 "Know Before You Go" Campaign |
AARP and Volunteer Coordinators receive "Know Before You Go"
training at their Salt Lake Office.
By Janet Tennison, Ph.D., Project Coordinator with HealthInsight
HealthInsight's Care Transitions Team met with AARP representatives and volunteers Tuesday, January 29th, to train them to provide "Know Before You Go" presentations at senior centers, civil and fraternal organizations throughout the state. The "Know Before You Go" campaign is meant to educate Medicare beneficiaries and others to understand how to optimize outpatient care services. Understanding what to do before, during, and after provider visits can help individuals improve their understanding of their care.
* Preparing for appointments includes such activities as making lists of symptoms and questions to ask, possibly inviting a friend or family member to help listen to instructions, asking for an interpreter, if needed, while scheduling appointments.
* Activities for during appointments: asking questions until directions are clear, taking notes, and sharing the goal for visits help organize and optimize time.
* Knowing what additional symptoms or "red flags" to look for, and when to call the provider are examples of what to do after the appointment. The importance of writing down and knowing medication names, doses, and reasons to take medications is also emphasized.
Jill Duke, an AARP representative, noted her gratitude for this type of information, "We really think this type of education can make a big impact for our communities." AARP volunteers, newly trained to provide the "Know Before You Go" presentation, agree that it has significant value, and are eager to begin sharing the information in their geographical locations such as Ogden, Logan, St. George, and Price.
Larry Garrett, HealthInsight's Care Transitions Team Leader, expressed his desire to have as many "Know Before You Go" presentations held this year as possible. "We are so thankful to AARP and the dedicated volunteers to extend this important education to as many people as we can. Our joint efforts can help reduce preventable hospitalizations, and more importantly, reduce unnecessary suffering and personal costs."
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Improving Patient Care, Safety, and Satisfaction with Better Discharge Communication |
By Cheryl Bailey, MBA BSN, CNO/vice president, Patient Care Services, Cullman Regional Medical Center
In October 2012, the Centers for Medicare and Medicaid Services (CMS) began penalizing hospitals for excessive readmissions within 30 days of discharge for heart failure, pneumonia, and myocardial infarction. Hospitals are also being penalized or rewarded based on how patients rate their experience. With reimbursement tied to performance, hospitals are searching for reliable, cost-effective solutions to improve patient care, experience, safety, and outcomes.
At Cullman Regional Medical Center (CRMC), Cullman, AL, we have found that solution. Working closely with ExperiaHealth, we conducted an assessment of our discharge process and quickly determined that relying on traditional discharge packets with multiple pieces of paper was not adequate. Patients and their family members are often anxious at discharge and don't always pay close attention when they are ready to leave, or the clinical information is complex and they do not fully understand it. Additionally, there is no guarantee the information makes it home with the patient and no way to track whether the patient reads or understands the instructions.
With the "Good to Go" solution, our caregivers can ensure patient understanding and compliance by engaging patients and their families in the care plan during and after a hospital stay. . . To read the entire article, click on this link to go to the NAHQ.org website. |
Care Transitions Case Study
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University of California, San Francisco Medical Center: Reducing Readmissions Through Heart Failure Care Management
By Douglas McCarthy
In 2008, the University of California, San Francisco (UCSF) Medical
Center embarked on a grant-funded program to reduce hospital readmissions for elderly patients with heart failure. With support from medical center leaders and a multidisciplinary team, program coordinators provide enhanced patient education and follow-up care connections to promote the patient's successful transition to home or to skilled nursing care. Over two years, rates of all-cause heart failure readmissions in the target population declined by 46 percent within 30 days of hospital discharge and by 35 percent within 90 days. With internal funding, the program is being sustained and expanded to younger patients. The medical center applies learning from the program to support the goal of reducing all readmissions as part of a performance incentive program for public hospitals. Program staff highlight collaboration and communication as key factors to the program's success.
The Program at a Glance
Organization: The University of California, San Francisco (UCSF) Medical
Center is a leading academic medical center with several inpatient and outpatient facilities and primary care clinics in San Francisco, including a 559-bed main hospital at its Parnassus campus, the site of the intervention (Exhibit 1).
Objective: Reduce by 30 percent the rate of hospital readmissions for any cause within 30 and 90 days of a hospital discharge among the target population. Target Population: Medicare patients age 65 and older (average age 80) hospitalized with a primary or secondary diagnosis of heart failure (representing approximately 700 admissions during the year the program began); more than half of these patients identified with a racial/ethnic minority group and almost one-third spoke a language other than English.
To continue reading, or download the PDF of this study, click on this link.
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Project BOOST |
What:
The Project BOOST Mentored Implementation Program is an evidence-based approach to improve patient care in the transition from the hospital to home. This 2011 Eisenberg Award-winning program matches institutions with an expert mentor in quality improvement and care transitions, providing customized coaching to map current processes and identify the root causes of deficiencies.
Why:
Preliminary data from sites that implemented Project BOOST Mentor Program for at least six months revealed a reduction in 30-day readmission rates from 14.2 percent before BOOST to 11.2 percent after implementation, producing a 21 percent reduction in 30-day all-cause readmission rates.
How:
Mentors work with sites to help tailor BOOST interventions such as comprehensive patient risk assessments and patient and provider communication strategies to the unique needs of the institution. Online collaboration and benchmarking tools allow hospitals to share ideas, documents and resources; and compare progress with over 150 BOOST sites nationwide. The target outcomes of Project BOOST are to:
- Identify high-risk patients upon admission and target risk-specific interventions
- Reduce 30-day readmission rates for general medicine patients
- Reduce length of stay
- Improve facility patient satisfaction and H-CAHPS scores
- Improve information flow between inpatient and outpatient providers
Upcoming Project BOOST Informational Webinar - FREE! For more information, see the National Events Section in the right column of this newsletter.
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Improving Care Transitions to Reduce Hospital Readmissions |
The Robert Wood Johnson Foundation will convene a national conversation on Feb. 13th to highlight successful ways to improve care transitions and reduce avoidable hospital readmissions. The conversation is part of Care About Your Care, a national initiative to share promising ideas with patients and health care providers.
Nancy Snyderman, MD, chief medical editor for NBC News,
will lead national experts and audience members in a discussion about bringing together patients, care providers, and community services to ensure better health care outcomes.
This webcasted event will feature:
- Risa Lavizzo-Mourey, MD - Robert Wood Johnson Foundation president & CEO
- Eric Coleman, MD - University of Colorado Anschutz Medical Campus
- Mary Naylor, PhD, RN - University of Pennsylvania School of Nursing
- Jonathan Blum, MA - Centers for Medicare and Medicaid Services
For details on this February 13th event, see the National Events Section in the right column of this newsletter. |
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About Our Work |
This information is provided by HealthInsight, a private, non-profit, community-based organization dedicated to improving health and health care. HealthInsight serves as the Medicare Quality Improvement Organization in Utah and leads an initiative to improve care coordination and reduce hospital readmissions across settings of care.
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Sincerely,
Larry Garrett, HealthInsight
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Local Events
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Patient Centered Care in Action Event When?
Thursday, March 7, 2013
8:30 a.m. - 2:00 p.m.
This FREE event will
feature an interactive morning plenary and three learning & action network sessions focused on patient centered care.
- Improving patient care through Meaningful Use
- Best medication list practices to deliver the best care
- Patient engagement tools and techniques
Click here for more information and to register. |
| National Events | |
"Shining Stars
Across the Nation"
Webinar Series
Presented by
ICPC, the Medicare Quality Improvement Organization for Colorado
When?
2nd & 4th Thursdays
3-4 PM ET
Who?
QIOs, healthcare providers, partners, HHS, and consumers
Register
For information:
Call 866-639-0744
Visit Qualitynet Website
(Password:Community)
View PDF of schedule
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| National | |
FREE
Project BOOST
Mentored Implementation Program
Informational Webinar
Presented by
Mark V. Williams, MD, FACP, MHM | |
When:
Wednesday
February 20, 2013
1:00 PM EST/12:00 PM CST/ 10:00 AM PST
Who:
Clinicians and front line improvement teams are invited to learn more about the BOOST mentoring program and how to apply to participate in the Fall 2013 cohort.
Register:
To join this free webinar,
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Improving Care Transitions to Reduce Hospital Readmissions
Webcast | |
When:
Wednesday
Feb. 13, 2013
12:30-2:00 PM EST
Register:
by emailing Joyce Kim at
or calling
202-745-5068
Continuing education credit available to viewers.
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You may unsubscribe to this newsletter at any time by e-mailing me your request.
Please feel free to forward this publication using the "Share this" button at the top right corner. Each edition will also be archived on our website. |
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You are receiving this newsletter as a result of your participation in the Patient Centered Care in Action - Care Transitions Learning and Action Network, or simply for your involvement in care transitions in your setting. Each month, this briefing will include a variety of information on different topics, tools and resources, upcoming trainings or events and your improvement stories. |
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