Best Practice Submission
Case Management re-Admission Strategy
Point of Contact: Sam Spencer, (210)297-1044, SJSPENCER@baptisthealthsystem.com
Group Involved with the Project. The Baptist Health System VP CM, CMO,
Nursing, Pharmacy, Allied Health, Quality Director
Executive Sponsor: David Siegel, Dave Williamson
Team members: Sam Spencer, CM directors
Submitted by Major Moises Soto
11 May 2012
Executive Summary: The process of readmission due to continued complications for the same
illness will become punishable under the new healthcare law starting October 2013. Under this
new initiative, funding will be reduced for hospitals that do not show improvement to
readmission rates, while facilities that achieve standards will benefit. The Baptist Health System
has set a goal to develop a comprehensive continuity of care program that includes thirty days
post discharge to improve patient care and reduce avoidable hospital readmissions. Patients
identified as moderate to high risk for readmission in Acute Myocardial Infarction, Congestive
Heart Failure, and Pneumonia have experienced a reduction in readmissions through one year
post discharge as evidence by readmission rate reduction on a combined composite of 1.91%
over four years.
Objective of the Best Practice: This practice focused on several major factors that were
identified through the re-admission process, which created a protocol that provided guidelines
for staff to follow. Through this best practice, the staff was educated on the specifics of their
individual responsibilities as well as the most comprehensive possible approach to implement
them.
Background: After the discharge process, patients tend to experience fragmented health care.
This fragmentation leads to inadequate care, which results in elevated readmission rates. Having
multiple nurses, and physicians involved in patient care allows for miscommunication during the
transition to post-acute care. There is also a lack of outpatient follow-up post discharge, timely
Primary care Provider (PCP) follow-up post hospital, and discharge instructions from hospital.
The first factor the Baptist Health System used was to identify medication reconciliation
to classify drug-to-drug interactions to avoid re-admission due to the mixing of medications.
Incomplete discharge summaries were also addressed through staff education to ensure everyone
addresses them the same way. Assigning dedicated roles focused on a specific cohort population
suffering from Acute Myocardial Infarction, Congestive Heart Failure, and Pneumonia. Early
identification included a comprehensive assessment completed within 24 hours of admission, and
daily huddles for progression of care planning with case manager. The discharge planning also
included an appropriate discharge plan within 24-48 hours of admission, home health or other
post-acute interventions for moderate to high-risk patients. Scheduled primary care appointment
4-7 days after discharge identified patients appropriate for palliative or hospice care, and daily
documentation in discharge notes by the Transition Care Manager. Coordinating the continuum
of care began during inpatient care and includes Patient Health Record, regular communication
and updates from post-acute care providers, awareness and escalation of “red flags”, missing
physician appointments, and abnormal or declining patient health metrics.
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Literature Review: The Baptist Health System approach to case management and re-admission
strategy is based on Dr. Eric A. Coleman’s model. Dr. Coleman is a professor of Medicine and
Head of the Division of Health Care Policy and Research at the University of Colorado, and
Director of the Care Transitions Program, who has being at the fore front of an initiative aimed at
improving quality and safety during times of care “hand-offs”. (Sullivan 2003)
The baby
boomer generation (1946-1964) has being setting trends since their inception. As this large part
of our population grows older, they continue to dictate how products and services must evolve to
ensure their proper care. Dr. Coleman’s approach is able to marry innovation and practice
through: (1) enhancing the role of patients and caregivers in improving the quality of their care
transitions across acute and post-acute settings; (2) measuring quality of care transitions from the
perspective of patients and caregivers; (3) implementing system-level practice improvement
interventions and (4) using health information technology to promote safe and effective care
transitions. (Coleman 2008)
Implementation Methods: Bridging a full continuity of care pathway started with daily patient
contacts & telephonic management. In order to accomplish this, several high quality post-acute
care partners were hired. These included but were not limited to: Interim Healthcare, Texas
Home Health, Restorative Health Care, Gentiva Home Health, and Home care Dimensions.
These institutions focused disease-specific programs and remote in-home monitoring. They also
conducted physician follow-up appointment coordination with specialty-trained clinicians.
These partners used Safe Life at Home Disease State Management Programs. These programs
promote high quality decision-making by patients, which is believed to be critical to effective
care management. According to Health Dialog (a leading provider of care management,
healthcare analytics, and decision support). Individuals that participate in Shared Decision
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making programs tend to choose less invasive care, and report being happier with both their care
and with their health plan. (Health Dialog 2012)
Results: Data collected for CHF, AMI, and PN since 2008 shows evidence of a downtrend in
the amount of readmissions over the last four years. As a result BHS has dedicated staff models,
and increased the amount of patient and family member interaction and education.
Conclusion: The impact of implementing this BHS initiative has shown progress over the last
four years demonstrating an improvement in the transition to post-treatment care. The initiative
is working and the trend reflects an assimilation of new ideas and directives in the part of the
staff.
The system as a whole is becoming more efficient in the treatment of these three
conditions on the 64 year an older population, as shown on table 1.
Table 1
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References
Eric Coleman, MD, MPH | Department of Medicine | University of Colorado Denver. (n.d.).
University of Colorado Denver. Retrieved April 26, 2012, from
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/hcpr/
Faculty/Pages/EricColeman.aspx
Coleman, E. A. (n.d.). Care Transitions Intervention (sm) - Innovative Care Delivery Models.
Innovative Care Models. Retrieved April 27, 2012, from
http://www.innovativecaremodels.com/care_models/12/leaders
Coleman, E. A., & Smith, J. D. (2002). Development and Testing of a Measure Designed to
Assess the Quality of Care Transitions. International Journal of Care Integration,
2(April-June), 1-9. Retrieved April 18, 2012, from
http://www.caretransitions.org/documents/Dev%20and%20Testing%20-%20IJIC.pdf
Sullivan, H. P. (2003). mproving the Quality of Transitional Care for Persons with Complex
Care Needs. Journal of the American Geriatrics Society, 51(4), 30-32. Retrieved April
19, 2012, from
http://www.caretransitions.org/documents/Improving%20the%20quality%20%20JAGS.pdf
The best medical decisions are those made together between doctor and patient.. (2012, February
7). http://www.Health Dialog.org. Retrieved April 24, 2012, from
www.healthdialog.com/Main/Solutions/PopulationHealthSolutions/DECISIONDialog?g
clid=CKSpo7HM8K8CFalgTAodsXmdYQ
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