SGCMH Reduces Readmissions through innovative program


Ste. Genevieve County Memorial Hospital now has a successful program in place to reduce potentially-preventable patient readmissions. Brandie Filer, MSW, LCSW, was asked by the Missouri Hospital Association (MHA) to share the hospital’s success story at the American Hospital Association’s annual conference this past July in San Diego.
But before we get into specifics, let’s take a look at just one patient’s scenario, one of hundreds that the hospital encounters on a regular basis.
Mr. Doe, as we’ll call our patient to protect his identity, was admitted to the hospital for an infection that had gone awry. The antibiotics he was taking at home weren’t doing the trick, but while in the hospital a successful care and medication plan was getting him on the road to recovery. The medications needed to be continued after his discharge to ensure the infection would be completely gone. However, Mr. Doe didn’t have enough money for his prescription until his social security check came in two weeks. Had Mr. Doe been discharged without anyone knowing this little detail, chances are without medication, he would have been readmitted to the hospital.
Luckily, SGCMH has had a pilot program in place to reduce readmits for a couple of years, and Brandie, as part of the program, asked Mr. Doe specifically about getting his prescription filled. She was able to coordinate with a family member to cover his co-pay and take him to the pharmacy. Readmission averted.
The Med Surg multi-disciplinary huddle team consists of the physician, pharmacist, PT, OT, speech therapy, respiratory therapy, dietary, nursing, social work, home health, and case management who consistently communicate to know the goals and concerns for every patient, every day.
“We have daily meetings or huddles as we call them to get everyone up to speed on the patients,” Filer said. “We work toward getting them well and out of the hospital. We want to know what obstacles there might be, and what we need to be aware of from the patient’s standpoint, the family standpoint, and a medical standpoint. We want to make sure when we discharge them that we’re setting them up for success.”

Filer explained that two major components of their program focuses on patient education and medication reconciliation.

“We need to know exactly what medication the patient was taking at home, and what needs to be different, so we spend the time to educate the patient at discharge,” she said. “We want to make sure the message from the hospital is the same as what the patient hears from his or her primary physician, the same from the cardiologist or other specialist—all across the board, from every level of care.”

Another major facet of the program is to identify those patients who are at high risk for readmission. The hospital’s Information Systems Department built in the electronic records system a point system that based on the patient’s history identifies them as high risk.

“That information populates to our status board, and that means all hands on deck for that particular patient,” Filer explained. “We need pharmacy in that room educating; we need the family involved and which particular family member to communicate with to motivate mom or dad to eat correctly. There are so many details that may be overlooked when giving day-to-day care, and this project has made us more aware of the details that make or break the success of a patient.”

Last October, the MHA gave SGCMH a tool kit of sorts that provided a number of resources and best practices to help with the program so the wheel would not have to be reinvented. The proof is in the pudding—readmissions at SGCMH are now below the state average.

“We were able to use their resources and build upon what we had already put in place to make positive outcomes and create change for the betterment of the patient,” Filer said. “This initiative to reduce readmits is being put into practice all across the country.”

Which made it all that much more gratifying when SGCMH was chosen by MHA to showcase their program at the AHA conference.

“It takes a whole team to accomplish this,” she said. “We’re very proud of our progress, and we’ll continue to evolve the process. Hospitals of all sizes from all over the country were there and they wanted to know what Ste. Gen hospital was doing. They had heard we were innovative and successful. It was very validating. We really are doing some awesome things here.”

In addition to the readmission committee that works daily on their multifaceted program, Filer credits the hospital’s leadership and medical staff.

“We definitely have an upper hand with the support from our administration and physicians,” she said. “There were people who work at 300+ bed hospitals who told me that the red tape they have to go through to create any change is almost beyond what they can do. And here in a year, we’ve incorporated so many changes because we have the support of our leadership. So it starts from the top. How lucky are we that we work in an organization that doesn’t want to put barriers in place to prevent things from happening.”

Filer will likely give her presentation again at the MHA convention in November at Lake of the Ozarks.

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