Lexington Regional Health Center, Lexington, Nebraska
Lexington Regional Health Center (LRHC), located in Lexington, Nebraska, was one of only four critical access hospitals (CAH) that received national recognition for demonstrating innovative care coordination initiatives to improve population health.
LRHC is committed to keeping pace with health care transformation, which is key to sustaining access to health services for the community. This commitment is evident through their population health program and care coordination work with patients having chronic conditions. In 2012, through the Nebraska Hospital Association, LRHC began work with the Hospital Engagement Network to identify causes for 30-day readmissions as an area of needed improvement and shared ways to implement evidenced-based practices at the facility. By 2013, the facility had made a 33.2 percent reduction in readmissions but recognized an ongoing need for better care coordination with patients having chronic conditions such as obesity, diabetes, chronic obstruction pulmonary disease (COPD), and heart disease. The readmissions work was a segue to moving on to develop a full transitions of care team.
The transition care team is made up of a hospital care coordinator, clinic care coordinator, utilization review nurse, community health worker, and social workers. Some of the early interventions for this group included discharge phone calls, stratified risk assessment for readmission, improved medication reconciliation, and coordination with clinics after discharge.
In addition to these focused areas of improvement, the hospital patient care coordinator began participating in daily patient rounding. Her focus was identifying educational opportunities and offering options for additional services post-hospitalization to increase patient success. LRHC continued to work on home visits, home safety visits, and extend care coordination efforts to primary care, obstetrics, and the emergency department (ED). The care coordinators, along with the social workers set goals for the course of the hospitalization, updated patients on their care plans, and provided education to the patient on how to manage their disease process at home; all of this begins at admission. Prior to discharge the physical and or occupational therapist would complete a home safety visit to assess for mobility needs in the home and to assure a successful discharge plan.
LRHC, located in Lexington, Nebraska
LRHC had an 82 percent reduction in readmissions from 4th quarter 2012 to 2nd quarter 2017. Care coordination efforts and better management of chronic conditions were the primary drivers.
Patient example: A 39-year-old female arrived at the ED by squad car after being found on the floor, unable to get up after falling. Her admitting diagnosis included rhabdomyolysis, skin abrasions, weakness, morbid obesity, and lice infestation. The patient had a five-day inpatient stay and then was readmitted to the hospital in thirteen days later after not being able to get off the toilet. The patient had a three-day observation stay followed by a thirty-seven-day swing-bed stay. During the swing-bed stay, the population health model was implemented. The patient began seeing a mental health counselor, a registered dietician, following the Ideal Protein diet protocol, and completed skilled physical and occupational therapy. This patient was discharged on Ideal Protein diet protocol, continued with mental health counseling, maintained regular visits with a registered dietician, and completed physical therapy. This patient has remained out of the ED and hospital since implementation of the population health model. She is now able to get out of her home and participate in her children's activities with a 102-pound weight loss.
Before implementing the population health model from March 2017 through March 2018, the patient had two inpatient hospitalizations, one observation hospitalization, and one swing-bed hospitalization. The total bill was $68,899.73. She had four clinic visits to a clinic not associated with LRHC. After implementing the population health model from April 2018 to April 2019, this patient’s total bill was $9,897.00 and she continued to utilize clinical social work, physical therapy, medical nutrition therapy, the Ideal Protein diet protocol, and completed follow-up visits to a primary care provider. The total cost savings from 2017 to 2018 was $59,002.73.
In 2018, the transitional care team was able to shift their home visit model into transitional care management and chronic care management, which are now billable services. Currently, the team’s efforts continue to focus on the previously implemented interventions in addition to continuing to move the practices forward. They have started to look at data and drill down readmissions by payer class, primary diagnosis, discharge disposition, behavior health comorbidities, and days since discharge. Examining this data has allowed them to continue to make strides in the quality of care they provide. They continue to work on building relationships and care practices with the assisted living facilities and nursing homes in the area through quarterly luncheons to discuss patient care collaboration.
The team continues to work closely with mental health providers to ensure that they are not only treating the medical conditions but also the behavioral health aspects that play a large role in their health practices. This is an extremely important aspect to ensure patients are successfully managing their health. The two social workers that are a part of the transition care team are both master’s prepared clinical social workers that can also provide counseling services.
One of the transition team’s focuses was diabetes management. For patients with diabetes, a dietician and certified diabetic educator work with them one-on-one to better understand their disease process, encouraging dietary changes and exercise. Due to the diversity of the population, classes are offered in English, Spanish, and Somalian languages. LRHC was awarded a grant to provide the Diabetes Empowerment Education Program (DEEP). It is designed to help people with pre-diabetes, diabetes, relatives, and caregivers gain a better understanding of diabetes self-care. The number of diabetic education referrals has increased three-fold.
“CAHs are uniquely positioned to identify and respond to barriers and challenges to general health,” said CEO Leslie Marsh. “Community Health Workers are one way we work to more effectively serve our diverse community. We understand the honor, privilege, and obligation that is inherent in health care and in optimizing health through innovation. The LRHC team is working hard to make a meaningful difference in the lives of those we serve. LRHC’s mission and values are not just words on the wall that serve to remind us of our purpose – they are who we are and what we do.”
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UPMC Cole, located in Coudersport, Pennsylvania, is one of three critical access hospitals CAHs that received national recognition for demonstrating an innovative approach to post-acute care that supports a patient’s continued recovery from illness or management of a chronic illness or disability.
Harrison County Community Hospital (HCCH), located in Bethany, Missouri, is one of three critical access hospitals (CAHs) that received national recognition for demonstrating an innovative approach to post-acute care that supports a patient’s continued recovery from illness, or management of a chronic illness or disability.