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Kitsap County, WA providers find the timing is right to collaborate on care transitions

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This article was originally published in December 2012.

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One of the challenges to improving the safety of care transitions is that it requires a new mindset for healthcare providers. Instead of keeping their focus (and information-sharing) within the four walls of their facility, providers must be willing to work hand-in-hand with outside organizations—not just the facility that delivers a different stage of care, but direct competitors as well.

Looking back over her years in healthcare, Annette Crawford, LNHA, the Administrator at Stafford Healthcare at Ridgemont (a skilled nursing facility located in Port Orchard, WA) recalls “I was definitely part of the problem. I’m very competitive and didn’t want to talk about internal processes.”

Over time, however, Crawford became convinced that a single facility, acting alone, can’t effectively tackle larger issues such as rehospitalizations without stepping out of the professional silo and partnering with other organizations along the healthcare continuum. “With all the changes and challenges occurring within the healthcare environment, the time to collaborate is now,” she explained. “The most important message of healthcare reform is a focus on communication and connections—and that’s an area where most have done the least….If we can improve communication systems between providers and across the healthcare continuum, there is a huge opportunity to improve outcomes and patient satisfaction.”

Getting started

With encouragement and networking assistance from Qualis Health, Crawford began discussions with Lauren Newcomer, RN, BSN, Director of Quality and Operational Improvement at Harrison Medical Center, as well as other healthcare stakeholders across Kitsap County, WA, to explore how a countywide, care transitions-focused coalition might come together. Since Crawford was already connected to the neighboring Pierce County coalition, they were able to build on lessons learned there. Crawford and Newcomer knew the time was right for collaboration. The community of care providers was ready to begin.

They organized a large community meeting, which included representatives from Harrison Medical Center, skilled nursing facilities, home health organizations, primary care providers, and organizations such as the Area Agency on Aging, to kick off the project in earnest. “We had never had all those people in the same room before,” said Newcomer. “It was really rewarding to see everyone come together, and become more aware of each other and what we each need.”

At the meeting, participants learned about the current state of affairs through Qualis Health’s presentation on Kitsap-specific readmission trends. “It was great; we were all a part of those numbers,” Newcomer noted.

The attendees compiled an inventory of transition-related activities already underway across the county. Next, they began to envision and describe their ideal future state—and ended up organizing into three sub-groups to focus on what were identified as the most pressing priorities: medication management, patient and family education/activation; and information-sharing across the continuum. Soon, the group also had a name: the Kitsap County Cross Continuum Care Transitions Project (KC4TP).

Coordination across settings

“Simply getting everyone together, just that act alone, really got us all thinking together,” Newcomer observed. One of the first interventions KC4TP undertook was standardizing patient education related to heart failure. “It’s confusing for patients to get one message in the hospital and then hear something different, or even nothing at all, from another care provider,” Newcomer said. The hospital re-purposed a standard educational piece called “Heart Zones” which guides patients to monitor their condition and appropriately assess themselves as being in the green, yellow, or red zones, then provided related training to the local skilled nursing facilities and home health agencies.

“Now, the hospital staff introduce the patient to the Heart Zones Tool, then upon SNF admission, that patient is interviewed, ‘Do you have your Heart Zones Tool?’” Crawford described. “We work with the patients, so that by the time they are ready to go home, they can monitor their symptoms on their own.” Crawford noted that they can also work with the patient and his/her family to uncover any barriers—such as not having a scale or blood pressure cuff at home—and solving those problems before the patient leaves the skilled nursing facility.

Based on follow-up calls to patients’ homes asking if they could recall certain information from the tool, the project is working. “It’s our goal that every healthcare provider in the county will be asking their heart failure patients ‘Are you completing your Heart Zones Tool?’” Crawford said.

Evaluating care, creating standard measurement tools

Another way that the skilled nursing facilities gauge their work in the KC4TP is to modify their resident satisfaction surveys to collect some of the same data that is gathered through the national Hospital Consumer Assessment of Health Care Providers and Systems (HCAPHS) survey. “We added HCAPHS questions #19 and #20 to our own facility satisfaction surveys so that we can begin to see how prepared patients feel when they leave our care,” Crawford explained. “Collecting the same data as the hospital means that we can get a larger perspective on how satisfied our community’s patients are across the care continuum.”

What are Crawford’s feelings about this larger perspective, now that she is working far out of her silo? “It’s taken a long time to get everyone on board, but it has been very rewarding to be involved with these partnerships and connections. Providers are getting to know each other and can support each other more….We’re working together to improve the quality of care we provide throughout the county and between all levels of care.”


Learn more about Qualis Health's work through the Communities for Safer Transitions of Care project.