Posts Tagged ‘patient handoffs’

HINfographic: 2015 Post-Acute Care Challenge: How to Foster Warm Handoffs

September 16th, 2015 by Melanie Matthews

With patient transitions between care sites a top post-acute care (PAC) challenge for 25 percent of healthcare organizations, discharge planning, hiring of care transition navigators and data exchange are helping to facilitate ‘warm handoffs’—full-circle communication between hospital and post-acute care clinicians regarding a patient’s care—according to 2015 Healthcare Intelligence Network metrics.

A new infographic by HIN examines the top strategies to improve post-acute care and reduce costs and the percentage of healthcare organizations that include post-acute care in value-based reimbursement methodologies.

2015 Healthcare Benchmarks: Post-Acute Care TrendsHealthcare is exploring new post-acute care (PAC) delivery and payment models to support high-quality, coordinated and cost-effective care across the continuum—a direction that ultimately will hold PAC organizations more accountable for the care they provide. For example: two of four CMS Bundled Payments for Care Improvement (BPCI) models include PAC services; and beginning in 2018, skilled nursing facilities (SNFs) will be subject to Medicare readmissions penalties.

2015 Healthcare Benchmarks: Post-Acute Care Trends captures efforts by 92 healthcare organizations to enhance care coordination for individuals receiving post-acute services following a hospitalization—initiatives like the creation of a preferred PAC network or collaborative. Click here for more information.

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Home Health on Care Transitions Management: Focus on Post-Acute to Home Handoff

April 7th, 2015 by Patricia Donovan

With the hospital-to-home care transition deemed the most critical by half of healthcare organizations, home health sits on the front lines of care transitions management.

An overwhelming majority of home health organizations, which comprised approximately 10 percent of respondents to HIN’s 2015 survey on Care Transitions Management, have a care transition management program in place: 80 percent versus 67 percent overall, and of those that don’t, 100 percent intend to implement one in the next 12 months, versus 56 percent overall.

Contrary to overall respondents, this sector considers the hospital to post-acute care transition key (50 percent versus 24 percent overall) as well as the post-acute care to home handoff (50 percent versus 9 percent overall).

Heart failure is the top health condition targeted by home health organizations (87 percent of respondents, versus 81 percent overall). This sector also targets acute myocardial infarction, or AMI (62 percent versus 51 percent overall), and the frail elderly, a top concern for 75 percent of this sector versus 44 percent overall.

Half of home health organizations surveyed self-developed care transitions programs (50 percent versus 34 percent overall). Similarly to most respondents, programs include medication reconciliation (87 percent versus 75 percent overall) and transition/handoff training (87 percent versus 39 percent overall). This sector also relied on telephonic follow-up (87 percent 79 percent overall) in their care transition programs.

Transition coaches were primarily responsible for coordinating care transitions, according to 37 percent of home health respondents, versus 25 percent overall.

Some ways home health organizations improved transitions of care included creation of community partnerships with acute care facilities, development of post-acute networks, and collaborations with all clinical and hospice providers.

Successful strategies for this sector included separating data input from hands-on patient discharge paperwork so clinicians doing the transition could focus more on the patient, and not typing. Also, maintaining open communication with all staff and following up on communication with the patient and/or caregiver to ensure they transitioned appropriately into the new setting helped them to identify any concerns in the hopes of avoiding an unnecessary hospitalization.

Provider engagement remains the biggest challenge to this sector’s transition management efforts, say 37 percent of home health organizations, versus 13 percent overall.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

2015 Healthcare Benchmarks: Care Transitions Management HIN’s fourth annual analysis of these cross-continuum initiatives examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and delivery of value-based care.

Communication During Care Transitions: Technology, Templates Clarify Handoff Message

March 19th, 2015 by Patricia Donovan

With communication between care sites a top barrier to efficient transitions for one quarter of respondents, HIN’s fourth comprehensive Care Transitions Management survey pinpointed information tools getting the message across during patient discharge and handoff.

Technology offers a leg up by way of telehealth and remote monitoring, respondents said; 75 percent of respondents transmit patient discharge or transition information via electronic medical records (EMR).

2015 Care Transition Survey Highlights

  • Discharge summary templates are used by 45 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.
  • Twenty-seven percent of respondents record patient discharge instructions for patients’ future access.
  • After communication, inconsistent follow-up is the most frequently reported barrier to care transition management, say 21 percent of respondents.
  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • A majority of respondents—72 percent—assign responsibility for care transition management to a healthcare case manager.
  • Download an executive summary of the February 2015 Care Transitions Management survey.

SFHN Cross-Continuum Care Transitions: Dashboard, Discharge Database Streamline Patient Handoffs

March 12th, 2015 by Patricia Donovan

Dr. Michelle Schneidermann and the SFHN Care Transitions task force mine administrative data to streamline patient handoffs.

As a physician, Dr. Michelle Schneidermann is accustomed to the clinical data driving daily decision-making: blood tests, x-rays, blood pressure readings.

But as part of a multidisciplinary task force charged with improving care transitions within the San Francisco Health Network (SFHN), Dr. Schneidermann faced a “black box” of administrative data buried in more than 60 siloed databases across the health network.

During Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, Dr. Schneidermann described how SFHN’s development of a dashboard, a database and uniform practices has helped to streamline care transitions across its care continuum.

Early on, a data analyst pulled together the siloed databases into a cohesive dashboard providing numerous insights on readmission rates, vulnerable populations, and pain points within SFHN—learnings that sparked action plans, pilots and partnerships designed to standardize patient handoffs and post-discharge follow-up.

One key strategy of the task force, which Dr. Schneidermann described as a “multidisciplinary village,” was a decision to engage primary care leadership.

“Most of our patients leaving San Francisco General go home from the hospital,” said Dr. Schneidermann. “Their post-acute care is in their primary care home. For that reason, we decided that engaging primary care leadership would be a key strategy for our improvement work.”

The population served by the network is largely uninsured or underinsured, and at high risk for readmissions, she added.

After piloting post-discharge outreach tactics at three separate primary care clinics, the task force identified a fundamental knowledge gap: the clinics had a hard time identifying which patients had been discharged and when.

Enter a hospital discharge database retrofitted into the electronic medical record (EMR) that populates each night from hospital censuses— a tool that has improved clinic staff workflow.

Not all interventions are technology-driven. The task force has also engaged primary care physician champions, and placed pharmacists in clinics where possible.

Having concluded its second year, much work still remains. Readmission rates have not dropped as low as the task force would like; the impact of behavioral health readmissions on overall rates is now being studied. The task force also hopes to bring the patient’s voice to bear.

“In theory, it would be most helpful to have representation from patients with chronic illnesses requiring significant self-management skills, who are also challenged by psycho-social barriers to care,” Dr. Schneidermann concluded.

Listen to Dr. Schneidermann outline the responsibilities of the three task force sub-groups: inpatient, outpatient and pharmacy.

Patient Handovers, Recorded Discharge Instructions Key to Improved Care Transitions

May 8th, 2013 by Patricia Donovan

recorded discharge instructions

Webinar Replay: Care Transition Strategies for Effective Patient Handoffs

For two healthcare organizations, care transitions began to improve when they focused less on readmissions data and more on their patients.

Retooled patient handovers — a subtle but significant shift in terminology from ‘patient handoff’ — and recorded discharge instructions were two strategies for managing care transitions, an area key to reducing readmissions and healthcare costs, and improving patient care and satisfaction.

During Care Transition Management: Strategies for Effective Patient Handoffs, a 60-minute HIN webinar on April 24th, now available for replay, Joshua Brewster, director of care management at Regions Hospital, a HealthPartners hospital, and Cheryl Bailey, vice president of patient care services at Cullman Regional Medical Center, shared these strategies and more, all of which have led to impressive results.

By focusing on the patient and the handoff process, Minnesota’s Regions Hospital has watched its readmission rates decrease from over 11 percent in 2009 to 9.5 percent for all patients and achieve readmission rates for 2012 that are better than its expected results, as predicted by modeling outside of the organization, says Brewster.

And Cullman Regional Medical Center’s award-winning “Good to Go” recorded hospital discharge resulted in a 15 percent decline in readmission rates for patients who received recorded discharge instructions and a 62 percent increase in HCAPS satisfaction scores.

For both Brewster and Bailey, their strategies began by paying attention to the patient. “We noticed our patients weren’t listening to their discharge instructions, and their caregivers were being left in the dark,” says Bailey. So began the seed for CRMC’s award-winning “Good to Go” program, where nurses began recording their patients’ discharge instructions. One of five winners of the Robert Wood Johnson Foundation’s Transitions to Better Care video contest, the idea was simple but effective: when patients were about to leave the hospital, their nurse would inform them that they were going to record their discharge instructions, and would share them afterwards via the phone and computer.

The benefits of the program were wide ranging, Bailey continues. Realizing the notes were being recorded enabled the patients to relax, and allowed better comprehension and compliance. Good to Go “extends the relationship between the nurse and patient beyond the walls of the hospital,” Bailey says.

In terms of technology, there was a 40/60 split between Web site and phone access; with 30 percent of the instructions accessed more than once, and more than 40 percent retrieval of instructions when notifications were sent to patients and families.

And internal analysis of the recorded discharge instructions helped CRMC to further refine its discharge process and identify patients in need of post-discharge support.

For Regions Hospital, micro-managing their patients was key to their decrease in readmission rates: in 2012, more than 380 readmissions were avoided, Brewster says.

Similarly to CRMC, Regions noticed that their patients might say they understood their medication instructions, but they didn’t. By establishing a process called Medication Boot Camp, they not only showed their parents and caregivers what to do, but sent them home with instructions and any necessary tools, i.e. numbered pill boxes.

They sought out small grants for lower income patients who would benefit from home care but couldn’t afford it, and even changed the wording of ‘patient handoffs’ to ‘handovers.’

They wanted to make sure that they weren’t turning patients off, but over to another facility/environment, but would still maintain communication and information, Brewster said.

But the most important change for Regions was establishing a Transitions in Care Committee, Brewster says.

“For a long time it was the ‘readmissions work group’, but we wanted to move away from the idea that all we are doing is preventing readmissions. What we are really trying to do is improve transitions as patients move from one care setting to the next. That’s not always just moving from the acute care setting or the hospital, back out into the community, but also those coming into the hospital. Because we think there is a lot that we can learn about patients and do to prevent readmissions before the patients even get to the hospital.”