Improving Care Transitions: A Partnership with Non-Medical Home Care
Katherine Watts, LMSW, ACM-SW, Lexington Medical Center
Mike Brown, Vice President of Operations, Right at Home
Objectives • To explain the process of partnering with a non-medical home care company to create successful transitions of care and reduce hospital readmissions. • To understand the importance of non-medical home care in the discharge planning process. • To learn the importance of addressing psychosocial issues when transitioning home from the hospital to create successful discharge plans.
Abstract Background
Study of the Interventions(s), Measures and Analysis The goal of the Hospital to Home Program is to reduce preventable 30-day readmissions for high risk patients focusing on those diagnosed with the Medicare Hospital Readmission Reduction Program’s selected conditions – heart attacks, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), hip/ knee replacement, and coronary artery bypass graft surgery. The hospital monitors the intervention by tracking several process and outcome measures.
Outcomes Measured
When the program began, people were not interested in enrolling. They did not understand the benefit so the nurse navigators changed their script and started using language like, “the doctor feels you would benefit from the program” or include that it “is a part of the transition process.” As a result of the script changes, patients were more responsive to the program and more enrolled.
The hospital also tracks previous 30-day readmissions and previous ED and in-patient stays to determine Data from the hospital and the home health agencies (HHAs) are used in the analysis of the Hospital to Home if they are reaching the patients they want to target. They also track readmission rates of the enrollees to Program. The hospital is monitoring the following measures: Total referrals to the program, Total number of determine the impact of the program. enrolled participants, Enrolled patients with a previous 30-day readmission, Enrolled patients with a previous Data analysis for the Hospital to Home Program is ongoing. All members of the care team track their data ED or in-patient stay prior to admission, 30, 60, and 90-day all cause readmissions for enrolled patients. monthly and review it at care team meetings. Intervention progress is also reviewed at the bi-monthly The hospital tracks total referrals to the program and total number of patients enrolled in the program hospital/HHA work group meeting. The hospital initially set a goal of a 40 percent relative improvement rate for the project, which it has already achieved. to measure utilization. In the early stages of the program, the hospital also tracked refusals. Due to low enrollment, the hospital changed their approach when introducing the program to potential participants.
Interventions to improve care transitions and reduce hospital readmissions must be patient-centered and address social determinants in addition to medical needs so that patients can stay in their homes. Patient-centered care focuses on the patient’s physical comforts and emotional wellbeing (NEJM Catalyst). Social determinants of health are the conditions in which people are born, grow, live, work and age and include factors like physical environment, social support, and access to health care (WHO). Vulnerable patients with complex needs who have recently been discharged from the hospital may need additional community support and social services in addition to post-acute medical care to safely stay in their home. Interventions that use a patient-centered approach can lead to improved health outcomes and reduced expenses throughout the care continuum (NEJM Catalyst).
Hospital to Home Data FY 2017
Hospital to Home Data FY 2017
Hospital to Home Transitions Program
Hospital to Home - Readmissions and Previous 30 day IP stay
Referrals for Patients with CHF, COPD, TKA,THA, CABG, TAVR, CVA and Pneumonia FY 2017
Local Problem
25
20
19
3) COPD Navigator program
23
4) CVA/Pneumonia program
19 16
6
40%
11
6 4 2
Oct 2016
6
5 3
Nov 2016
5) EPIC Readmission Risk tool
13
8
The Hospital to Home Program is a collaboration between a hospital, home health agencies, and nonmedical home care company to provide additional support to patients when they transition home. Using a team approach led by a transitional care coordinator, the program provides eligible patients with appropriate non-medical assistance in their home. The interdisciplinary care team consisting of the hospital, home health agencies, and the in-home care company hold weekly face-to-face meetings to improve communication and coordinate patient care.
3
Dec 2016
8 6
5
4
3
Jan 2017
Feb 2017
Mar 2017
Apr 2017
32%
30%
6 4
3
May 2017
4
Jun 2017
26% 3
Jul 2017
Aug 2017
38%
33% 33%
8
25%
24%
20%
3
16%
16%16%
16%
21% 17% 13% 9%
Sep 2017
Total number of referrals Number of patients with previous ED or IP stay within 90 days preceding admission Number of readmissions within 30 days from total referrals this month – all causes
Intervention
14% 11%
13%
Summary
12% 8%
The Hospital to Home program uses a patient-centered approach to address care transitions by providing services that focus on the specific non-medical needs of high risk, medically complex patients. The program has demonstrated its success through a decrease in avoidable readmissions for the target population. Patients receive an additional level of support to help them successfully transition to their home environment and stay there. In our opinion, the transitional care coordinator is the glue that holds the program together by managing the patient and the communication process among healthcare providers. The non-medical home care team become the eyes and ears for the hospital to avoid readmissions if at all possible. Improving communication among the care team members through weekly meetings has contributed to the success of the program by providing a more coordinated approach and allowing the patients to have more points of contact to support their transition home.
4% Oct 2016
Nov 2016
Dec 2016
Jan 2017
Feb 2017
Mar 2017
Apr 2017
May 2017
Jun 2017
Jul 2017
Aug 2017
Sep 2017
30 day readmission rate % of patient with previous IP stay 30 days preceding admission
The Hospital to Home Program uses a non-medical care model to provide the necessary services for patients to safely transition to their home environment. It focuses on the psychosocial needs of the patients to ensure they have the proper supports in place to transition safely back to their home. Services provided typically include meal preparation, assistance with activities of daily living (ADLs), chronic disease management education, medication reconciliation, and transportation to physician appointments, but are tailored to meet the needs of the patient.
Target Population Prior to implementation (2016): • 33% readmission rate for targeted population
Hospital to Home Data FY 2018
Hospital to Home Transitions Program
Hospital to Home Transitions Program
Referrals for Patients with CHF, COPD, TKA,THA, CABG, TAVR, CVA and Pneumonia FY 2018
Referrals for Patients with CHF, COPD, TKA,THA, CABG, TAVR, CVA and Pneumonia FY 2018
61
45%
• Providing in-home support for approximately 20 patients per month (up to 20 hours of non-medical home care within 30 days of hospital discharge) for those with chronic, complex, co-morbid conditions.
• Reduce unnecessary consumption of health care resources• Reduce unnecessary cost to the health system
Testimonials
Hospital to Home Data FY 2018
Goals set:
• Improve publicly reported quality data (readmission rates on CMS Hospital Compare)
National Benchmark (6/16) 15.3% 21.6% 4.4% 16.3% 19.8% 16.9% 12.2% 13.8%
2) Focus on HTH program with Total Joints to improve transitions of care
21
10
We also expected to:
3) Increasing the ability for patients to manage their health care needs. We work with Right at Home to address any barriers to transitioning home successfully. We have even addressed pest control issues, transportation barriers, language barriers, access to care concerns and many other psychosocial needs.
Initiatives:
25
24
23
12
Outcomes Projected
2) Reducing unnecessary 30-day post-discharge readmissions by 40% or more for program-enrolled patients. Our readmission rate for this program prior to Duke Endowment involvement was 24%. We are happy to report that as of September 2018 our readmission rate for the program is 17%, a total reduction of 30%.
Internal hospital data for readmissions (Medicare) Overall FY 2017-12.7% FY 2018-13.9% CHF FY 2017-18.6% FY 2018-19.7% Total Joints FY 2017-4.0% FY 2018-4.4% Heart Attack FY 2017-14.5% FY 2018-9.9% COPD FY 2017-16.1% FY 2018-11.8% Pneumonia FY 2017-15.2% FY 2018-11.0% CVA FY 2017-11.6% FY 2018-8.0% CABG FY 2017-14.2% FY 2018-9.4%
28
Methods
• Increasing the ability for patients to manage their health care needs by providing transportation, arranging meals, obtaining medications, scheduling MD appointments, and supporting daily living activities.
1) Providing Hospital To Home (“HTH”) for approximately 20 patients per month. Since Oct 2016, we have provided HTH services to 484 patients which is an average of 20 patients per month.
1) Hospital-wide team addressing CHF readmissions
Improving coordination of care in all healthcare settings leads to improved health outcomes. In South Carolina, hospitals are still prioritizing efforts to reduce avoidable readmissions. There is a new emphasis on implementing community-based, patient-centered interventions that provide social support for high risk patients once they transition home. By partnering with non-medical, community providers and improving communication during patient transfers, these patients receive an additional level of care that enables them to remain at home following a hospitalization.
• Reducing unnecessary 30-day post-discharge readmissions by 40% or more for program-enrolled patients with diagnoses including but not limited to CHF, COPD, Pneumonia, AMI, CVA, Total Joint Replacements and CABG.
Below are the measures of the progress towards the goals we set out to accomplish:
43
39
38
21
27
1213 6
4
1 21
Oct 2017
3
6
5
16
14
12 5
3 2 1
23 2
Nov 2017
16
Dec 2017
44 3 1 Jan 2018
7
44
21
Feb 2018
26
25
22
19 15 13
18
31%
38
27%
26% 26
23
38
36
34
5
10
8 2
00
2
Mar 2018
34
Apr 2018
9
8 10
May 2018
21%
17
15
14
13 7
00
25
24
11
Jun 2018
3
5 1111
Jul 2018
231 2
Aug 2018
18% 18%
16%
14%
10 5 44 2
“Absolutely, some people don’t have help from family, so this is a great program for them.”
27
26
4 5 2 1 0 Sep 2018
Total number of referrals
Referrals not opened
Referrals opened
Number of patients with previous ED or IP stay within 90 days preceding admission
Number of patients with previous IP stay 30 days preceding admission
Number of readmissions within 30 days from total referrals this month – all causes
Number of readmissions within 60 days from total referrals this month – all causes
Number of readmissions within 90 days from total referrals this month – all causes
18%
16% 13%
11% 11%
13%
12% 8%
8%
0% Oct 2017
Nov 2017
7% 7%
8%
0% Dec 2017
Jan 2018
Feb 2018
Mar 2018
Apr 2018
“We need all the help we can get…I live alone, my husband has passed away and my daughter is not really able to help like I need her to, so this program became the lifeline I needed and took the place of a family member or friend. It is a huge service to the community.” “I feel it provides a wonderful service to the community, it gave me hope and the ability to think about life beyond a hospital stay, it gave me another chance.”
35%
43
“I am a prime example of what is possible when given the opportunity and resources to go home. Without this help I would have had to be placed in a facility, for that I am very thankful to LMC and the grant program.”
May 2018
Jun 2018
Jul 2018
Aug 2018
Sep 2018
30 day readmission rate Percentage of patient with previous IP stay 30 days preceding admission
“I feel it is essential that there be programs that give back to the community that has helped grow the hospital system into what it is today. I hope programs like this stay in existence as it is a much-needed service with our age group.”
References NEJM Catalyst. What is Patient-Centered Care? Available at: https://catalyst.nejm.org/what-is-patient-centered-care/ World Health Organization (WHO). What are social determinants of health? Available at: http://www.who.int/social_determinants/sdh_definition/en/