Using an early warning system, the 188-bed acute care facility reduced its unplanned ICU admissions by 20.4 percent in two years — potentially saving thousands of dollars in transfer-related costs.
Care teams at Shawnee Mission Medical Center (SMMC) reduced emergency department (ED) visits by 46 percent and penalties associated with Medicare readmissions with the help of Cerner Acute Case Management.
As CMS adds diagnoses and increases readmission penalties, health systems are responding by developing new ways of identifying and keeping costly, repeat patients out of the hospital.
Part 2: Transition coaching
Shawnee Mission Medical Center did not receive a penalty for congestive heart failure readmissions in 2014. It credits that, in part, to its transition coach program.
Using Cerner Acute Case Management, transition coaches track and document education and follow up on target patients. The staffing is a social worker, Melanie Davis-Hale, LMSW and a nurse, Peggy Pace, RN. The two disciplines complement one another, with Davis-Hale often dealing with the psychosocial issues and Pace with the medical issues.
“The documentation in Acute Case Management allows me to document follow up,” said Pace. “So, if that patient comes back in, we can go in and see what happened with the patient.”
“We started in 2011 and reduced our heart failure (HF) penalty by half in the second year,” said Kim King, administrative director of care coordination. There have also been considerable reductions in pneumonia (PNA) and acute myocardial infarction (AMI) readmissions. “In 2014, we had zero penalties for HF,” she added.
Overall, SMMC has reduced HF readmissions by 10.4 percent, PNA readmissions by 5.2 percent and AMI by 8.9 percent. At end of 2014, all readmissions sat 6 to 10 percent below the national average.
When SMMC first began developing the model, the staff learned most of their readmissions came from skilled nursing facilities (SNFs).
To mitigate this, Pace uses Acute Case Management and works with nurses at the SNFs to ensure they understand what to look for in each patient.
“It’s a matter of educating staff to know when to alert the doctors for each patient,” said Pace.
Pace will also track home visits or phone calls with patients to help them understand how to care for themselves, and refer them to their primary care physician whenever necessary.
“Many patients learn so much better when they are at home,” said Pace. “They are more receptive in a familiar setting, even if you’re educating them over the phone.”
“We also plan to use transition coaches for the recently added knee and hip replacements,” said King.
Read Part 1: Reducing ED department visits by 46 percent.