The NE QIN-QIO provided a Care Transitions report to identify opportunities for improvement and described the “Perfect 10” Campaign and available resources at the webinar. The “Perfect 10” Campaign aims to help hospitals achieve a 12 percent relative improvement in readmissions. “For BWFH that translates to reducing our readmissions by just eight patients per month,” explains Barney.
The webinar also explored how HRET HIIN readmission toolkits can support hospitals’ improvement efforts, something BWFH is already doing. “We certainly still have a lot of work to do,” says Barney. “We’re not yet at the goal, but what we have done is make some significant improvements over the last year.”
The improvements Barney was able to point to during her talk related to creating tools for the inpatient teams to use. She explains, “Every morning, Tayla Hough, our Patient Safety Project Manager, pulls a list of readmitted patients and sends it to key leaders on the inpatient services, as well as social work, case management, pharmacy and the Chief of Medicine.”
Using that report, members of the care teams can look into cases of patients who are readmitted during rounds or daily huddles. “We’ve found that many of these readmitted patients have substantial medical issues as well as comorbidities that include substance abuse and behavioral health issues,” says Barney. “They have challenging issues outside of the hospital.”
She continues, “It’s not that these patients don’t get the care they need while they are here. Our extensive reviews of charts show that we provide excellent care during the patients’ stay. It’s that they often have a hard time taking the resources we show them and running with that as an outpatient.”
That’s where social work has been able to step in and make an impact. Social Work Supervisor Will Bromstedt, LICSW, and Emily Lapidus, LICSW, developed a quality improvement project aimed at identifying patients who have high-risk social issues contributing to readmission and offering appropriate interventions.
“Our goal is to identify psychosocial issues that may be contributing to patients’ readmissions to the hospital,” says Bromstedt. “The psychosocial issues that have been identified range from substance abuse and mental health issues, homelessness/unstable housing, patients having limited support/resources, medical non-compliance and complex family dynamics.”
Lapidus explains, “By analyzing trends related to this population’s readmission rates, we are working on optimizing social work interventions to both reduce readmissions and to ensure patients have the resources they need in order to thrive in the community. Types of interventions include collaborating with outpatient/community providers, utilizing acute care plans within EPIC and providing necessary resources/referrals for dual diagnosis treatment.”
For these patients, many of the resources they need to recuperate at home are available right here at BWFH or in the community. “We are unique in that we have a wide array of addiction recovery programs and other counseling services available at BWFH on an outpatient basis,” says Barney. “For patients who might be at risk for readmission, we can have an addiction recovery consult before discharge to help them make the most of available services after they’ve left the hospital. We can refer appropriate patients to our Psychiatric Partial Hospital and Dual Diagnosis Partial Hospital programs to meet their behavioral health needs. We can also use acute care plans in the medical record in the event that the patient presents to the Emergency Department. Rather than readmit those patients, the ED can reconnect them with the services they have been referred to in the community.”
BWFH has been using the HRET HIIN readmission toolkits and hopes to continue to do so to meet the national readmissions reduction goal. Barney stresses that our frontline staff are vital in these efforts. “If staff on the units have ideas, we want to hear them,” she says. “You work with these patients every day and you may have ideas on how best to support them as they transition from the inpatient to the outpatient setting. Associate Chief Nurse of Inpatient Nursing Lynne Morrison, MS, RN, and Chief of Medicine Dr. Scott Schissel are the Chairs of our Readmission Taskforce. Staff can contact them if they are interested in joining our team.”
Barney also encourages all staff to explore some of the resources available here on reducing readmissions.