This Tiny CAH Says 'No Excuses'

The belief that every patient deserves excellent care, regardless of setting, drove a small Illinois hospital to develop the same rigorous approach to care "that any hospital would undertake to avoid [CMS] penalties," says its CEO.

Given their isolation, dearth of resources, and the challenging demographic they care for, critical access hospitals could be excused if the services they provide aren't up to the standards of resource-rich larger hospitals in more urban settings.

The staff and management at HSHS St. Joseph's Hospital in Highland, IL, beg to differ.

Peggy A. Sebastian, president and CEO of the 25-bed critical access hospital located in this town of about 9,500 souls, 30 miles east of St. Louis, says she and her staff of nearly 300 believe that every patient deserves excellent care, regardless of the setting. Being small and isolated, she says is "no excuse."

"We're a critical access hospital, but we want to behave as if we were a PPS (Prospective Payment System)  hospital. We want to behave like we're a pay-for-performance hospital," Sebastian says. "We developed three years ago the same rigors that any hospital would undertake to avoid penalties or to be in the bonus earn-back [pool] with Medicare."

HSHS St. Joseph's Hospital is part of the Hospital Sisters Health System, which operates 14 hospitals in Wisconsin and Illinois. The Highland market's patient mix is about 65% Medicare; Medicaid and self-pay account for less than 10%. The hospital has had an average daily census of about 20 patients for the past six months, Sebastian says.

The quest to reduce readmissions started even before the hospital opened its $63 million, 125,000-square-foot hospital and medical office complex in August, 2013. "We wanted to be well on our journey to quality and what we call 'perfect patient care' before we moved into the new facilities," Sebastian says. "The new bricks and mortar were nice, but we were focused on the quality outcomes that patients expected."

"In order to get there we knew we needed a culture that looked at patient-centered care and that perfect patient care was a right of all patients," Sebastian says. "That required some new learning."

Focusing on CMS guidelines on compliance with core measures was a key component of the quality initiative. Sebastian says the hospital just recorded its 29th month of perfect core measure compliance.

Perhaps the most important component in the drive to reduce readmissions and improve outcomes was the strengthening of a 14-member multidisciplinary team that held "daily huddles" to assess each patient's status and discharge plan.

"We expanded their depth and breadth to review all patients for the risk of readmissions," Sebastian says. "The group is quite large. They meet every morning at 8:30 using nursing, physical rehab, pharmacy, cardio-pulmonary, quality, and case management. Over the past year we've added home health, infection prevention, pastoral care, wound center, senior renewal, which is outpatient geriatric psych, and cardiac rehab, along with the hospitalist."

In the past few years, Sebastian says St. Joseph's has taken a more comprehensive and thorough look at the discharge settings for patients. "We look at their living situation currently. What is their support system, meaning family and friends, and what is their access to nutrition? What is their access to travel or transportation to appointments and pharmacy? Can they afford their medications? Those kinds of pieces."

The rigorous discharge review also improved coordination and collaboration with area long-term care and assisted living facilities. "We developed a community collaborative and this group meets six times a year and reviews best practices, their own dashboard or scorecard of performance, and we provide them with feedback on their particular readmission rates and their admissions," Sebastian says.

Accolades
The improvements have not gone unnoticed. HSHS St. Joseph's Hospital was just named an Illinois Hospital Association 2015 winner of the Outstanding Quality Excellence Achievement Award. IHA cited the hospital's patient-centered approached to reducing readmissions and noted that "by improving their care coordination and expanding their multi-disciplinary team approach to discharge planning, St. Joseph's Hospital has successfully reduced their readmission rates by 20% in the past two years."

Sebastian's back-of-the-envelope return on investment estimates show that the multidisciplinary team costs about $46,000 a year, when the compensation for each member of the team is clocked. If St. Joseph's were operating under the pay-for-performance model, she estimates that their earn-back and bonuses each year would be just shy of $100,000.

Of course, there is no bonus because St. Joseph's is a critical access hospital. So, why bother with the expense if you're not going to collect the bonus?

Powered by Culture
"Because we believe that every patient deserves perfect patient care. That is our commitment," Sebastian says. "When you surround yourself with inspired people excellence is achievable. I surrounded myself with management and colleagues who aspire to perfect patient care, who believe in the Catholic mission of the Hospital Sisters, and we pursue excellence. Because we are all aligned under that same culture it is not three or four people moving the needle, it is 300 people moving the needle."

See Also:
Hospital Cuts Readmissions in Half with Help from College Students
CMS Predictive Readmission Models 'Not Very Good'
Readmission Responsibility Extends Beyond Hospitals
Readmissions: No Quick Fix to Costly Hospital Challenge