Knowledge is infectious and that’s a good thing for a diverse group of healthcare innovators in Nashville, Tenn., known as the Transitioning Patients Across the Care Continuum (TPACC) community.
The group meets monthly to share knowledge, host speakers and discuss how they can impact and improve healthcare in the Middle Tennessee area. It was in one of those meetings where Teresa Shelton heard a presentation from the COPD Foundation about the harmonica classes they offer for patients to practice breathing techniques. She knew that what she had learned would make a real impact in her hospital and she was eager to spread the information.
“I had no idea these resources were available for my patients,” said Shelton, a founding member of TPACC and Director of Case Management at Tennova Healthcare Lebanon. “I was able to share this new knowledge with my hospital staff so our patients could benefit and participate in the program,” Shelton added.
Catching the Fever
TPACC began in April 2012 with just five members. Quality Improvement Advisors from Qsource, a part of atom Alliance, ignited the group and facilitated the creation of the Care Coordination Community. Now, the community has more than 150 members from 50 different organizations, representing a wide variety of healthcare providers like doctors, nurses, pharmacists, hospital administrators, home health caregivers, nursing home caregivers, paramedics and patient advocates. State and local healthcare associations also support the community by participating and sharing resources.
“Healthcare is ever changing. Our community brings all kinds of ideas – fresh ideas – to the group that are tried and true,” said Shelton. “TPACC comes together for the sole benefit of the patient and bettering patient care,” she explained.
TPACC members conducted root cause analysis studies to define the reasons patients were being readmitted to the hospital less than 30 days after being discharged. From discharge nurses to case workers, TPACC capitalized on the diversity of their membership, encouraging open discussions about all aspects of a patient’s transition from the hospital.
“We took off our badges and everyone focused on what was best for the patients,” said Shelton.
TPACC members identified barriers that patients face on a daily basis. For example, many patients did not have a primary care doctor and if they did, transportation to follow up appointments was not always available. They also determined many patients could not pay for their prescriptions, causing many to return to the emergency room or back into the hospital sicker than before. They discovered that misunderstandings and lack of education caused the most readmissions, because patients and family members simply did not understand instructions during the discharge process.
To address the causes they identified for hospital readmissions, TPACC members divided into workgroups – discharge planning, medication safety, hospice care and transportation. Each workgroup was charged with finding solutions to the problems they outlined. For example, the transportation workgroup applied for and won a grant to help give patients rides to follow up appointments and prescription pick ups.
“It’s a lot easier when we’re hand-in-hand than when we are trying to work within our silos and solve problems by ourselves,” said Greta Mullinax, founding member of TPACC and Director of Social Services for NHC Place at the Trace.
“We know what each one of us does, but we don’t know what other people do. It’s much easier to work with someone when we know what they’re doing,” Mullinax said.
atom Alliance has fostered Care Coordination Communities just like TPACC across the five-state region – Alabama, Indiana, Kentucky, Mississippi and Tennessee. All of them share the same goal – to keep patients out of the hospital and prevent them from readmitting once they are discharged.
In Kentucky, the Bluegrass Community Healthcare Coalition partnered with a local hospital and the Bluegrass Area Development District to provide coaches who are assigned to high-risk patients transitioning from the hospital. The coaches assist the patients for 30 days, ensuring they get everything they need to stay out of the hospital and healthy. So far, the program has assisted 586 patients with only fifty returning to the hospital within 30 days.
“The grassroots efforts from the Community have assisted individuals to remain in their homes, helped family members and caregivers to more fully understand the needs their loved ones have and provided alternative solutions to care outside of hospitalization,” said Cynthia Todd, Quality Improvement Advisor for atom Alliance in Kentucky.
In Indiana, a hospital conducted a pilot project aimed to improve readmission rates for patients with COPD. They developed an action plan for patients that included a medication review and breathing techniques, among other educational tools. Within six months, they managed to improve their 30-day readmission rate by 42 percent.
“The Wabash Valley Care Coalition helped share the hospital’s successes, best practices and tools from the pilot project with healthcare providers and stakeholders,” said Ann Hayworth, Quality Improvement Advisor for atom Alliance in Indiana. “This spread the knowledge throughout Indiana and into the other atom Alliance states,” she added.
In Alabama, the new Tuscaloosa Area Care Coordination Coalition has brought two dozen healthcare organizations together to begin working on reducing readmission rates in the western part of the state. They met for the first time in July.
“We are excited to get this community going and start addressing some of the issues that cause hospital readmissions, like health literacy and access to primary care,” said Cynthia McIntosh, a Quality Improvement Advisor for atom Alliance in Alabama.
In Mississippi, a small rural hospital launched Project RED (Re-Engineered Discharge) as a part of the Three Rivers Health Care Coalition’s efforts to improve hospital discharge transitions. They assembled a team of providers and conducted a retrospective chart review. The team implemented several interventions, such as hourly rounding, bedside reporting and post discharge phone calls. The hospital decreased its Medicare readmission reduction penalty by half from 2013 to 2014.
Sharing is Caring
“Care Coordination Communities bring together a variety of stakeholders, keep them focused on the ultimate goal of reducing hospital readmissions and allow them to learn from each other,” said Betty Deblasio, Quality Improvement Advisor for atom Alliance in Tennessee.
atom Alliance is dedicated to spreading knowledge across the region to prevent patients from going back into the hospital and improving the care they receive during their transition.
“It’s one patient at a time, and if we can keep one patient from going back to the hospital, that’s a success,” said Mullinax.
For more information on Care Coordination Communities and the work that atom Alliance does, visit our website www.atomalliance.org.