On December 9, the GNYHA/United Hospital Fund IMPACT (IMproving Processes And Care Transitions) to Reduce Readmissions Collaborative’s participating hospitals, nursing homes, and home health care organizations celebrated two years of collaboration during a Year in Review session. GNYHA, with the support of its long term care affiliate, the Continuing Care Leadership Coalition, has supported the participants in making significant strides toward building and strengthening relationships, developing standardized processes for communication and information transfer between care settings, and incorporating the patient and caregivers in the care transition process.
The session featured presentations from Collaborative teams who shared their successes, challenges, lessons learned, and plans for sustainability in improving care transitions. Susan Goldberg, RN, BSN, MPA, Vice President, Organizational Performance at Maimonides Medical Center, discussed Maimonides’ Transfer Center, which is staffed around the clock by nurses who field and triage calls from nursing homes when patients are transferred back to the Emergency Department. Maimonides implemented the Transfer Center with four facilities and has seen tremendous progress with two: one nursing home uses the Transfer Center for more than 90% of discharges, and another for more than 70%.
Fran Silverman, ACSW, LCSW-R, Director of Social Work at Mount Sinai Beth Israel, discussed efforts to improve communication via a “warm” handoff process between the hospital and referring nursing homes. The Mount Sinai Beth Israel team has focused on hardwiring the actual “warm” handoff communication process and plans to standardize the communication’s content going forward. Ms. Silverman emphasized that focusing on “one thing at a time,” along with having their Chief Medical Officer engaged in meeting with nursing home leadership, was critical to success.
The NYU Langone and Visiting Nurse Service of New York team gave an update on implementing “teach back,” a method used to educate patients and caregivers to ensure that essential information is conveyed prior to discharge. The team also provided an update on their efforts to align care transition planning with the requirements of the recently enacted New York State Caregiver Advise, Record, and Enable (CARE) Act.
Amanda Ascher, MD, Chief Medical Officer at Bronx Partners for Healthy Communities, a Delivery System Reform Incentive Payment (DSRIP) program Performing Provider System, discussed how IMPACT’s providers can strategize and leverage the benefits of their care transition activities to more broadly affect improvement. Dr. Ascher commended participants’ efforts and noted how the work going on among collaborating providers is essential to DSRIP’s success. Dr. Ascher also commented on the importance of leveraging technology to optimize care coordination, as well as collecting and analyzing measures to determine if rapid-cycle process improvement can help motivate and sustain these efforts.
The first two years of the Collaborative focused on creating a strong foundation for communicating across facilities. In this third year, the focus will shift towards working on problem areas and effectively hardwiring changes to administrative and clinical processes. Programming will be offered on conducting effective case reviews, operationalizing the CARE Act, collecting appropriate process measures, and enhancing communication at care transitions with “warm” handoffs and medication reconciliation.