Improving Care and Reducing Re-Hospitalizations - Crozer-Keystone Health System - PA

Improving Care and Reducing Re-Hospitalizations

Fewer patients in the Crozer-Chester community are making return trips to the hospital thanks to the efforts of CHKS Home Health. Recognized and respected for its success in reducing re-hospitalization rates, CKHS Home Health is now working to improve upon its already strong reputation.

“Since Medicare began collecting data in 2000, we have consistently reported low re-hospitalization rates – exceeding the national benchmark by seven percent,” says Terri Cullen, MEd , B.S.N., R.N., clinical director of CKHS Home Care and Hospice. “Our goal is to be better than the best, moving from 20 to 19 percent by 2014. The national reference is 27.5 percent.”

One way that CKHS Home Health is doing this is by researching and implementing disease-specific best practices.

“Take our congestive heart failure patients for example,” says Jane Hanahan, R.N., B.S.N., M.H.A., administrative director of CKHS Home Care and Hospice. “Research has shown that the first seven days following hospital discharge is the period of greatest risk for these individuals. In response to this, we have front loaded visits so that conditions such as edema, weight gain and shortness of breath can be caught and treated quickly – before they necessitate a trip to the hospital.”

Medication reconciliation is another area where CKHS Home Health is focused.

“Time and again we see patients readmitted to the hospital because they either didn’t understand the medication instructions they were given at discharge or they aren’t able to pay for their prescriptions,” says Cullen. “We’re helping patients overcome challenges related to their medications by explaining dosages and frequency to them or identifying resources that will help offset costs.

“Our goal is to promote self-management of their disease process through education of medications, knowing signs and symptoms to report to their physician, and timely and regular physician follow-up,” she continues. “Home Health staff encourages and helps patients make follow-up appointments with their physicians within five to seven days of hospital discharge.”

Other steps being taken to reduce re-hospitalization rates include:

  • Calling patients on the same day as their discharge to address any questions or concerns they may have regarding their healthcare.
  • Partnering with Crozer Keystone Senior Health Services in the Community Care Transition Program.
  • Piloting a telemonitoring program for patients at high risk for re-hospitalization.
  • Working with community providers – physicians, care managers, social workers, nursing facilities, etc. – to improve care transitions.

According to Hanahan, reduced readmission rates benefit not only patients, but CKHS as well.

“In the changing healthcare environment, health systems are expected to provide safe, high quality care with good outcomes in an environment of lower reimbursement,” she says. “When
we reduce our re-hospitalization rates, CKHS hospitals avoid re-admission penalties. We are important members of the CKHS team ensuring optimal patient care along the entire continuum.”

Crozer-Keystone Home Health was recently named a member of the Home Care Elite for 2013 for the seventh consecutive year. This designation as a top home care performer is based on quality of care, quality improvement, patient experience, process improvement measures and financial management.

“We are proud of our staff members who are out in the community providing care,” says Hanahan. “As leaders in the healthcare arena, the Crozer Keystone Home Health leadership team strives to improve patient outcomes and meet the needs of our patients in the community. Patients are our customers and exceeding their expectations is our goal.”