A Culture of Collaboration: How Physicians and Clinicians at WellSpan Work Together to Reduce Hospital Readmissions and Improve the Patient Experience

By Katy Mena-Berkley
Friday, November 11, 2016

WellSpan Health is taking action to reduce the occurrence of preventable readmissions at WellSpan’s hospitals.

Communication between providers and staff is key to helping prevent hospital readmissions.

Costing hospitals money and creating anxiety for patients and families, readmissions have topped the priority list of the Centers for Medicare & Medicaid Services (CMS) since the passage of the Affordable Care Act (ACA). The Hospital Readmissions Reduction Program, launched by CMS on Oct. 1, 2012, was designed to enhance quality of care delivered at acute care hospitals to patients readmitted for high-cost or high-volume procedures or conditions, such as chronic obstructive pulmonary disease (COPD) and congestive heart failure. WellSpan leadership and staff drew inspiration from this program as they looked to reduce preventable readmissions.

“Hospitalization is not like going to Disneyland — particularly with our vulnerable populations, such as the elderly or those with multiple medical problems,” says Steven Delaveris, DO, Vice President, Medical Services, WellSpan Health. “It takes something out of people physically and emotionally every time they are hospitalized.”

And because hospital stays are significantly shorter today than they historically have been, enhancing the quality of care — especially focusing on the transition points between multiple healthcare providers or back home following hospitalization — is absolutely critical.

“It has been rewarding to get all of the WellSpan teams together to appreciate one another’s efforts to provide a quality patient experience after discharge from the hospital.”
— Kimberly Yinger, RN, BSN, Director of Service Delivery and Patient Care, WellSpan VNA Home Care

“Not too many years ago, the average hospital stay was eight to nine days. You would get admitted for a gall bladder surgery, come in the day before the surgery, have the surgery and stay in the hospital until the stitches came out,” Dr. Delaveris says. “Or if it was a medical condition, you would be in the hospital until you finished your course of antibiotics or regained your strength and were basically done with treatment. Now the average length of stay is about four days.”

Care continues once patients leave the hospital as they have a follow-up appointment with their primary care physician or clinician and may be seen by specialists. For this reason, it is essential to get everyone involved in a patient’s treatment — primary care, specialty and hospital physicians, nurses, and home health providers — on the same page.

A Strategy for Success

Focusing on a data-driven approach to evaluate opportunities for reducing readmissions, WellSpan physicians utilize risk-adjusted observed-to-expected ratio methodology, which is consistent with measures employed by CMS and similar entities. The goal is to reduce the readmission observed-to-expected ratio to less than 1.0. To achieve this objective, physicians have identified key drivers of readmissions at each WellSpan hospital, basing their assessments on volume of discharges and readmissions, not limiting the scope of their investigations to the areas identified by CMS. They found coordinating care and encouraging patient compliance post-discharge through appropriate education and home health care were key factors that could enhance outcomes.

Based on collected data, strategies are underway to reduce readmissions at WellSpan Ephrata Community Hospital, WellSpan Gettysburg Hospital, WellSpan Good Samaritan Hospital, WellSpan Surgery & Rehabilitation Hospital, and WellSpan York Hospital. The approach to reducing readmissions at these facilities is based on three core strategies — care management, post-discharge medical management and home care.

Care management has been an area of focus for a number of years as part of the patient-centered medical home model.

“Resources that once existed on the hospital floor are now spread throughout the patient-centered medical home, which has the advantage of longitudinal relationships with patients,” says William A. Landis, MD, SFHM, Medical Director, WellSpan Hospitalists.

The disadvantage is that approach has reduced some of the resources on the unit in the hospitals. To address the issue, team members from WellSpan VNA Home Care collaborate with other WellSpan teams and families to ensure patients have the resources they need when recovering from illnesses and injuries or managing chronic conditions at home.

“Everyone from various departments works as one to help patients through their journey,” says Kimberly Yinger, RN, BSN, Director of Service Delivery and Patient Care, WellSpan VNA Home Care. “I think one thing that’s been very helpful about the team approach is our members range from leadership at the corporate, physician, and case management levels to front-line clinicians at the VNA.”

Yinger’s team instituted three patient coordinators who interact with case managers to provide support to patients during and after the discharge process.

“When a patient selects WellSpan VNA as their homecare agency, we then go see them at the bedside,” Yinger says. “We work with case management to make sure the patients have their prescriptions and discharge instructions and really know what to expect when they get home.”

Post-discharge medical management — specifically of targeted higher-risk, higher-volume conditions, including heart failure, pneumonia, COPD, and sepsis — is a strategic area of focus for the WellSpan teams. And home health is closely tied in with successfully reducing readmissions in these areas as well.

“We find that for certain conditions — sepsis, for example — patients who utilize home health services experience better outcomes than patients who don’t,” Dr. Delaveris says.

However, patients do not have a history of welcoming home health recommendations 100 percent of the time. This is in part due to the fact that patients dealing with a condition like COPD, for example, may have returned to lifestyle choices such as smoking that are known to be detrimental to health and wellness. They are hesitant to let healthcare providers see them regress. WellSpan is working to shift the mind-set and the conversation.

“Such scenarios are reflected in care management,” Dr. Delaveris says. “We needed to do a better job in terms of managing up and messaging and communicating to the family why home health care has value, and that these are not just strangers coming to the home and worrying about anything other than the care and quality outcome for the patient.”

Prescribed Processes

Educating and communicating with patients about the importance of post-discharge medical management is a team effort among physicians, nurses and case managers because integrated care is most beneficial to the patient and most effective for preventing unnecessary readmissions. One way to ensure those efforts are successful is through a structured follow-up plan. For example, WellSpan Good Samaritan Hospital uses a prescribed process to follow up with patients and families through nine specific touches within 30 days after discharge from the hospital. These touches could be in-person clinic visits or phone calls.

“As a consequence of that discipline, Good Samaritan was a very high performer nationally and locally as it related to congestive heart failure outcomes, so we thought there was something to learn there in terms of staying actively connected with our patients when they leave the hospital,” Dr. Delaveris says. “Patients dealing with multiple medical problems have the most needs, so we developed a better discipline around following up with them.”

Putting the Pieces Together

Recognizing a need to standardize areas such as care management, case management and post-discharge medical management, WellSpan established a “swim lane” diagram of priorities. Three main owners of the process — physicians, nurses and case managers — worked together to develop guidelines for nursing, and they are currently developing similar standards for physicians.

“Who owns those swim lanes varies a bit,” Dr. Delaveris says. “But we want to make certain our standard work assures that every patient has all needs addressed and that we are communicating fully at transition.”

The concept of care applies to WellSpan physicians and healthcare providers outside of the system, as well, to anyone responsible for the care of the patient. The process makes communication about patient care easy and seamless for all healthcare providers.

“We have taken measures to ensure that at the time of discharge, the summary of hospital care has been documented and is available within 24 hours,” Dr. Landis says. “We have our standard of work for the discharge of the patient and the plan of care available to the next provider, whether that’s the visiting nurse, the primary care physician or the surgeon who is following up with the patient.”