Harrison County Community Hospital, Bethany, Missouri

Harrison County Community Hospital (HCCH), located in Bethany, Missouri, is one of three critical access hospitals (CAH) 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.

HCCH identified a lack of interdisciplinary communication regarding hospital discharges and a lack of structured post-hospital discharge follow-up when reviewing satisfaction survey scores and hospital inpatient 30-day readmissions. In April 2019, HCCH established an interdisciplinary transitions of care team to improve the discharge process, enhance communication between patients, health care providers, and other caregivers, and to reduce the likelihood of readmissions within 30 days. This team is made up of a care coordinator, nursing staff, ancillary departments, home health, primary care clinics and physicians, and a local pharmacy. The team provides post-discharge, patient-specific follow-up care at various intervals based on a risk-adjusted assessment performed upon admission.

Upon admission at HCCH, the patient is highly involved in the plan of care and discharge process. Patient preferences are taken into account by the multidisciplinary team and are the driver of daily care. The Transitions of Care team has implemented evidence-based practices to facilitate a high standard of care. The Transitions of Care team aims to provide safe care throughout the patient’s stay through increased communication with the patient and across the care team. The Transitions of Care initiative provides timely post-discharge care coordination services to the patient within 72 hours of hospital discharge. The objective is to identify and prevent any potential risk factors for re-hospitalization, considering each patient’s preferences. Post-discharge care visits are conducted with every patient including home environmental safety observations.

From left to right: Amy Pickren, Director of Inpatient Services and Quality Management; Elisa Welp, Care Coordinator; Tina Gillespie, CEO.

Positive Outcomes

• Forty percent of all patients discharged to home received a complimentary nurse home visit, and the care coordination nurse attempted 100 percent of follow-up phone calls.
• The readmission rate (11 percent) remained below the national average for 2019. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Care Transition scores averaged 3.5, communication about patient medications scores averaged 3.6 out of 4, and overall patient satisfaction averaged 9.1 out of 10.
• Prior to the initiative, 40 of patients discharged to home reported that they had questions or concerns with discharge to home medication lists upon their next doctor visit. As of Quarter 1 2020, that number was reduced by more than half. Eighty-eight percent of patients surveyed stated they had a good understanding of their discharge instructions.

Top Accomplishments

The overall goal for this team is to improve patient satisfaction HCAHPS scores, lower hospital 30-day readmission rates by enhancing patient education methods, and providing structured, scheduled, timely follow-up calls and/or visits with patients after discharge. The overarching goal of the program is to improve health outcomes for all patient populations that are discharged from the hospital. This is directly linked to the hospital strategy by monitoring HCAHPS scores, sending surveys to swing bed patients upon discharge to monitor for areas of improvement for this particular patient population, and providing care coordination follow-up phone calls to identify and resolve any concerns or educational gaps.

“HCCH has developed an innovative Transitions of Care team to help patients transition to home safely,” said CEO Tina Gillespie. “Our goal is to reduce or eliminate the need for rehospitalizations and to keep the patient in their own home for treatment rather than in the hospital setting.”

“Harrison County Memorial Hospital is a valuable asset to the health care system. Through their excellent work, patients are receiving quality care close to home. By using population health management, high quality care outcomes are being achieved while reducing avoidable health care costs. Patients receive education throughout the community through long-term care facility care coordination, local retail pharmacy program, rural clinics integration, and hospital population follow-up care,” stated Sara Davenport, Chief of the Missouri Office of Rural Health and Primary Care.