The second thing the Holyoke team discovered was that the pulmonary program's own policy prohibited people from attending pulmonary rehabilitation sessions if they refused to quit smoking.
"We changed that immediately, offering patients nicotine replacement or smoking cessation support while they're in the hospital."
To date, Holyoke has tripled the number of people attending pulmonary rehabilitation sessions. "We're seeing a volume shift from three to five patients a week to more than 20," Keefe says.
Adds Roberts, "These patients are building up their physical endurance and activity, and I just looked at the stats. Hardly any of these patients is getting readmitted. It's been a real win-win."
Another initiative at Holyoke that is now paying off is the use of a scoring system for every admitted patient to rate his or her own likelihood of readmission, with five points indicating high risk and triggering much closer monitoring after discharge. Cognitive impairment, prior repeat hospitalization, and a repeated emergency department visit within the past three months score three points each, while having an end-stage condition scores a five.
Then, a multidisciplinary effort kicks in involving hospitalists, primary care physicians, the pharmacy, physical and respiratory therapy, "or anyone else who is going to touch that patient." Everyone on the team shares information about that patient, including transportation needs.
Efforts involving skilled nursing care stress "warm handoffs" between the patient's discharge nurse and the facility's nurse, including medication reconciliation, teach-back, and other aspects of the patient's care to prevent the patient from coming back, including cases where the patient returns to the hospital after first being discharged and sent home by the skilled nursing facility.
The program is starting to work because, Keefe says, "I honestly feel that there's a sense that if the nursing facility is not on board, being a partner with us, they lose the opportunity for referral. It's an all-in situation."
At Mercy Health, Margie Namie, RN, MPH, CPHQ, divisional vice president of quality, says care transition teams target specific disease populations "where it makes financial and clinical sense to reduce readmissions," especially Medicaid and self-pay patients, who often have more barriers after discharge.
"These patients are such a cost burden to the system that it really makes financial and clinical sense to provide support for them because it drives cost out of the system that flows to the bottom line." Mercy Health started with pneumonia, heart failure, and heart attack early last year because it was a Catholic Health Partners system objective. Then in October, Mercy Health focused on all-cause diagnoses, tailoring interventions to particular types of patients.