Chadron is located in rural area of Northwest Nebraska. A group of committed individuals came together to form a care transitions work group to ensure safer and improved coordination of care. Communities represented sit along Highway 20 in Western Nebraska; including Crawford, Chadron and Hay Springs.
The work group committed to improving transitions of care and communication among care providers. They also worked to increase success as individuals are discharged home. Quarterly meetings were set in July 2015 and are ongoing. The group’s vision was to establish a healthcare system where patients and their caregivers understand their conditions and medications, know who to contact with questions (and when) and are supported by healthcare professionals who have access to the right information at the right time.
Project participants included healthcare providers, stakeholder organizations and individuals within the community. The care transitions work group included key staff from the hospital and skilled nursing facility, including but not limited to, directors of nurses, pharmacy, discharge planners, administrators, social services, therapists, quality managers, diabetic educations and home health and hospice directors.
Prior to this effort, coordination of care was lacking. Letters were sent to discharge planners for feedback. Phone calls were made and repeated until information that was needed was obtained. The process was time consuming with limited success in obtaining needed information. In addition, rural areas face obstacles in accessing services, including work force shortages, health inequity, socioeconomic issues and cultural and social differences.
The care transitions group identified several areas to focus their efforts, including:
- Complete medication list provided at discharge
- Implementation of a Long-Term Care transfer form (INTERACT tool)
- Improved medication reconciliation
- Timely coding
- Sharing information between Electronic Medical Records (EMRs)
- Timely discharge summaries
- Improved communication from the Emergency Room
In addition, exchange visits were established. Participants were given the opportunity to visit organizations that are different from their own facility. For example, the nursing home staff visited the hospital. Visiting with organizations different from your own allows the opportunity to rethink care coordination; improve communication with staff, patients, residents and families; facilitate a safer care transition; promote better patient and resident outcomes; facilitate best practices for care coordination and medication safety; and potentially reduce avoidable 30-day readmissions.
The work group experienced several positive outcomes early on. Some of the highlights of their efforts are included below:
- Established one medication list sent from the hospital
- Long-term care discharge orders were created by the three partnering nursing homes, which included routine orders and statement of skilled therapy needs
- Calls from the Emergency Department to the facilities were established for those patients who were not admitted to the hospital
- Lower hospitalization rates
- A diabetic educator shared programs she could offer facilities
- The hospital shared its mental health programs via telehealth
- The home health team started talking about home-based value purchasing
- Participants shared their staffing concerns and positive experiences
- Relationships have developed and communication is easier and more effective
As a result of this community effort, the hospital Emergency Room admissions from the nursing home decreased to five percent. The total admission rate from nursing homes is currently at ten percent; a four percent decrease.
“The greatest opportunities for improving care transitions center around improving communication, building cross-setting relationships and redesigning our workflow, stated Diana Lecher,” administrator and director of Chardon Community Hospital’s Home Health and Hospice Program.” Lecher continued, “The answers are in the room. We all come from a different place, respect all voices. Everyone has a bright idea and each has a shared ownership of improvement. We must commit to work together to identify challenges and focus on solutions with input, discussion and decisions as a group. We want to leave each meeting with a sense of accomplishment and purpose, and acknowledge the difference you are making to improve the lives of patients and residents in our communities.”