Multiple barriers exist in providing effective communication and coordination during care transitions, including lack of standardized and accurate information transfer and community infrastructure for achieving common goals. Recognizing the limitations of the existing care delivery model, which supported little direct communication between providers, presented an opportunity for IPRO, the QIO for New York, to make improvements through a comprehensive community effort.
Beginning in January 2012, IPRO established a cross-setting community coalition involving a 651-bed tertiary medical center and 13 nursing homes. The coalition focused on improvement in care coordination for clinically complex patients who are at high risk for readmission. IPRO assists in facilitating monthly cross-setting coalition meetings to disseminate strategies, tools and best practices.
The acute care hospital and nursing homes took an active role in collaborating to address care coordination, information exchange, patient education and medication reconciliation on a cross-setting level through monthly meetings and case review. They also investigated their own internal systems and processes in these areas to target opportunities for improvement and to implement strategies and interventions to improve care coordination.
Interventions implemented to date:
- Community root cause analysis through case reviews to identify readmission drivers and opportunity for process improvement
- Cross-setting medication discrepancy identification and review
- Implementation of verbal report upon transfer to nursing home
- Hospital provided access to its electronic medical record system for nursing homes to track their patients
- Identification of single-source of truth document for transfer of discharge medication information
- Implementation of standardized transfer information through use of INTERACT transfer form
- Education of emergency department physicians on capabilities of nursing home to manage complex medical conditions as alternative to hospitalization
Provider-generated data indicates that the nursing home 30-day readmission rate for this community has had an average decrease of 7% between April 2012 and February 2013 with actual decreases ranging from 3.3% to 14.2%.