"We cannot tell patients who they should choose to provide home health care or which doctors to use, but we can certainly identify those we think are the best partners, those who want to help us reduce readmissions and create safe transitions for our patients," White says.
"You absolutely cannot restrict care, but you can identify who you think are the preferred providers." DMC gives patients and their families a list, emphasizing they have the right to choose whoever they want. That strategy is so successful that DMC is looking to use the same type of analysis to evaluate skilled nursing facilities and their physicians, especially regarding their readmission track record.
"We've developed quality metrics to look at a physician's readmission rate, asking questions like, 'Did they reconcile medications during the patient's office visit?' and 'Are they managing ambulatory-sensitive conditions appropriately?' "
Lack of transition science
Among the other items on the DMC list are checks to make sure patients have prevention care, such as pneumococcal vaccination. And the hospital system has produced educational videos for a variety of conditions, such as congestive heart failure.
There's an effort to not just have the patient "teach back" what they've been told, which means merely repeating words, but to actually demonstrate what they have been instructed to do so the coaches can witness that the patient understands. "Show me what you're going to do if you become short of breath, or show me how you're going to take these medications in the afternoon versus at bedtime," White explains.
But unlike infection prevention bundles or surgical checklists, the science behind effective transition is poorly developed. No one thing on the list, if omitted, is certain to place the patient at higher risk of readmission, she says. "Transition care is in the early stage of quality measurement," White says. It's a wide-open area for further research.
Leora Horwitz, MD, a researcher, assistant professor of medicine, and expert on hospital-to-home transitions at 1,541-bed Yale-New Haven Hospital, says many providers liken the challenge of managing patients at home to that of "solving world hunger" because the issues are so diverse and complex.
That's why her hospital is taking aggressive steps to dissect the process in an effort to make it more efficient and accountable in terms of what doctors, nurses, and pharmacists are supposed to do to prepare for the patient's departure.
"Up until now, we've left each to their own devices," Horwitz says. "Doctors may or may not discuss the diagnosis or medication changes, the after-care plan, or the home care needs. The nurses may or may not do those separately. And hospitals may not have pharmacists involved in creating medication lists. Instead, everyone does that as time permits."