Autumn 2009
Making it Happen… The Stepping Stones Way
How the Stepping Stones Project is Achieving Its Goals
Imagine a community where patients, families and healthcare providers work seamlessly together to ensure safe and effective care transitions. It is possible and participants of The Stepping Stones Project are working hard to see that it happens!
The Care Transitions Steering Committee recently restructured to better meet the current needs of the project. They added two new physician members. Bertha Safford, MD represents the Family Care Network and Serge Lindner, MD, represents the Center for Senior Health and Peace Health Medical Group. Additional sponsors include St. Joseph Hospital, Critical Junctures Institute, Northwest Regional Council, and Qualis Health.
The Steering Committee has adopted a charter, forming workgroups to maximize the goal to improve care transitions. Members have agreed to focus on three important areas: supporting patient and family self-management; physician and healthcare continuity; and improving and standardizing hospital discharge processes. Workgroups for each area of focus are implementing the following interventions:
Improving Family/Patient Self-Management
Using the Care Transitions Intervention (CTI). In the CTI, a transition coach helps a patient become good at and comfortable with managing their care after hospital discharge. Volunteer community transition coaches have been trained in Whatcom County and are ready to coach patients being discharged from the hospital. The CTI workgroup is putting a referral process in place that will allow patients to connect with the transition coaches.
Improving Physician & Healthcare Continuity
Engaging two large, physician networks and post-acute providers (such as home health and nursing homes) to determine how handovers happen and what steps can be implemented to improve physician follow-up after discharge.
Improving Hospital Discharge
Implementing a re-designed discharge process that includes the new patient “Takeoff” checklist that seeks to assure the following perspectives are addressed:
Improving Family/Patient Self-Management
Information with understanding: assure that the patient/family understands the diagnosis and the discharge plan, and that the patient’s primary care and/or specialty physicians are notified that the patient is being discharged.
Red flags: understand what signs or symptoms might signal a worsening condition, and what to do.
Medications: confirm a medication plan with the patient/family, including reviewing each medication’s purpose, how to take it correctly, and side effects to watch out for.
Follow-up care: provide the patient/family with a list of follow-up services that need to be scheduled or completed, including: primary care/specialist physician follow-up; outpatient lab, radiology, or other tests to be scheduled; and pending results of tests completed during hospitalization.
In addition to achieving the stated goals (see graphic above), an overarching goal of the Steering Committee is to put in place a working model that will produce sustainable outcomes going into the future… taking Whatcom County hospital readmission rates from good to great!
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Patient Christine Robinson Empowered by Transition Coaching
For Christine Robinson, a 77-year-old grandmother with several chronic health conditions and a complex mix of medications, being admitted to the hospital has become an all-too-frequent activity. And she’s not alone. According to a 2004 study, nearly one in five people with Medicare coverage who were hospitalized that year were readmitted within 30 days of being discharged.
As part of The Stepping Stones Project funded by the Centers for Medicare & Medicaid Services (CMS), Qualis Health is training coaches to empower Whatcom County, WA residents to better manage their own care after a hospital discharge. Robinson is very pleased to have been one of the project’s first coaching recipients. “Working with [my coach] was great. She gave me something to think about—and to do,” she says.
For example, Qualis Health coach Karla Hall helped Robinson develop a list of questions to ask her doctor and role-played how that conversation might go. “That list was so useful,” Robinson reports. “The talk with my doctor went very well.”
Hall also encouraged Robinson to make the appointment within days of returning home from the hospital, and connected her with a community resource to get transportation to the clinic. For someone recently discharged from the hospital, checking in with the primary care physician is an important, but often missed, step.
In this case, Robinson’s list of questions not only helped her better understand her own treatment, but also prompted her physician to begin making system changes in the 13-clinic family medicine practice.
Among the tools proven to improve the safety of care transitions, coaching is a simple approach with long-lasting results. “We chose to use the coaching model because it makes sense on so many levels,” Selena Bolotin, Qualis Health’s Care Transitions Project Manager, said. “Helping patients and their family caregivers become more engaged in their healthcare not only reduces hospital readmissions, but can also improve their ability to manage a host of care-related issues.”
In Robinson’s case, coaching certainly appears to have made an impact. She now knows the proper dosage, as well as the intended purpose, of each her medications. Going a step further, she has made a commitment to better manage her diabetes—which wasn’t a trigger for her hospital admission or a focus of her coaching sessions. The intervention has even spread to others, now that Robinson’s doctor is actively discussing care transition issues with her practice.
Robinson is feeling a lot better, and it’s not just her medical conditions that have improved. She is now more confident about her ability to manage her own health. According to Hall, Robinson very quickly went from a “hopeless and helpless” attitude to one of empowerment—a care transition of the very best type.
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Reducing Unnecessary Readmissions in the Forefront of Healthcare Reform
Whatcom County Gets a Head Start Improving Care Transitions
Across the US, the potential for healthcare reform is headline news. While the debate rages about just what should be done, most agree that changes must be made to America’s healthcare system. One of the biggest drains on American pocketbooks is the high cost of health care. According to the Office of Management and Budget, the United States spends over $2.2 trillion on healthcare each year—almost $8,000 per person. The need to control spiraling healthcare costs means doing things differently. And the reform spotlight is focusing on reducing unnecessary hospital readmissions.
According to HHS Secretary Kathleen Sebelius, “The President and Congress have both identified the reduction of readmissions as a target area for health reform. When we reduce readmissions, we improve the quality of care patients receive, and cut health care costs.”
As of late October 2009, both the House and Senate are considering potential provisions intended to track and/or prevent avoidable hospital readmissions, and to produce savings from improved care coordination and differential hospital reimbursement based on readmission rates.
Meanwhile, as it seeks money to provide healthcare for more Americans, the Administration has already identified hospital readmissions as a source of potential cost-cutting. The president’s budget calls for $26 billion in savings from readmissions over 10 years, which includes lowering payments to hospitals with high numbers of patients who are readmitted.
And Medicare is taking steps to address unnecessary hospital readmissions. In July, 2009, the Centers for Medicare & Medicaid Services (CMS) added hospital readmission data to the Hospital Compare website, www.hospitalcompare.hhs.gov. And Whatcom County’s Stepping Stones Project is one of only a handful of communities around the nation chosen last year for Medicare’s Care Transitions Project, already working to eliminate unnecessary hospital readmissions.
The goal of Medicare’s Care Transitions Project is to improve health care processes so that patients, their caregivers, and their entire team of providers have what they need to keep patients from returning to the hospital unnecessarily. By promoting seamless transitions from the hospital to home, skilled nursing care, or home health care, this community-wide approach seeks not only to reduce unnecessary hospital readmissions but to yield sustainable and replicable strategies that achieve high-value health care for Medicare beneficiaries.
The Stepping Stones Project places Whatcom County in the forefront of those adopting solutions to improve the quality of patient care and reduce unnecessary hospital readmissions.
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