Quality improvement staff at Hereford Regional Medical Center in Hereford, Texas, knew that a hospital readmission rate of 33% in 2021 – well above state and national benchmarks – was too high and that they needed a strategy to reduce those numbers.
Hereford, a rural hospital with 33 staff beds and 200 employees, is a Level IV trauma center and provides short-term acute care. Quality improvement staff, led by Veronica Gafford, LVN, director of quality and infection control, convened a meeting with several hospital departments, including the rural health clinic, to drill down on the specifics of patient readmissions. They discovered that many patients were missing the hospital follow-up visit/transitional care management (TCM) visit after discharge.
“This meant that they may or may not have understood the discharge instructions, including what new medications were prescribed,” said Gafford. “This is a vital part of keeping our patients healthy at home during the transition phase from inpatient to home care.”
After identifying the problem and analyzing resources and interventions, the team developed a community paramedicine program to reach out to all discharged patients and provide support during the transition phase.
The program, which has steadily evolved over the past two years, began as a collaboration between Gafford and the facility’s wellness center staff when they recognized that annual wellness and TCM visits had dropped to around 38%. Staff brainstormed for several months about how to reach the patients who do not show up for scheduled follow-up visits or respond to post-discharge TCM phone calls before deciding to send the emergency medical services team to check on them at home. When early results proved successful, the team expanded the program to all discharged patients.
Specifically, a nurse practitioner is assigned to follow a patient during the hospital stay and at the transition care visit. Next, the wellness department calls the patient within two days of discharge to follow up on discharge instructions and any new medications prescribed. The wellness team relays any patient issues or needs to the paramedicine team, which then visits the patient’s home two-to-four days post discharge.
Paramedicine staff conduct home visits to determine each patient’s social determinants of health needs, as well as any care or medical needs, and connects the patient with social resources if needed. The paramedicine team communicates directly with the patient’s nurse practitioner and wellness staff at the hospital throughout the process.
To be successful, the program requires considerable cooperation and communication among staff. The Hereford team consists of emergency medical services, transitional care providers, wellness staff, case management, social services, quality improvement staff, the medical director, the chief nursing officer and the chief executive officer. Program staff hold weekly meetings to review current home visits, recent hospital discharges and any referrals made by clinical staff. Program staff also host monthly meetings with additional departments to discuss the program’s success and opportunities for improvement.
“This program has been extremely successful and has reduced our transitional care no-show rates as well as our hospital readmissions,” Gafford said. “Our readmission rate for 2021 was 33%, in 2022 it was 5% and as of July 2023 we are at 0%.”
Hospital Quality Improvement Contractor (HQIC) data for Hereford shows an 81.18% relative reduction in its 30-day readmission rate from October 2022 to March 2023 to 3.23% – surpassing the Centers for Medicare & Medicaid Service’s HQIC goal of 5%.
As a partner in TMF Health Quality Institute’s HQIC program, a TMF healthcare quality improvement specialist worked directly with Gafford to share resources TMF developed, such as the Modified LACE tool, Process Improvement Discovery tool and Readmissions Tracer tool, to analyze their hospital’s data. Gafford and her team were also invited to attend educational webinars TMF hosted where they learned about different interventions to implement to help reduce readmissions.
“TMF is great,” Gafford remarked. “I have learned so much, Kimberly (Veal) has been there to answer questions and to give tools to achieve and maintain the facility measures.”
Gafford and the quality improvement staff at Hereford Regional have identified a new goal for the community paramedicine program – reduce emergency department visits. To that end, they have incorporated a chronic care management program that provides enrolled patients 24/7 access to a nurse via telephone.