Seamless Transitions Back to Daily Life
To better ensure that patients being discharged can successfully return to normal life, hospitals in the U.S. are developing and implementing improved care transition procedures. The Hawai‘i Island Beacon Community Care Transitions initiative provided a standardized methodology for effective discharge planning based on the Better Outcomes for Older adults through Safe Transitions (BOOST) guidelines developed by the Society of Hospital Medicine. The three Hawai‘i Island acute hospitals selected Project BOOST to minimize the tremendous variations in how hospital dischares are handled on the island and within each hospital. Hilo Medical Center, Kona Community Hospital and North Hawaii Community Hospital discharge planners worked collaboratively to develop a standardized discharge summary tool based on Project BOOST’s CarePass to improve the patient and family understanding of important steps to follow post-discharge.
Through data analysis, Hilo Medical Center identified the top three diagnosis for readmissions - psychosis, cellulitis, and congestive heart failure (CHF). HIBC chose CHF for a focused Project BOOST implementation involving the coronary care unit.
A standardized electronic health record checklist template and clinical pathyway for congestive heart failure was created. During the admission process the admitting physician clicks on the pathway for CHF, triggering the assessment. Any risk factors identified on the the assessement checklist automatically activates an EHR based referral to another hospital department (e.g. pharmacy) or to a community based support service such as Hui Malama Na ‘Oiwi for standardized interventions such as medication evaluation or participation in nutrition support post-discharge.
HIBC’s key accomplishments are:
- Selected Project BOOST methods and tools for reducing readmissions. Target population included patients with diagnosis of congestive heart failure (CHF), community acquired pneumonia (CAP), or acute myocardial infarction (AMI).
- Developed Beacon Neighborhoods around each hospital, consisting of community based care networks involving key care coordination partners and other community support services.
- Implemented a common discharge tool among Hilo Medical Center (HMC), Kona Community Hospital and North Hawai‘i Community Hospital.
- Reduced total acute inpatient days, 30-day readmissions and ER hours at Hilo Medical Center.
- Used an electronic health record template to standardize the electronic care pathway for CHF patients.
Kona Community Hospital We are a 94-bed full-service acute care hospital with 24-hour emergency services, proudly serving the West Hawaii community.
Hilo Medical Center Hilo Medical Center is the largest facility in the Hawai‘i Health Systems Corporation in addition to being one of the largest employers in Hilo.
North Hawai‘i Community Hospital North Hawai‘i Community Hospital (NHCH) is a private, non-profit community hospital that serves more than 30,000 residents in North Hawai‘i.
Society of Hospital Medicine’s (SHM) Project BOOST®
(Better Outcomes for Older adults through Safe Transitions) is providing training and mentoring to support the development and implementation of improved discharge processes.
- 1) Hospital executives must support an overall performance improvement strategy.
- 2) Existing hospital policies can be a significant barrier to creating community based care networks.
- 3) The discharge advocate is essential for coordinating the patient's experience throughout the hospitalization and transition to another setting, whether it is home or another institution.
- 4) Be adaptable to unanticipated roadblocks such as changes in senior leadership.
- 5) Close alignment with payers and payment reform strategies as improvements are made are essential for change.
- 6) Integrating Project BOOST into the overall quality and performance strategy at Hilo Medical Center was a critical success factor for the hospital.