Monday December 18th 2017

Stopping the revolving door

Nurses lead, implement strategies to reduce readmissions

Like other health care facilities across the nation, Bronson Methodist Hospital in Kalamazoo, MI, wanted to reduce the number of patients readmitted to its facility for care shortly after being discharged. And leaders there understood that nurses would be pivotal in helping them accomplish that goal.

So over the past few years, they’ve implemented and strengthened a number of RN- and nurse practitioner (NP)-led strategies aimed at helping patients better manage their health once they leave the hospital.  Collectively, their efforts have been successful. Many of the strategies were a pilot with heart failure patients, which led to readmission rates dropping from 22.6 percent in 2010 to 16.9 percent in 2013 in this population. Additionally, the overall acute care readmission rate was 10.3 percent at the end of 2013.

Bronson, along with the American Nurses Association (ANA), has been an active member of the National Quality Forum’s  (NQF) Readmissions Action Team, and as such, has worked to identify, implement and share with other facilities best practices that reduce avoidable admissions and readmissions across care settings. The action team has been supported by the Partnership for Patients (PfP) initiative, which the U.S. Department of Health and Human Services launched in April 2011 to lead a nationwide effort to decrease preventable hospital-acquired conditions by 40 percent and readmissions by 20 percent, and to create a culture of safety.

Strategies that work at Bronson

The nurses within the Bronson Health system are trained in two formal strategies designed to help patients get more involved in their care and better understand what they need to know once they are discharged, according to Stacy Ochsenrider, MSN, NP, a care transition coach with Bronson Methodist Hospital and readmission action team member of NQF.

One strategy is the National Patient Safety Foundation’s “Ask Me 3” patient education program.  This program focuses on engaging patients to ask health care providers three questions: What is their main health problem, what do they need to do about it, and why is it important that they follow care instructions.

The other is called “Teach-back,” which is similar to the long-time nursing practice of having patients do return-demonstrations. However, the Teach-back method emphasizes having patients describe in their own words how to take a medication, for example, or other parts of their discharge instructions. They also might explain their understanding of their health condition or diagnosis, as well as the self-management skills necessary to best manage their health.

“The nurses dedicate time to perform these [patient education] strategies throughout a patient’s stay and work to make every opportunity a teachable moment, so they are not overloading the patient with information right at the time of discharge,” Ochsenrider said.

These strategies are then reinforced in the ambulatory setting by the nurses in the system who follow up with the patient after hospital discharge, for example through Bronson home health care, primary care offices and the Care Transition Coach program.

Another key initiative is an NP-led program that focuses on follow-up care. Initially, RNs at Bronson Methodist Hospital make post-discharge phone calls to patients.  They also identify which patients require a face-to-face visit – health coaching – which Ochsenrider and two other NPs provide throughout an eight-county area. As part of those visits, the NPs help patients to better manage their conditions; they reiterate to patients what they were taught by RNs in the hospital; and they offer them ways to better communicate with their primary care providers and specialists to avert any preventable problems.

“We follow patients for 30 to 45 days, or longer if needed,” Ochsenrider said. “Our goal is to help patients safely transition from inpatient back to the community, and this looks a little bit differently for each patient we see.  We assess their current resources and support, and identify if additional support or resources are needed or available.  Medication reconciliation, self-management education and early medication intervention are key to our program and impact.”

Further, another “key connection” is the nursing hand-off between RN case managers in the hospital and RNs in the primary care provider offices, according to Ochsenrider. And Bronson also utilizes inpatient nurse navigators to aid in care coordination for specific surgical populations.

“Nursing is key across the entire continuum of care,” Ochsenrider said. For example, nursing has initiated daily multidisciplinary rounds on each unit and also a daily huddle with case management for early discharge planning.

As for next steps, Ochsenrider said that Bronson wants to ensure all the readmission-prevention strategies are implemented throughout the system, and some of the initiatives will be refined.

“We want to make sure that the right patient is getting the right level of resources at the right time,” she said.

Mount Sinai’s mission: communication, collaboration and partnership

For more than 10 years, Mount Sinai Hospital in New York City has partnered with the Visiting Nurse Service of New York (VNSNY) as a way to ensure that patients who leave the hospital receive the care they need at home.

Beth Oliver

In 2009-2010, nurses within the two organizations began working very closely to fine tune post-discharge care for patients with congestive heart failure, and more recently, to optimize wound care and prevent surgical site infections in post-cardiothoracic surgery patients, according to Beth Oliver, DNP, RN, vice president, Cardiac Services, Mount Sinai Health System and an ANA member.

“For several years, we’ve been working to more strongly integrate the care given by nurses on the units with the care provided by nurses in the field,” Oliver said. For example, clinical nurses and VNSNY nurses use the same patient education materials for patients with congestive heart failure.

“By using the same materials we provide patients with consistent content, and we are able to begin teaching for discharge readiness earlier – even on the first day of admission right at the bedside,” she said. Further, patients have more time to absorb and familiarize themselves with the information, which is subsequently reinforced by visiting nurses. This ongoing education is crucial to helping patients recognize and respond to symptoms so they can more effectively manage their condition and avoid readmissions.

Another early strategy to reduce preventable readmissions involves holding joint meetings.

“These meetings provide a forum for VNSNY and Mount Sinai nursing staff to put their heads together to hone in on specific factors related to readmissions, and then develop and implement interventions to address those factors,” Oliver said.

The organizations also implemented a direct hand-off procedure between unit nurses and field nurses. This practice was developed when Mount Sinai clinical nurses observed that a number of post-cardiothoracic surgery patients were being readmitted for wound infections.

“We wanted to ensure that the procedures which brought patients to the point of discharge readiness were being continued in the field, and found that direct communication between clinical nurses and visiting nurses improved patient outcomes and coordination of care,” Oliver said.

To continue to build that personal communication, the organizations hold events where unit and field nurses can meet face to face.

“Not only does this strengthen our partnership, it puts a human face on those we work with and allows nurses to benefit from one another’s expertise and experience.” Oliver said. “This partnership has been essential to transitions in care. And it is so simple.”

Readmissions of patients with heart failure, alone, have been reduced by 13-14 percent. And the model for nurse hand-offs – from inpatient staff nurses directly to those in outpatient or community settings – is expected to be implemented throughout the entire hospital.

Oliver also noted that now that health care is moving toward value-based care, nurses’ assessments and roles in preventing readmissions should be even more evident.

“You can’t replace nurses,” Oliver said. “Nurses are pivotal in the whole discharge process, and their care results in better patient outcomes.  And because of our conviction that nurses are so important to the discharge process and to preventing readmissions, we are participating in the READI Study. It’s a multisite study of Magnet® hospitals commissioned by the American Nurses Credentialing Center and led by researchers at Marquette University College of Nursing assessing the relationship of nurses and patient assessment of discharge readiness on readmissions.”

For more information on the partnership, go to http://partnershipforpatients.cms.gov/.

— Susan Trossman is the senior reporter for The American Nurse.

Making progress for patients

The Partnership for Patients (PfP) has two goals: decrease preventable hospital readmissions by 20 percent and reduce preventable hospital-acquired readmissions by 40 percent. The PfP works to meet these goals by sharing information and evidence-based strategies through a system of 27 hospital engagement networks, which include more than 3,700 participating hospitals nationwide.

A U.S. Health and Human Services progress report on the PfP initiative revealed that after holding constant at 19 percent from 2007 to 2011 and decreasing to 18.5 percent in 2012, the Medicare all-cause, 30-day readmission rate has further decreased to approximately 17.5 percent in 2013.  This translates into an 8 percent reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.

In 2014, the National Quality Forum (NQF) Readmissions Action Team focused specifically on leveraging patient, provider and community partnerships, and on identifying and addressing patients with psychosocial needs. The strategies included working together across stakeholder groups to enhance systems improvement, collaboration, and patient and family engagement. The group’s efforts in sharing and spreading best practices and approaches to improving the quality of care aligned with these strategies and served as a vital driver in fostering both individual and collective efforts to further progress.

Related articles

“Check out this progress report on hospital-acquired conditions” in the Sept/Oct issue of The American Nurse and online at www.TheAmericanNurse.org

www.theamericannurse.org/index.php/2014/11/04/check-out-this-progress-report-on-hospital-acquired-conditions/

“Issues up close Partnership for Patients Update” in the May 2014 issue of American Nurse Today at www.americannursetoday.com/issues-up-close-24/. (Member login required.)

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