Collaborating to Enhance Patient Care and Outcomes
A low hospital readmission rate is a key marker of care quality recognized by Medicare, health plans and health systems across the country. A readmission occurs when a patient returns to the hospital within 30 days of an initial discharge and can indicate that a patient’s condition has worsened after treatment. To meet the challenge of improving postdischarge care and reducing readmissions, the MaineHealth Accountable Care Organization (ACO) is working to spread an important heart failure treatment protocol to nursing homes across the MaineHealth service area.
The protocol was developed and piloted by Maine Medical Partners Geriatrics, the MaineHealth Cardiovascular practice and other system partners in response to variations in heart failure care reported by local nursing homes. To improve care and reduce readmissions, the partners developed a standardized protocol that nursing homes could use to safely and quickly treat heart failure exacerbations on site using existing resources. The ACO, in collaboration with MaineHealth Healthy Aging, is training dozens of nursing homes on the protocol and helping them implement it successfully.
The protocol establishes a “target weight” for heart failure patients, established when their condition is well controlled. Rapid weight gain over the target triggers the protocol, particularly when accompanied by other symptoms. Nursing home staff consult the patient’s provider and a simple intervention typically returns the patient to baseline function within 48 hours.
The protocol was first piloted at a rehabilitation facility within the MaineHealth Senior Living Collaborative (SLC), a group of over 40 nursing homes in the MaineHealth footprint that convenes to share best practices. The ACO and MaineHealth have helped spread it to additional members of the SLC. Currently, 20 nursing homes have adopted the protocol with exciting results. Preliminary data collected from a sample of 10 facilities show a heart failure readmission rate of 6 percent, well below the national skilled nursing facility readmission average of 22.4 percent. Based on this small sample, the ACO estimates that the protocol has contributed to 48 patients avoiding readmission.
“Lower readmissions is closely correlated to better patient outcomes,” said Dr. Betsy Johnson, president and CEO of the MaineHealth ACO. “You can think of each avoided readmission as a patient who is recovering from a hospital stay successfully. They’re stronger, healthier and happier than they would have been had they returned to the hospital.”
Today, the ACO and MaineHealth are working together to spread the protocol to all members of the Senior Living Collaborative through additional trainings and continued implementation assistance.