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Healthcare Quality Strategies, Inc., (HQSI) is one of only 14 quality improvement organizations nationwide selected by the Centers for Medicare & Medicaid Services (CMS) to create pilot projects designed to improve care coordination and reduce unnecessary hospital admissions and readmissions. Nationally, 20% of Medicare patients are re-hospitalized within 30 days of discharge.* It’s believed that many of those readmissions may be preventable.**
The New Jersey Care Transitions Project (NJCTP) focuses on improving coordination as patients move between healthcare settings, as well as educating and activating patients to facilitate self-management. Begun in late 2008, the project encompasses multiple communities in Burlington and Camden Counties. The 30 day re-hospitalization rate among Medicare patients in this area is 19.5%.
The NJCTP team is working with 10 hospitals, including the Virtua health system, 11 nursing and rehabilitation facilities, six home health agencies, seven hospices, and four dialysis centers, as well as a number of physician practices, to implement strategies that will improve transitions of care. A series of interventions and community outreach efforts were implemented, with additional activities planned as the project continues.
The NJCTP has been featured in area news media, including the Philadelphia Inquirer and National Public Radio-affiliate, WHYY-FM. In addition, a monthly newsletter is sent to NJCTP participating providers. Effective communication helps decrease readmissions, while increasing patient involvement and adherence to treatment plans. HQSI is working with participating NJCTP organizations to identify ways to expand communication, especially at the critical point when a patient transitions from one healthcare setting to another, including transfers within a facility, from one facility to another, or a transfer home.
Nurses working at Virtua health system hospitals are stressing goal-focused communication in shift reports, as well as participating in multidisciplinary care (MDC) rounds. Patients are being instructed on how to use a personal health record (PHR) as part of enhanced patient/family education. HQSI has also distributed tips for improving communication between nursing facilities and covering physicians, using tools from INTERACT (Interventions to Reduce Acute Care Transfers). Examples of Change
Positive steps taken by some project participants include: An exciting effort, now underway at Virtua Home Care, utilizes the Transitional Care Model pioneered at the University of Pennsylvania Health System in Philadelphia. Under this model, “transitional care nurses” work with hospitals to identify patients at high risk of re-hospitalization and then visit these patients at home within the first 24 to 48 hours after discharge. Transitional care nurses serve as both educators and advocates, allowing recently discharged patients to take a more active role in their healthcare. HQSI is working with community agencies such as senior centers, libraries, and local Offices on Aging to raise awareness about improving care transitions. Through these efforts, HQSI has distributed over 10,000 PHRs. A number of hospitals now provide PHRs to their patients, and local groups are distributing the booklets to physician offices and at community events.
Communicating with high-risk Medicare beneficiaries can be a major challenge. One method of reaching them is through their adult children. A campaign targeting major area employers introduced Human Resource Directors to the NJCTP. The goal is to provide them with information and tools, such as AskMe3, a patient education program designed to promote communications between healthcare providers and patients in order to improve health outcomes. In turn, they will make them available to employees with elderly parents.
HQSI briefed SHIP (State Health Insurance Assistance Program) counselors about the NJCTP. These counselors are trained volunteers who provide free help to Medicare beneficiaries experiencing problems with, or questions about, their health insurance. There is also collaboration between HQSI and the Office of Community Education and Wellness (OCEW), a branch of the New Jersey Department of Health and Senior Services. | |
