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There are a number of unnecessary re-hospitalizations. Recent data show that one in five Medicare
beneficiaries that leaves the hospital is going to be re-admitted within thirty days
and many of those are said to be potentially preventable.
What happens when caring for a patient becomes more important than increasing the bottom
line?
In 2012, healthcare providers in Kitsap County Washington came together and connected to
form a community coalition, taking matters into their own hands to better the lives of
their patients.
Don't duplicate the services that are already in the community.
The following logos of different organizations are listed on the screen:
Harrison Medical Center Kitsap Mental Health Services
Hospice of Kitsap County Qualis Health
Kitsap Aging and Long Term Care Kitsap Medical Group
Hospice of Kitsap County
KC4TP logo appears.
Kitsap County Cross Continuum Care Transitions Project.
Map of Kitsap county in the state of Washington, showing it as a seaside/coastal community,
appears on screen.
Animation of seagulls on rocks looking at fish labeled as "Patient" appear. They say,
"Mine, mine, mine." Then it becomes "Ours!" when a ferry labeled KC4TP sails across the
water in the same frame.
Our county is small, you know, there's nine nursing facilities that are in our cross continuum
and we are very competitive. But it's been an opportunity for us to get to know each
other. For me personally, I think I've gained way more in getting together with these folks
and learning from them and what they're doing in their facilities than I could have ever
wished to teach them, says Annette Crawford, the Administrator at Stafford Healthcare at
Ridgemont.
In the care transitions work, so much of what happens in the early stages of a community
coalition and the building of a community coalition is growing awareness between the
community partners of who their partners are, finding out just who the stakeholders are
in their community, because we're about the patients here, that's what we're centered
on and it's whoever intersects and interacts with the patients, those are the people we
want to have in the room, in our community coalition, says Carol Higgins, from Qualis
Health.
Text on screen reads: "Annette connected with Carol Higgins from Qualis Health".
I met Carol Higgins from Qualis at Pierce County meetings that I was going to and I
kept saying to her, I would like to start this work in Kitsap County. How do I start
this work in Kitsap County? So she found Lauren Newcomer, who was the Quality Director here
at Harrison and so I came to the hospital, I was very excited, this was going to be the
first time I had talked to the hospital about this work and I talked about the things that
we were doing at my facility, at Stafford, she talked about monitoring and the initiatives
that they had been working on and we just, connected.
Text on screen reads: "They discovered their shared visions."
It's really kind of opened my eyes to the problems that other facilities have and sitting
down together and brainstorming and coming up with solutions has been very valuable to
me and the facility I'm running right now, says Ron Adams, Bremerton Health and Rehabilitation.
Annette says, "I thought it would be the perfect scenario to be able to go to the hospital
when we had a re-hospitalization and sit down with someone at the hospital and say this
is what happened, this is where the failure was, this is what we could have done better,
and to have that hospital person take that information and do something with it."
Alicia Goroski, Associate Director from ICPC NCC, CFMC says, "You took everything, all
the resources, that were already here, you leveraged them toward a common goal, and you
know, look what you've created."
Graph appears on screen showing reduced Readmissions per 1000 fee-for-service Medicare beneficiaries
from Quarter one 2011 through Quarter two of 2012.
Footage of elderly seniors in and out of facilities appears.
Text on screen reads,
KC4TP Community Partner Initiatives:
Health Home Model Enhanced Case Management KC4TP Cross - Continuum:
Home Health Utilization Heart Zones Tool Standardization
Warm Handovers SNF to Hospital Transfer Packet
KC4TP IHI SNF STREAM: SNF Capabilities Worksheet
INTERACT Warm Handovers
Teach Back Enhanced Assessment of Post-Discharge Needs
Reduce Return to ED for Non-Admitted
Teach Back
Annette says, "I've been a nursing home administrator since 1989. Through the years, I never imagined
I'd be standing over 100 hospital employees explaining how skilled nursing facilities
can be their strongest partners in reducing unnecessary hospital admissions. But if we
come together, and improve communication between each other, we can improve care transitions,
and the patient's healthcare experience. Skilled nursing facilities can help to identify high
risk patients and provide support and education in a safe environment. Our cross continuum
team has worked hard over the past year, just connecting, and learning from each other.
We've shared some successes and failures. I'm excited to see what we can accomplish
together next."
The logo, KC4TP Kitsap County Cross Continuum Care Transitions Project appears. Along with
text reading, Together we go further, faster.
Credits:
Created by CFMC, Colorado's Quality Improvement Organization,
by the Learning & Action Network National Coordinating Center (LAN NCC)
and the Integrating Care for Populations and Communities National Coordinating Center (ICPC
NCC)
A Special Thanks to:
Qualis Health Stafford Healthcare at Ridgemont
Harrison Medical Center Kitsap Medical Group
Kitsap Mental Health Services Kitsap Aging & Long Term Care
Hospice of Kitsap County
Directed by Kimothy Pikor
Produced by Cinepro Studios
This material was prepared by CFMC (the Medicare Quality Improvement Organization for Colorado),
the Learning and Action Network National Coordinating Center, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. PM-4060-214 CO 2013