Sarasota Memorial Healthcare System's focus on care transitions for its elderly and heart failure patient population has continually resulted in good readmission scores. Other hospital leaders could do the same, but the process has taken years and attention to detail.
In some ways, the Sarasota (FL) Memorial Healthcare System is already at the point where many of America's hospitals want to be. It has distinguished itself by caring for a significant elderly population for years, serving patients in a county that has the fourth-oldest residents in the country.
As more hospitals struggle to lower readmissions, Sarasota Memorial has been there, done that, despite caring for a challenging group of patients. Its 804-bed safety-net health care system's inpatient population is 50% Medicare, and it provides about 85% of local Medicaid hospital services. Yet the hospital achieved a 30-day readmission rate for heart attacks of 16.9% last year, compared a national rate of 20%, according to CMS data.
Getting there involved a "long and winding road" to improving quality, safety, and outcomes, says Fred D. Jung, RN, PhD, CPHQ, executive director of quality and patient safety.
One of the most significant and successful aspects of care for Sarasota Memorial has been its heart failure clinic. "If you look at it, we're comprehensively doing everything that everyone identifies as being significant [to improve care]," Jung says. Sarasota has been tracking its outcomes, costs, and efficiencies for years. "It wasn't 'wow, value-based purchasing is coming and there are going to be penalties for readmission rates.' We did this before people really thought about readmission rates," he says. Heart failure care has been a centerpiece and a focus for over a decade.
Sarasota Memorial got a head start years ago by putting structures in place to improve patient care transitions, Jung says. He characterizes his hospital's traditionally lower readmission rates as the result of a "combined, synergistic effect" from the success of multiple strategies built into the system over time.
"It's a given throughout healthcare—and physicians know this particularly well—that putting patients first is the way to go," Jung says. But how exactly is that done? Jung highlights managing care transitions after patient discharge, focusing on readmissions, and yes, keeping an eye out for regulations and penalties.
As Sarasota Memorial embarked on its path to better quality, establishing a strong electronic medical records system was a major area of need at the outset. Making this commitment allowed hospital workers to reach out to aging patients who were sometimes alone and uncertain about what prescription they should take next.
A heart failure nurse meets with patient and caregiver for intensive bedside counseling. Patient educational programs include an RN case manager, social worker, dietitian, pharmacist, and heart failure program coordinator. Patients also receive an informational letter each week for four weeks to reinforce their discharge education.
"You want to make sure medication reconciliation is done effectively," Jung says. "We have pharmacists do that in the community; we have bedside medication delivery." Sarasota Memorial maintains a partnership with Walgreens that enables the pharmacy to provide bedside pharmaceutical deliveries, and then follows up with patients in their homes. Under the arrangement, Walgreens manages a WellTransitions program with the hospital to provide pharmacy care for heart failure and other contracted health plan patients, both before and after discharge. There is no cost to the patient but the hospital pays a fee to Walgreens for the heart failure patients.
The arrangement with Walgreens was motivated by the need for care for patients after they leave the hospital. "If you don't have an onsite retail pharmacy, it makes it a lot harder for patients to get their medications," Jung says. Sarasota Memorial physicians must ensure they are complying with the medication reconciliation programs "or they can't discharge a patient."
Coordinating care for elderly patients is especially important, and that's why Sarasota is forging relationships with nursing homes, too. "That's where one-third of our readmissions come from," Jung says. Over the last two years, Sarasota has improved its bonds with local nursing homes. There are some aspects of patient care, such as improving diet, that can only be successful if different health facilities agree on the plan to achieve it. With some nursing homes, "we've talked openly about the fact they've got salt and pepper shakers on the table. A few of the nursing homes follow through and give their patients salt-restricted diets," he says.
Those conversations with nursing homes, as Jung sees it, are "baby steps toward clinical integration."
Case management of patients after they leave the hospital is also becoming more important, he adds. The hospital has begun a pilot "transition case manager program" to help monitor patients, which includes home visits. Many of Sarasota Memorial's patients are discharged to an empty home, or to one with an elderly care giver. "They've got baking soda, fried food, and soup with a lot of sodium. And in the refrigerator there's a six-pack or two of beer. If you are going to knock down the readmissions, somebody needs to do a home visit and see what's going on at the home," Jung says.
To implement these programs, Jung says coordination with primary care physicians is paramount, but has yet to be fully realized. It's an ongoing process, the focus of constant discussions. "We need to talk with them and coordinate with them—that this patient is going to be discharged," he says.
While Sarasota Memorial has case managers on staff, Jung says that leaders realize the importance of case managers also working out of the primary care physician offices. Still, there are kinks to work out, particularly related to fiscal incentives for physician groups. Case managers "probably need to be in primary care offices, but we need the incentive between the two, to work together to make it worthwhile," Jung says. That means diving a bit "into the weeds," as they discuss revenue codes and fiscal returns, he notes.
Once a patient is discharged from the hospital, "we need to talk with [the physicians] and coordinate with them," Jung says. "That promotes the clinical integration piece that payers are going to look for as well. Everyone needs to be around the table and discuss information about people who are discharged."
Keeping an eye on quality measures is a constant. "Our readmissions rate is pretty stable and we're focusing on it," Jung says. "We remain competitive, and we are starting to push this transition case manager program."
The general feeling at Sarasota is, "let's do this—we're good at it, and let's see if we can remain good at this."
(To learn more, tune into a HealthLeaders Media webcast, "Patient-Centered Care Transitions for Better Quality, Costs and Readmission," on Wednesday, May 29, 2013, with speakers Fred D. Jung, RN, PhD, CPHQ, executive director of quality and patient safety for the Sarasota Memorial Health Care System and Kathleen M. Martin, RN, BSN, CCM, CPC-H, VP of Patient Safety and Care Improvement for Griffin Hospital, in Derby, CT.)
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
