The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: MI hospitals (page 1 of 3)

How Michigan can be the best in CHF readmissions

Deby Evans

Deb Evans is the MVC Site Engagement Manager

Last November, the Michigan Value Collaborative (MVC) launched its goal to work together to be number one in the country for CHF readmissions. MVC hospitals have shared best practices and challenges with one another through workgroups, toolkits and blogs to collaboratively meet this goal.  In addition to learning from one another, there is information to be gained in how hospitals outside of Michigan are addressing readmissions.

A report from the Commonwealth Fund titled “Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals” identified quality improvement strategies implemented with measurable impacts on reducing readmissions. One of the hospitals studied is in Utah, which currently has the lowest CHF readmission rate in the nation according to CMS Hospital Compare.  According to the study, successful quality improvement strategies included incorporating evidence-based practice into daily protocols, standardizing procedures along with information gathering, providing feedback and supporting clinical decisions through electronic information systems.

Specific initiatives underway include:

Providing clinically excellent patient care with a focus on patient safety. Doing this leads to a fall in readmission rates, improvement in quality measures and savings are realized as a byproduct.

Using information technologies as tools that improve quality, integrate care and ease patient transitions.

Early involvement of case management and discharge planning.

Targeting high risk patients and ensuring frequent communication across the whole care team.

Teaching patients and families how to manage their conditions.

Maintaining a life-line with high risk patients after discharge.

Aligning the efforts of hospital and community providers to ease transitions across care settings.

The authors noted that hospital environments played a role in each facility’s ability to reduce admissions. Specifically, the success of the initiatives were influenced by policy environment, local health care markets, association with an integrated health system and the priorities set by hospital leaders.

Many of the programs implemented by the top performing hospitals are similar to initiatives discussed by the MVC CHF readmission workgroup. For more information on the workgroup or toolkit, please contact Deby ( ) or Abeer ( ).

Read the full article here



Michigan Innovators: Improving Patient Discharge at St. Mary Mercy Livonia

Maya Peters is a research associate with MVC.

Members of the Care Transitions team at St. Mary Mercy Livonia recently shared with MVC an innovative effort to improve the discharge process at their hospital, which resulted in increases in the HCAHP scores for both Patient Satisfaction and Transitions of Care. I had the privilege of speaking with Catherine Ponder, RN, BSN, and Sue Klotz, MS, BSN, RN-BC, both of whom were integral in the development and implementation of a concise, organized system to manage the personalized information each patient receives throughout their hospital stay.  

An unorganized discharge process leads not only to confusion, but can contribute to future readmissions due to medical discrepancies, unscheduled follow-up appointments and a lack of education on disease symptoms. Catherine and Sue’s team realized many patients struggle to keep all of the information received at the hospital straight after being discharged, and often feel overwhelmed once they’re back at home. 

To help address the disjointed nature of the acute to post-acute transition, the care transitions team, along with input from frontline RNs and the Patient Family Advisory Council, created a three pocket folder that each patient receives upon admission to the hospital. This folder follows each patient throughout their hospital stay and extends into the home. The contents of the folder include: name and number of the patient’s primary doctor and follow-up appointment; discharge information, including symptoms and the patient’s health problems; medications, prescriptions, and side-effects; education materials, advanced directives, goals of care; and finally, questions the patient has for their doctor. The folder is introduced to the patient upon admission.  A nurse helps patients to fill out the “Questions for my doctor” section, and other medical professionals visiting the patient may add relevant materials to the folder as needed.  The day following discharge, each patient receives a follow-up phone call.

Initially conceived in 2012, the folder has undergone a number of iterations and revisions. The Marketing team helped make the folder as usable as possible for seniors by increasing the font size, adding icons and using concise language.  According to Catherine and Sue, the key to making the discharge folder initiative and implementation successful was the involvement, assistance and engagement of the nurse practice council who were actively involved and provide ongoing feedback.

Since the roll-out of the new discharge process in summer 2015, Catherine and Sue have seen positive results in supporting patient engagement.  More importantly, one of the most rewarding aspects of the program is seeing patients’ confidence increase.  The folder allows patients to feel more capable of managing their health and discussing their needs with medical professionals.

Questions or comments? We’d love to hear from you!  You can comment on this article, or use the form at the bottom of the page.

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