Project Description: Page Memorial Hospital (PMH) identified a need for patient care coordination and continuity for post discharge care.

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1 Title: Improving Care Transitions by Utilizing a Multidisciplinary Approach Including a Transition Coach and Primary Care Model Hospital: Valley Health Page Memorial Contacts: Portia Brown Vice President Pbrown3@valleyhealthlink.com Tabatha Keyser Case Management tkeyser@valleyhealthlink.com Project Description: Page Memorial Hospital (PMH) identified a need for patient care coordination and continuity for post discharge care. Background: Page Memorial Hospital, a critical access hospital located in Luray, Virginia identified a need for improvement with patient care coordination based on the new HCAHPS questions proposed in There was an opportunity to improve care coordination for patients discharging from the hospital to home, skilled nursing facility, Home Health or hospice care. Many of the patients cared for in the hospital are over the age of 65 with multiple chronic conditions including those taking three or more medications. In addition, PMH is located in a rural area with disparities and socioeconomic challenges to manage for successful care transitions. The following questions were added to the CMS HCAHPS survey beginning late 2014: 1. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left. 2. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. 3. When I left the hospital, I clearly understood the purpose for taking each of my medications. Key Strategies: Lack of coordinated care and disjointed communication between providers are the leading cause of avoidable readmissions. Therefore, it is understood that discharge does not need to occur prematurely, discharge to the appropriate care setting must occur, and the patient must receive appropriate resources and adequate information for a successful transition of care. The approach taken to develop a successful coordinated care and transition post discharge program is multifold.

2 1. Page Memorial Hospital, alongside Shenandoah Memorial Hospital and Warren Memorial Hospital, hired a transition coach that is shared among the three facilities. The responsibility of this position is to bridge the gap from hospital to home. The transition coach follows the post discharge care of the high risk readmission patient for 30 days with follow-up calls and home visits. Readmission rates were successfully reduced collectively over a three year period during the transition coach program. 2. Readmission risk assessments are conducted during the patient hospital stay by case management. The LACE tool is utilized as well as checklists to assist in the assessment. The transition coach follows the patient while in the hospital as well as post discharge for 30 days based on the assessment. The transition coach ensures the assessment for compliance with medications, answers questions, promotes disease management and education, and has a follow-up appointment with the primary care provider. 3. Case management is instrumental in appropriate discharge planning process with close communication with other care team professionals including the physicians. The case managers assist with meeting the current patient challenges of safe discharge and care environment. The case managers, nurses, and physicians fully assess the capacity and capability of the patient and family to perform the necessary care post discharge and reach a mutual decision about the plan. The assessment includes active listening while determining physical, psycho-social, emotional and financial needs of the patient. Timing of discharge is coordinated among the care team. Case managers also provide education to the patient and care partner on the disease, medications, and care at home. 4. Patient care partners are incorporated in the care of the patient during the stay as well as the discharge process to understand the disease condition, comorbidities, rehab, follow-up care needed and medication administration timing. Care partners are someone who is close to the patient and permitted by the patient to stay as long as willing during the hospital stay to assist with patient education and follow-up post discharge. 5. Pharmacists and pharmacy technicians round on the patients during their hospital stay and at time of discharge to ensure all patient, family, and care partner questions have been answered. The pharmacy team ensures the patient and care partner are aware of side effects and also understand the purpose of the medications. Medication reconciliation occurs at time of discharge to ensure no duplications or omissions of medications. 6. Page Memorial Hospital offers a swing bed (transitional care) program. If a patient qualifies for transitional care following an acute care discharge (minimum of three inpatient midnight stay), the patient is moved to swing bed status. This transition in status provides a hospital environment for a safe care transition to home. 7. The healthcare staff provide multiple teach back opportunities for the patient, care partner, and family to validate understanding of self-care and discharge

3 instructions. Additionally, the transition coach or home health personnel provide teach-back post discharge. 8. To ensure patients have follow-up care post discharge, a primary care office appointment is arranged by hospital staff prior to discharge. This appointment is communicated to the patient at time of discharge to ensure follow-up within 7 days. If the patient is discharged on the weekend, the clinic calls the patient proactively to schedule an appointment. In addition, the primary care clinic calls the patient as a reminder prior to the appointment and asks if transportation is a barrier, often providing a solution real time. 9. The hospital nursing staff conducts post discharge phone calls on 100% of patients within 24 hours of discharge. This provides additional support for the patient and care partner to ask questions on care and ensure medications are available and dosing regimen understood. 10. One PMH primary care clinic offers a Nurse Navigator program for patients who are discharged and also for patients with chronic conditions such as heart failure or COPD who have potential for hospital readmission. The nurse proactively calls patients inquiring with a set of questions and interventions. Outcomes: Along with HCAHPS care transition scores, PMH assesses readmission rates as a strategic priority and indicator of successful care transition. The PMH Readmission Committee includes representatives from administration, home health agency, nursing, case management, quality, risk management, medical staff, transition coach, and clinic management. The committee reviews the data and identifies root cause for each readmission, barriers in continuity of care, and opportunities to improve the process. Figure 1: Continuum

4 2016 PMH Data on Readmissions: total of 28 readmissions 30% of readmissions were multi-visit patients (4 or greater hospitalizations). Of the 30% of readmissions, 100% of patients were followed by home health services post discharge. 43% of readmissions had an opportunity for improvement. Of the 42%, 31% were patient driven by refusal of care planning as offered and 69% were due to system driven factors. Figure 2: Data Report Lessons Learned Staff Engagement: Discussions for improvement of the care coordination and transition must involve all stakeholders including the patient and family. Based on the 2016 data, the readmission committee requested a home health representative participate in team meetings for improved transitions and reduction in readmissions. Additionally, there is an opportunity to enhance the communication between hospital providers and home health agency providers. The process is multifaceted and not one specific facet was the sole barrier for improvement. Patient Partnership: Include the patient and family as full partners in the discharge planning process. Listen to and respect the patient and family goals, preferences, observations and concerns.

5 Appendix Patient Interview / Readmissions Chart Review