One in five older adults in our state is readmitted to the hospital within a month of discharge and it takes an emotional and financial toll on the patients, families, communities, and healthcare providers. But in Atlantic and Cape May Counties communities are taking action to better patient care by improving how patients transition between healthcare settings with the ultimate goal of preventing avoidable hospital readmissions.
Healthcare providers in the region have teamed with Healthcare Quality Strategies, Inc. (HQSI), the non-profit, federally-designated quality improvement organization for the state of New Jersey, to form the Atlantic-Cape Community Coalition. The Coalition held its kickoff meeting on Tuesday, December 6, 2011, at the Atlantic Cape Community College in Mays Landing, bringing together representatives from area healthcare providers to identify improvement areas, share best practices, brainstorm about ways to make patient care better, and reduce avoidable hospital readmissions. More than 22 organizations participated representing regional medical centers, nursing homes, home health agencies, rehabilitation facilities, the local Office on Aging, HQSI, and the New Jersey Department of Health and Senior Services.
The team at AtlantiCare Healthcare at Home, based in Egg Harbor Township, has already begun implementing a care transitions intervention to improve patient care and prevent avoidable hospital readmissions. The intervention employs a nurse-coach to help patients understand and follow through with healthcare instructions. Caitlin Lehrfeld, an Advanced Practice Nurse, facilitates communication among patients, caregivers, primary treating doctors, and other treating healthcare providers to organize appointments, transportation, medication, and more.
Instrumental to the process is use of a Personal Health Record, a booklet that patients can use to collect all of their vital health information in a single place. “It’s supposed to be with them for doctor’s appointments, hospitalizations, really at all times,” says Lehrfeld. “My number is on the front if they have any questions, and I point them in the right direction.” Although Lehrfeld is a constant resource for support, the goal is to empower patients to take charge of their own health. “The patients are going to have these health problems forever, so what we’re trying to do is teach them in a short period of time how to do it on their own,” she says. “If I do it for them they won’t learn. If a crisis is happening then yes, I will call 911 but generally speaking, they’re supposed to do it for themselves.”
In Somers Point, Shore Medical Center is focusing on enhanced care and education for heart failure patients as a way to reduce avoidable readmissions. “A simple thing like weight is a key piece to a heart failure patient,” said Barbara Juzaitis, Administrative Director of Care Management. “But getting every nurse in your facility to focus on heart failure weights is a huge process, so we identified that going back to the simple basics was what we needed to do.” Teaching patients about the importance of monitoring their weight back at home is now emphasized. Juzaitis said, “We realized it’s not just what happens in the hospital. We have to go well beyond that point—we need to advocate across the continuum of care.”
The Coalition was formed with encouragement, resources, and facilitation from HQSI, as part of its role in implementing statewide healthcare quality improvement initiatives from the Centers for Medicare & Medicaid Services. “We are thrilled with the enthusiasm and participation we saw at the kickoff in Atlantic and Cape May counties,” said Janet Knoth, BS, RN, CHPN, HQSI Quality Improvement Specialist. “It takes a community to make a difference in improving patient care, care transitions, and avoidable readmissions; and these counties have shown great commitment to do just that. Area residents navigating the health system will see the ultimate benefits, and that, above all else, is our goal.”
East Brunswick-based HQSI partners with healthcare providers, organizations, communities, and consumers to make healthcare safer, more efficient, and more effective. Working under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, HQSI is the nonprofit federally designated quality improvement organization (QIO) for New Jersey. Its methods include assessing opportunities for improvement, sharing best practices, and designing strategies with measurable and sustainable results. The goal is for consumers to receive high-quality, patient-centered care with the best possible outcomes.
