In 2011, MetroWest HomeCare & Hospice, in partnership with MetroWest Medical Center, initiated a strategic and evidence-based effort to reduce their emergent care visits and acute care hospitalization rates.
The effort began with the formation in November 2011 of MetroWest’s Re-Admission Intervention Strategy Council (RISC). The RISC includes representatives from management, nursing, rehabilitation, palliative care, and a heart failure nurse specialist. In addition, RISC invites specific expertise – for example, social worker, wound nurse, physician specialists – when needed to address particular issues. The Council took a multi-disciplinary approach to reducing unnecessary re-hospitalizations, improving quality of care and optimizing patient outcomes. In the beginning, RISC met every other week and eventually was decreased to a monthly meeting. Often special projects or educational programs require additional time of some RISC members.
Together these efforts have proven successful in reducing overall acute care hospitalization rates. In June 2012, only six months into RISC, MetroWest Home Care’s readmission percentile ranked 46th in the state and 55th in the nation, according to CMS’s Home Health Compare and CASPER reporting system. In May 2013, after all RISC initiatives had been implemented, MetroWest was ranked in the 4th percentile for the state and the 6th percentile for the nation. These numbers have been maintained.
The goals of RISC include:
• Use data collection and analysis to identify any trends in hospital transfers;
• Increase team awareness of patients who return to the hospital, especially repeat visitors;
• Use of Case Conferences and Plan of Care modifications to keep patients at home;
• Reduce hospital re-admissions and improve patient quality outcomes.
To identify trends, RISC developed a user-friendly data collection tool tracking patients transferred to the hospital....
To read the rest of this story, and other quality improvement success stories at Massachusetts hospitals, please click here.