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How to create a sustainable transitions program: Three crucial tips from Via Christi Health

For policy-makers and health systems alike, reducing unnecessary readmissions is a cardinal priority. A low rate of readmission is a reliable indicator of care quality, and under CMS’s Hospital Readmission Reduction Program (HRRP), it’s also a key driver of a hospital’s financial health.

Despite the benefits, many organizations struggle to find practical means to keep readmissions low. However, Via Christi Health, Kansas’s largest provider of healthcare services, has discovered some tactics that work. Over the last five years, Charity Clark, MSOHRD, director of case management and transitional care, and Robyn Chadwick, LSCW, vice president, oversaw a remarkably successful readmission-reduction initiative.

They have advice to offer for healthcare leaders who want to do the same. Their first piece of advice: focus on care transitions.

“We know that one of the most dangerous times for a patient is when they leave acute care and go to another setting,” Charity says. “So that’s where we want to focus our attention. That’s where we can have the most impact.”

They’ve found that there are three essential elements of a transitions program that keeps patients safe.

Element one: Build understanding

There’s no one-size-fits-all approach for safeguarding care transitions. Institutions must carefully weigh their populations’ needs against their operational capabilities and engineer a sustainable solution.

This starts with understanding what happens to patients once they discharge from the hospital. Unless they achieve this understanding, organizations can only guess at what interventions might help.

To learn about patients’ post-discharge experiences, contacting them after their care episodes is the logical next step. But it’s also a considerable hurdle—especially for a system like Via Christi, which has 12 hospitals under its management.

The enormity of their patient population meant that there was no practical way for Via Christi’s staff to reach every one of their patients. So they turned to NRC Health’s Transitions solution for help.

Transitions is an automated platform that uses Interactive Voice Recognition (IVR) technology to reach 100% of patients within one day of discharge. By surveying patients, it rapidly identifies which of them might need extra support, and notifies providers so they can offer guidance.

Via Christi has been using Transitions since 2015. Before then, Via Christi’s staff was only able to reach about 14% of patients after discharge. Transitions brought that proportion up to 100% and, even more importantly, discovered that about 27% of Via Christi’s patients required post-hospitalization guidance.

Not only was Via Christi’s staff able to intervene in these individual cases, but Transitions also automatically aggregated the case data to reveal useful trends. Those trends, in turn, guided Via Christi’s interventions.

Element two: Attend to social determinants

The aggregated Transitions data showed Via Christi’s leadership which patients tended to need the most help, as well as what they needed assistance with.

The results were none too surprising. As is often the case, Via Christi’s neediest patients were low-income or otherwise disadvantaged, and their primary concerns were about affording medication or confusion about discharge instructions.

These trends showed leadership a clear direction in which to focus their efforts, leading them to create Via Christi’s Transitional Care Clinic.

80% of our patients’ wellbeing derives from social determinants,” Robyn says. “We recognize that, and that’s why the Clinic’s focus is on integrating clinical care with social work.”

Led by nurse practitioners, the Transitional Care Clinic has four distinct goals:

– Teach patients autonomy by educating them about their conditions
– Connect patients with resources to help them meet their care needs (e.g.,  Dispensaries of Hope, which provides low-income patients with essential medications free of charge)
– Address the socioeconomic (e.g., transportation, affordability) and psychosocial (e.g., stigma, mistrust) barriers that prevent patients from seeking care
– Connect patients with a primary-care provider within 60 days of discharge

In short, the Clinic’s goals extend Via Christi’s work outside the hospital, empowering patients to better manage their own care. The results speak for themselves:

In all the time it’s been running, the Clinic has never seen less than a 91% reduction in hospital encounters from its targeted population.

This shows just how efficient it can be for health systems to attend to the social determinants of healthcare—and how some of the best uses of hospital resources may not take place in the hospital at all.

Element three: Targeting high-risk patients

Finally, Via Christi’s leadership knew that, no matter their socioeconomic status, patients with certain conditions would always be more vulnerable to repeated hospitalization.

Academic research shows that chronic obstructive pulmonary disease (COPD) is the single highest driver of 30-day readmissions. One study found that COPD explains 27.6% of all readmissions.

With such strong evidence in mind, Via Christi’s team designed the Community Cares Program.

 This is an intervention specifically targeting patients with advanced COPD. Under the Community Cares program, nurse practitioners visit patient homes and work with patients to manage their illness.

The APRNs would help patients identify environmental risks like smoke or other irritants; they’d collaborate with specialists and primary-care doctors to ensure that each patient had a medical “home”; and they’d consult with patients to develop emergency plans and palliative-care decisions, so that patients wouldn’t have to wait for a crisis to force these decisions on them.

Charity calls this kind of care “seeing beyond the bedside,” and in one dramatic example, it proved essential for a patient’s safety.

“We had a nurse visit one woman, and it was shocking,” she says. “She lived in a trailer in the middle of a salvage yard. There was no refrigerator, so she had no fresh food. She had just enough electricity to run either her space heater, or her oxygen—not both.”

This woman lived on the outer edge of vulnerability. There’s no question that her lifestyle put her in serious danger. But with help from Community Cares, she was placed into an assisted-living facility, an intervention which saved her life—and greatly improved her comfort.

Much more to learn

While each of these tenets is important for a transitions program to work, Robyn believes that they won’t work unless health-system staff members internalize one important principle: caring for the patient doesn’t stop at discharge.

“We’re creating a bridge to the next phase of care, whatever that may be,” she says. “It’s our job to make sure that bridge gives patients the support they need.”

She and Charity are eager to help other organizations build that bridge for their patients, which is why, in conjunction with NRC Health, they hosted a webinar: Cultivating a Reliable Transitions Program.

In addition to the advice above, they shared a wealth of useful information:

– What operational shortfalls lead to high readmission rates in the first place

– Which psychosocial/socioeconomic barriers create the biggest post-discharge problems for patients

– A cognitive model for arriving at the “Why?” behind a patient’s difficulties

– An approach to preventing heart failure readmissions—including the staffing and costs involved

Attendees also received several resources to help them plan and execute a transitions program at their own facilities.

Although the webinar’s already over, it’s not too late for you to learn from it. You can watch a recorded cast of the webinar for free at this link, or download their case study to learn more about the work that Via Christi is doing in their community.

 And click here to make sure you don’t miss the webinars coming up!