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Preventing readmissions: Lakewood Medical Center’s CNO on the secrets to their success

Each year, NRC Health honors one hospital with the Excellence in Care Transitions award at the Annual Symposium.

This award goes to a hospital that, among the 101 organizations that use NRC Health’s Care Transitions solution, has the lowest rate of readmissions, as reported by the Centers for Medicare and Medicaid Services (CMS).

Keeping readmissions low is an enormous challenge, achieved only through impeccable care coordination and effective communication with patients.

In 2018, one hospital demonstrated outstanding commitment to these organizational priorities, achieving a readmissions rate of just 6.22%. It’s NRC Health’s pleasure to recognize Lakewood Ranch Medical Center in Bradenton, FL, with this year’s award.

Even with a robust and healthy population, maintaining such a low rate of readmissions is a challenge. But Lakewood accepts a large number of vulnerable and elderly patients, which means they must take extra steps to ensure that discharged patients are whole and healthy at home.

Lakewood’s CNO, Judy Young, explains the philosophy—and the policies—that keep the hospital’s care to such a high standard.

Proactive prevention

The first point that Judy makes is that preventing readmission starts well before patients ever make it to the hospital.

“Always be looking for opportunities,” Judy says, “especially at the beginning of the care process.”

Keeping patients from being unnecessarily admitted in the first place, for instance, is an important strategy Lakewood deploys. The team distributes phone numbers for emergency-department providers to senior-living and long-term-care communities around the area, so that caregivers at these facilities can call if they need assistance or question whether the patient should return to the hospital. Sometimes a quick phone call can avoid a readmission.

“Very often, a hospital’s not the appropriate care setting for these patients,” Judy says. “If they call us first, a doctor can weigh in on the case, and they can make a more informed decision.”

If a patient does need to be admitted, though, other opportunities arise to ensure a healthy discharge.

“Knowledge deficits in patients are the most important thing to correct,” Judy says.

Patients must leave the hospital with a clear understanding of their post-discharge care. They need to understand their medications, their recovery processes, and their paths to intervention if something unexpected arises.

Judy explains that this means hospital staff must learn to effectively communicate, so that patients will internalize what they say. “Education is a big part of a successful transition home,” she says.

Support where it’s needed

Sometimes, however, despite staff members’ best efforts, some discharge information will slip through the cracks. Overwhelmed patients or complex cases can lead to patients inadvertently forgetting crucial parts of their post-discharge care.

To close these gaps in patient understanding, Lakewood relies on NRC Health’s Care Transitions solution.

Using IVR technology, Care Transitions automatically reaches out to 100% of patients, without a heavy investment of staff hours. This enables Lakewood to quickly and reliably identify those patients with lingering confusions or concerns, which Lakewood’s more experienced caregivers can then clear up.

“After Care Transitions identifies who needs assistance, we have our unit nurse leaders make the follow-up calls,” Judy says. “They have a grasp of the bigger picture, they’re knowledgeable about what patients might need, and because of their positions, they’re empowered to find solutions.”

She brings up two examples where a Care Transitions call made all the difference:

Diabetes care

One patient was discharged after an admission related to diabetes. When the patient got home, the automated call from Care Transitions flagged her for urgent follow-up. The unit nurse leader called her back and learned that the patient’s blood-sugar levels were dangerously unstable—because she couldn’t afford her insulin. She was rationing her doses, putting herself at substantial risk.

Over the course of the call, however, the Lakewood unit nurse leader was able to reinforce the importance of insulin with the patient, and connect the patient with resources that helped to ease the burden including discussing the situation at her appointment with her primary care physician. Had it not been for that phone conversation, the patient would almost certainly have needed a visit to the ER.

Total joint rehab

Another patient had joint-replacement surgery at Lakewood. Upon discharge, the patient assured Lakewood’s staff that she owned a walker at home. However, after a Care Transitions call, the unit’s Nurse Practitioner learned that not only did the patient not own a walker, she wasn’t even sleeping on a bed.

The patient was instead recovering on a friend’s couch, using a chair instead of a walker to ambulate around her friend’s house. Under such conditions, an injurious fall was almost inevitable.

Lakewood’s quick-thinking Nurse Practitioner was able to prevent that. She commissioned a courier to deliver both a walker and an ice-machine to the friend’s house, and the patient made a full recovery. Some time later, the patient stopped by Lakewood to return the equipment. She also brought a bouquet of flowers, to thank the staff who had helped her.

A commitment to continuous improvement

While these individual cases illustrate the importance of post-discharge follow-up, they belie what Judy believes to be the real value of Care Transitions: the data.

“Care Transitions gives us centralized trending reports, so that we can look at data over time,” Judy says. “It’s all integrated into one place, so we can see exactly where we need to improve.”

Through the reports from Care Transitions, Judy and her team were able to uncover common sticking points for patients. Certain questions about medications, for instance, kept recurring, as did confusion about post-surgical rehab instructions.

Once Judy and her colleagues understood the problem, they convened multidisciplinary teams to design communication protocols, create clearer patient-reference materials, and streamline discharge instructions. These steps have helped keep Lakewood’s readmissions rate low, and Judy believes that clear longitudinal data has been critical in enacting these changes.

“Visibility into the data is what gets everyone to buy in to the process of improvement,” Judy says. “In the end, it’s another way to keep patients’ best interests at the front of everyone’s minds.”

That spirit of service—and the commitment to follow through on it—is the real secret to Lakewood’s readmissions success. NRC Health commends the Lakewood team, and looks forward to seeing how that spirit will animate their work in 2019.

We hope you consider joining us for the 25th Annual NRC Health Symposium to celebrate the next winner of the Excellence in Care Transitions award.  It will be held in Nashville, TN on August 14-16 and all details can be found here.