the education was done largely one-on-one with the doctors. We showed them our information and what we what we were providing to the patients, and they really had no issues once they saw that. I have an email list of the heavy hitters at our hospital, and I emailed all of them before the program began.
We put posters in the doctors' lounge, and we had a newsletter, as many of you do, and we highlighted Project RED at the inception on the front page, so people knew about that. We also got questions about why is this 7-day follow-up appointment so important, and we just knew that it was from the Project RED literature. But, retrospectively, we looked at those 6-month readmissions, and one of the common denominators on those readmitted patients, they did not receive a followup within 7 days. It was 2 weeks or later.
So it was an important thing, and I discussed that with the physicians. So the physicians, actually, as the thing rolled out and the months rolled along, they began to seek me or Michelle Lane, our Discharge Advocate, they would seek us out, and they ask if their patient could be included in the study. The materials that were given to the patients and the amount of time we spent were valuable to the physicians and to the patients, and everybody realized that.
We had easy compliance with the discharge summary portion of it. Doctors were used to doing those for nursing home discharges, so this was not a stretch for them. I think it was helpful. I've got a copy of our Hospital Times just showing the article, I think in March of this year, that had the team members and discussed the Project RED goals.
The results have continued. They've requested an expansion of it, the receiving physician at the other end, when we communicated with them, they were very surprised and pleasantly surprised at the information and the amount of data that they received. It made that transition much easier than what they were accustomed to. So clearly that was beneficial, getting that discharge summary to them and making that appointment.
And we even, to this day, continue to have – even though we've stopped enrollment and are looking at the next phase -- we continue to get physicians requesting the Project RED materials be given to their patients. So physicians are aware. In fact, physicians were so engage that we could actually get them to do little tricks for us in order to buy our involvement with Project RED, getting their patients involved.
And my last slide is a picture of Dr. Steve Starr, who actually is planking on the nurse station on the eleventh floor of our hospital in exchange for the reward of getting his patients seen by our Project RED team. So if you don't know what planking is you can Google that. So I had an easy topic, engagement was not difficult. Education is key. Thank you.
Kathy Lauwers:
Dr. Carter, thank you so much, and if all our lines were not on mute, I'm sure you would be hitting a lot of endorphins to be released with that great, creative slide. So thank you so much and for your topic on engagement of the medical staff.
I need to move us along a little quicker. Our third part of the agenda now is going to be two sites presenting on lessons learned from follow-up calls with patients. So I would like to ask Cheri Sisson to get us started, please.
Cheri Sisson:
Thank you. I am Nurse Manager of the Med-Surg Unit, and I have taken on the Project RED in our facility. I work at Lake Regional Hospital. We are in Osage Beach, Missouri, and for those that are wondering about their geography lessons, we are located at Lake of the Ozarks, which is one of the largest manmade lakes in North America, so that's where the beach comes from.
We have a population of 4,000 and on any given weekend in the summer, it rises to over 100,000. We are a 116-bed Medicare-dependent hospital with seven clinics that we run as well. And the topic that we are going to discuss is our follow-up phone calls.
When we started Project RED, we actually started with one hospitalist. Our n number was too small. We were only getting like one a month, so we expanded that to add one cardiologist. We did primary diagnosis of CHF, English-speaking with a phone, and we excluded end-stage patients.
To date, we have 15 patients that were enrolled. Something that's kind of unique with us, is through the whole process Project RED kept saying to start small and then roll it out. Our CEO requested that we call all patients that had congestive heart failure not just the ones enrolled in Project RED. And so we don't have a process for concurrent coding here, so what we did was, we just called everybody with a history of CHF and/or that were discharged on a diuretic.
So we have attempted 1,151 calls to date, and we've contacted over 550 patients. Other things that we did, we weren't doing any discharge phone calls prior to this Project RED starting and didn't really know where to begin. We were given no money and no FTEs to do it. So we utilized an online survey called FormSite and then we staffed that using FTEs that we are stealing from light duty work comp injuries or we have some task nurses and then whenever we have their hours are distributed among all of the units so you don't have it just coming out of one pot. And we've been able to keep our FTE usage very low with that.
This slide is our hospital-wide CHF readmission rates. You can see Project RED started on June 1st, and we went from the 25 percent readmission rate down to the 20 percent readmission rate, and if we look at just at our Project RED participants, for July to September, we went to 13 percent. And the cardiologist that is involved in that, if I break it up, he had 0 percent readmission rate, so he's doing really well with that.
For the follow-up phone call setup, we actually designed an algorithm, and we looked at prescriptions, follow-up test appointments, dietary concerns, and weight monitoring. We set the system up so that if they questions about their medications, that it went to actually one of our retail pharmacies that is owned by our system. They actually said they would take on the questions since our hospital pharmacist felt like it would be too much of a load for them.
And dietary concerns, we hooked up resources, everything is built into the algorithm, so if they have a question it automatically sends a notification to the person that needs to help with that area. The FormSite that we used cost approximately $1,000 and we had already budgeted for that to use for other quality projects in our facility.
Another thing that's nice about FormSite is once they log on, it starts their call, it electronically takes them through that, and then it also tracks the amount of time that they spend on that call, so I can give you a list of how long the phone call lasted, who is talking longer than others, and then we get a monthly data that says you spent 51 hours on the phone making these phone calls. And then we are also able to export that data into Excel which gives us a nice graph.
So these are some of the improvements that we found. When we started, we asked all patients if they had the written information at home. Some people we have to tell them to go back out to the car and get it so that we can go over it with them, but you can see that they received the written information. And then if we had it posted for easy reference, you can say we started out 82 percent when we started that and had a really big improvement in that area.
We did the Stop Light Report and asked for them to put that on the refrigerator so it would be easy for them to refer to. Lessons learned, we make appointments for all of our patients, but when they are discharged after hours or on the weekends, we fax the information to the follow-up physician and then ask them to call the patient and make the appointment. We also tell the patient to call the office to make the appointment, so we've got two ways going on, and we feel, by the time we make that phone call between 3 and 5 days out, we still have 6 percent that have not been able to make that appointment.
So we've met and we are discussing the possibilities of having a centralized scheduling so that we only have one contact person, and hopefully that will help with some of the things, I think, that are getting in the way of that.
The other interesting thing is: Are you weighing yourself daily? You know, keep in mind this is not just Project RED patients, that was the 550 patients, but everybody is given a weight log, and instructed to weigh themselves daily and the highest we've hit is 51 percent on this, and then do you have it posted, that's not getting better, either. So we are going to have to work on that, but it's nice because using this FormSite we are able to be tracking trends on what our answers are and what areas of improvement that we need to do.
And that's all I have, thank you.
Kathy Lauwers:
Thank you so much Cheri, and let's ask Suzanne to talk about the topic of lessons learned and their phone calls.
Suzanne WellsThank you very much, Kathy. I'm very excited to share our call center's follow-up intervention with everyone on the call today.
Christian Hospital, with 482 beds, is one of our eight community hospitals within BJC HealthCare. BJC is the largest healthcare system in Missouri with 27,000 employees and 13 facilities. Two of our facilities are academic: one is our adult urban hospital, Barnes-Jewish, and the other is St. Louis Children's Hospital.
BJC HealthCare works in partnership with Washington University School of Medicine. As a full-service call center, the BJC Call Center does have responsibility to all 13 facilities within the system. And this is the first opportunity we have to work with Christian Hospital in our readmission initiative. As the clinical leader in the call center, I have function as the champion for the follow-up calls.
On this slide, you can see that our start date for the pilot was February 7th, 2011, and our population is designed as at-risk patients with AMI and heart failure admit history within 60 days. We initially started the pilot with 60 days. We've moved to 90 days to capture more patients, and those patients are reported to the team via computer generation.
We also have listed our pre- and post-readmission rates. You can see they are in a rolling 4 months, and our heart failure rates are down, our AMI, I wish I could say is down, but we bounced back up a bit May through August this year. We have five interventions. Three of those are inpatient, being nursing, dietary, and pharmacy education, and then our post-discharge interventions are the follow-up call made by the call center and our homecare.
I'll now provide a bit of history about how the call center became involved in this readmission initiative. We were contacted in late 2009 by a group called Continuous Workflow Initiative. It's part of BJC, it's an entity that works on standardization of processes across our eight community hospitals. And they reached out to us, the team working on the standardization of the patient discharges, to investigate the post-discharge call.
The call center appointed the RN champion, being myself, to work on the follow-up survey with CWI. We developed an online survey, so it is automated. It is part of our clinical software that we use in the call center, and it is a survey that is based on medical orientation versus patient satisfaction. We feel that patient satisfaction is obviously secondary because of the call, but it truly is a medically oriented call.
We make the call at 48 hours post-discharge, again using our clinical call center software. For efficiency and for effectiveness in the development of the pilot, we approached our call center registered nurses to participate on the team. We use a part-time staffing model, and we reached out to those who had adult nursing experience to assist us with the pilot, and so it's really been a win-win situation. It's great for them because they have added responsibilities that they enjoy, and we were able to do that without having to go through a hiring process.
So what we are doing today, the call center actively participates with the readmission team. We started out meeting weekly since the go-live in February, we have since moved that to every 2 weeks. We see ourselves in the call center as really having that responsibility to close the loop for our at-risk readmissions, so we are asking all those questions that we're all familiar with from Project RED being issues of transportation, medications, the physician visit, daily weights, et cetera.
And if at any point in our call there is a need to assist the patient, we do that, and we help them with their transportation, we will help them find a scale, we will help them with the physician visit using our resources in physician referral in the call center to do that. At our meetings we are looking not only at our metrics, but we are also maintaining action items for review and progress towards those goals.
What we hope to implement very soon is case studies, looking at the actual cases, patients who were admitted, went home, and were readmitted, trying to evaluate for successful care coordination and transition management. The call centers always have to ask themselves the question of what part can we play in the initiatives of health care reform, and readmissions was our first opportunity to do that.
This next slide is the process. It represents the process of our readmission call and I won't go through too much detail on the call center process, but to just make some key points, and I think the takeaways are, number one, the first rectangle that you see is actually how the calls flow into the call center. Again, those are computerized. We've built an interface so that those patients identified drop into the call center queue for the nurses to contact them at 48 hours.
You can also see that our process is fluid. The process has been changed over time as indicated by the red font that you see, which shows that as our process is changed we go back and we update this call flow.
And then lastly, as I mentioned a few moments ago, we utilize our experts in physician referral to help us with any issues of physician appointments, if the patient doesn't, perhaps, have an appointment at the time of the call.
Then the next slide that I wanted to show is a sampling, there are a couple of slides here that sample our survey responses as we mined our data, and I think these are important because as we reviewed them as a team with the other disciplines on the readmission team at Christian, we are finding information that's really valuable to different disciplines, and this one, for example, when you look at bullet point number three, it says that eight of our patients said that their prescriptions were not in stock at the pharmacy.
This too, our pharmacist was a very, very valuable thing to identify. She was able to then go back to physicians who were ordering a medication that didn't have ready availability and be able to substitute that with something that would be available for those patients. So it was an issue that was able to be addressed through the data that we were able to mine in the call center.
And then the next survey response is about weighing yourself daily, and our foundation at Christian Hospital had purchased approximately 50 scales for patients, and when our Director of Case Management saw that 38 of our patients were telling us they didn't have a scale at home, that was opportunity for us to educate the nurses in-house as well as those on the calls to direct those patients back to Christian Hospital to get a scale. So there's lots of very, very valuable data in the calls.
Our lessons learned, first of all I just want to say that I understand that all of us on the call have varied resources available to us, so I hope what I mentioned when referring to this slide is certainly transferable information to everybody. One of the things that we are doing as we prepare for the pilot to end and then to go live with Christian Hospital as an actual intervention in the readmission work is to reevaluate the time that it's taking the nurse to review the patient's history and medications prior to making the call.
I'm finding out as I talk with colleagues across the country that this is probably the longest part of the call, just becoming familiar with the patient so that you are not making a cold call, so that's one thing we are looking at.
Kathy Lauwers:
Suzanne?
Suzanne:
Yes.
Kathy Lauwers:
This is Kathy. I'm just going to ask for a pause for a moment...
Suzanne:
Sure.
Kathy Lauwers:
We have only moments left on our call and a lot of slides to go. And I'm wondering if I could just suggest that people could contact you with their questions.
Suzanne:
Absolutely.
Kathy Lauwers:
Thank you so much and I so appreciate all of your input.
Suzanne:
Sure, thank you, Kathy.
Kathy Lauwers:
And I wonder now, Gina, I'd like to just get into the innovative slides and do a very rapid review. First of all, looking at Hennipen, and in terms of this being a facility that is looking at mental health issues, and they were struggling with the issue of prolonged time for follow-up appointments. So they developed a transition group, a voluntary group, that allows patients to be seen before they get their official physician appointment. And about 40 percent of their discharges in their psychiatric pilot took advantage of that transition group.
They had been running their pilots February through August, and they have made a substantial improvement in their readmission rate with their baseline being at 13 percent and now their pilot is showing 7.9 percent. Their caveat, of course, is to say they have not included schizophrenic disorders.
Moving onto Concord Hospital, their Project RED is focused on cardiac and thoracic surgery. Their pilot started in August, and they've been evaluating tools and identifying resources required for their pilot. They've had 38 patients and their pilot with three readmissions and they go on to explain more, and those of you that might be interested in the surgical pilot would be free to contact them.
Moving to Park Nicolett Methodist, they have been restructuring their case management department and they have some really creative ideas. Typically case management is assigned geographically, and they wanted to improve that model, and so their pilot involved aligning their case managers with their hospitalist, and so they've been able to show some substantial improvements in terms of roles and are catching medical errors, and believing they're more efficient.
Riverwood Healthcare Center is a critical-access hospital, and the next two that I'm going to quickly report on, they are critical-access hospitals. And this particular hospital has developed some customized handbooks and computer pathways. And so the interesting thing is they applied to their foundation for start-up cost, so the takeaway here is perhaps to think about grant writing within your own facility.
Sparta Community Hospital has implemented Project RED, and they've implemented RED over all of their med-surg patients. They've had an average readmission rate drop by 10 percent, and they've had an increase in their patient satisfaction results by 9 percent, so good work, Sparta.
St. Luke's East Hospital is looking and has placed care coordinators in their emergency rooms, and this was to provide a strong resources for their emergency room physicians and to be able to partner with those physicians, med-rec and a variety of issues, they've been able to realize a 75 percent reduction in their Code 44, so that is good work.
Schneck Medical Center, they have developed a COPD training course, and they've been initiating that course prior to starting RED with the idea being that prepare your resources and align them to be able to deliver appropriately. They've also done offsite physician training.
Southeast Hospital has a Hospitalist Training Program, and this has been kind of an interesting model because they started their training program that was so successful the hospitalists were having more admissions than the cardiologists. They were having a bed challenge situation, and the hospitalists reduced their readmissions, and now what they've done is expand their bed capacity for cardiac patients.
So very good to step back and read these. I'm well aware that we are at summary, and my summary is really to thank all of you for your participation, your active and inactive roles. I really thank all our speakers for providing their names and contact information so you'll be able to go back and ask more specifically and find out more about all their accomplishments.
I would like to just remind you, we are appreciating that those sites that have been most successful in reducing readmissions are encompassing all 11 components of RED. I would like to also say, on behalf of all the Joint Commission consultants, we have learned so much from all of you, and we are so appreciative and feel very honored to be working with all of you.
We have prepared a brief evaluation so you can give us feedback on this webinar. We would so appreciate that. We have that contact information on the screen now, and again, thank you all for participating.
Bye, now.
[End of Audio File]
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Current as of December 2011
Internet Citation:
Project RED Summary Webinar (Transcript). December 2011, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/projectred/webinar1213.htm
540 Gaither Road Rockville, MD 20850 