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Meeting the challenge of care coordination, preventing readmissions at University of Washington Medical Center

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This article was originally published in June 2013.

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While care coordination can be challenging for any organization, the University of Washington Medical Center (UWMC), located in Seattle, confronts two particularly difficult issues. First, as a large teaching hospital, its staff includes many rotating attending physicians and residents. Second, its patients are high acuity and referred from five states. UWMC recently created two positions to facilitate care coordination, enhance patient education and activation, and decrease hospital readmissions. Initial results are promising.

Medicine Services team assistant handles non-clinical coordination

Carol Charles, UWMC’s project manager for their initiative to reduce readmissions, reported “One gap became obvious—our communication with primary care physicians was not as good as it could be.” They created a new team assistant role for Medicine Services, to work in concert with the nurse care coordinator and to relieve the residents of some non-clinical tasks. The team assistant:

  • Participates in a daily huddle with the nurse care coordinator and medical team.
  • Sends information about each patient’s admission, and instructions for reaching the resident caring for the patient, to the patient’s primary care provider (who is often outside the UW system and therefore unable to access the records electronically).
  • Requests records from outside providers, as necessary.
  • When the patient is nearing discharge, communicates with physicians to learn what follow-up appointments are needed and the best timing for those visits. For example, in complex cases, a patient may need four appointments, in a particular sequence, with different specialists. The team assistant checks with the patient and family to make transportation plans, then tries to line everything up in a way that will best suit the family’s needs.
  • Within 48 hours after discharge, faxes the discharge summary to the patient’s other providers.
    • “That has been hugely well received,” Charles reported. “Now the information is in their hands before the patient arrives for the follow-up visit.” She further described that a report showing the percentage of discharge summaries completed on time is emailed to staff each week. “Without any other action, compliance rates have increased dramatically,” she noted.
  • Piloted distribution of an internal report to physicians who have rotated off, showing which of their patients have been readmitted and the diagnosis. Based on the positive response from physicians, the report has been automated.
    • “That prompts the physician to call the current provider to clarify the situation, see if he or she missed anything, and begin thinking about what could have been done differently,” Charles said.

While UWMC’s readmissions rate has only decreased slightly since the creation of the team assistant role, significant improvements are evident in terms of care coordination. Previously, a little more than half of patients left with a follow-up appointment printed on their discharge summary, and roughly 60% of discharge summaries were provided timely to primary care providers; both of those rates are now nearing 100%.

Plus, Charles noted, “The nurse care coordinator doesn’t have to prompt residents to do this or that non-clinical task; the team assistant is focused on getting all those things done.”

Heart failure transition RN conducts follow-up educational calls

Based on research into best practices, evidence that heart failure patients nationwide are at high risk for readmissions, and the particularly high acuity of heart failure patients treated at UWMC, the organization created the heart failure transition nursing position about six months ago.

“We saw a gap in getting heart failure-related education to new patients, and repeat patients needed an extra layer of review,” Charles said. The RN teaches patients self-management skills and how to recognize the “red flags” that need attention.

Education is provided at bedside, then the RN asks for the patient’s permission to follow up at home. Her first follow-up call is completed within three days after discharge, and she continues checking on the patient for 30 days. She discusses the patient’s medications and probes for the patient’s understanding of his or her diagnosis and the red flags.

“She uses the teach back method and we’re finding that patients are able to correctly relay the information about 60 or 70% of the time after the first call, and that percentage goes way up after the second call,” Charles described.

In addition to helping the patient identify and respond to symptoms early, and providing other assistance tailored specifically to the patient, the RN is also looking for trends. “We want to know what we can do in-house, in advance of the discharge, to prevent a readmission. What specific things might we do that are the most beneficial?” Charles explained.

She continued: “We know that month-to-month rates don’t always go in the direction we want….But we keep looking at the big picture and realize that it will require a lot of interventions working together to address something as complex as readmissions.” Through its Communities for Safer Transitions of Care project, Qualis Health is assisting UWMC with that big picture, at the hospital itself and with its network of skilled nursing facilities.