Text Size

A rural healthcare organization takes a patient-centered approach to care transitions

Archived content

This article was originally published in May 2012.

Read about the other 2012 award winners, or contact us for more information.


Qualis Health presented Clearwater Valley Hospital and Clinics (CVHC)—an integrated healthcare organization comprised of a 23-bed Critical Access Hospital in Orofino, Idaho, and three associated rural health clinics located in Clearwater and Idaho Counties—with its Award of Excellence in Healthcare Quality. Like the four other winners of this year’s award, CVHC demonstrated leadership and innovation in improving healthcare practices.

One of the nation’s most pressing healthcare challenges is improving the safety of care transitions and reducing the rate of avoidable hospital readmissions. CVHC approached this issue from several angles and instituted a host of innovations, which are illustrated in Figure 1 and outlined below.

Figure 1: Anatomy of a Safer Care Transition at CVHC
(enlarge the graphic)

Figure 1: Anatomy of a Safer Care Transition at CVHC


One patient’s experience

A CVHC patient had several readmissions related to intermittent atrial fibrillation.

Despite what everyone felt was optimal teaching at the time of discharge, it was only through the Visiting Nurse Service (VNS) assessment in the home that it was discovered the patient was not taking her medications properly.

The VNS uses the same electronic health record (EHR) as the patient’s medical home team so was able to communicate this information to them directly.

CVHC’s chief medical officer, Kelly McGrath, MD MS, notes that this example—and several more similar occurrences—show the “tremendous value of assessing the patient in their own environment, to identify and eliminate the barriers to the patient’s success.”

He further describes that “shared EHR records have fostered the team-based care that has helped make this project a success.”

During the hospital stay

  • Within 24 hours of admission, the inpatient RN must complete a standardized readmission risk assessment, which refers high-risk patients to the Visiting Nurse Service (VNS) at discharge.
  • Medication reconciliation must be completed by the emergency department or inpatient RN within 24 hours of admission.
    • Previously, this task was the responsibility of the discharge planner, but the rate of completion was only about 61% since this position did not provide coverage every day. The new process has resulted in an 87% completion rate.
  • If the patient’s primary care is delivered by the clinic which is co-located with the hospital, the MA or RN on the patient’s medical home team visits the patient in the hospital, which improves awareness of conditions and issues for a post-discharge follow-up appointment, and also allows for scheduling of the follow-up appointment itself.

At discharge

  • Physicians are now using a standardized “best practice” format for their discharge orders; to improve communication with other providers within the CVHC system, discharge summaries must be transcribed within 24 hours, and most are done within 12.
  • RNs are using the teach back technique to ensure that patients understand their discharge orders.


  • For high-risk patients, the VNS visits the home within 72 hours of discharge, with most completed within 48 hours.
    • The visit not only dramatically impacted readmission rates, but this patient-centered intervention also improved the experience of care since the visit takes place in the comfort of home. Given CVHC’s rural setting, many in the high-risk population would not have had access to other care providers. At baseline only half of high-risk patients received VNS services; now that rate has climbed to more than 90%.
  • Follow-up phone calls are completed by the inpatient RN within 48 hours of discharge.
  • Follow-up visits with the patient’s medical home team are completed within seven days of discharge.

How did CVHC manage to undertake such a comprehensive approach? CVHC’s chief medical officer, Kelly McGrath, MD MS, explains

“We initially viewed this project as a “task” that we would complete and then move on to the next task. It became clear early on that the work of optimizing care transitions around the hospital discharge is a process that, even in high performing systems, is really never complete.

While this may seem discouraging, it should not be since it drives improvement in so many critical areas. This kind of work improves patient safety, care quality, population health, healthcare cost reduction, patient satisfaction and so many other areas that it is hard to list them all.”