Communicating With COVID-19: A Transitions of Care Model

Background - Duke University Hospital was working on implementing a series of transitions of care interventions focused on General Medicine patient populations when the COVID-19 pandemic hit. Hospitals across the US have experienced an increased need to optimize patient flow in order to improve bed capacity for the COVID surge. Due to urgency and need, the project team quickly pivoted and decided to focus interventions on the COVID patient population. These patients have many unique needs post-discharge with unprecedented medical complexity. After completing data reviews and gathering patient feedback to guide the interventions, the team focused on streamlining communication and transitions of care for these patients. Since COVID was a novel disease, there were significant challenges to traditional communication pathways and lack of standard protocols to support patient transitions from the hospital to full recovery at home. Discharging actively infectious patients presented additional barriers from access to routine lab draws and infusions, dialysis center changes, and family/caregiver strain. The project had senior leaders and key stakeholders who championed the work across Hospital Medicine, Nursing, Case Management, Primary Care, and Population Health. The project was supported by project managers guiding the team through a reiterative Lean Six Sigma improvement process. The multidisciplinary team identified three major areas of focus: communication, discharge planning, and handoff from inpatient to outpatient care teams. Focused interventions went live in September 2020 and have continued to use the continuous improvement cycle to check and adjust based on feedback from patients and providers. This work is important and impactful as it serves to improve discharge pathways and communication for patients in an active infectious disease state which has traditionally been mainly unexplored. Intervention Detail- The multidisciplinary team conducted a value stream analysis and interviewed various team members from across the continuum of care. The team mapped patients’ journeys and identified opportunity areas for further observation. Vizient benchmark analyses were also conducted to assess length of stay, readmission rates, and follow-up appointment scheduling rates. After analyzing data sources, the significant gaps in care identified were communication, discharge planning, and the handoff from inpatient to outpatient care teams. Hospital leadership supported adding a new Care Transitions Manager position, to help the team implement the following key interventions: • Conducted daily multi-disciplinary huddles to discuss and develop potential solutions for discharge barriers and readmission risk factors with providers, nurses, pharmacy, utilization management, and case management • Engaged patients to discuss discharge readiness and review educational materials • Assisted with patient portal enrollment to support access to important health information, electronic educational materials, appointments, etc. • Interviewed readmitted patients to discuss root cause of readmission and to identify preventable gaps in care Discharge Planning • Completed discharge checklist to ensure a safe and efficient discharge • Ensured patient has follow-up appointment scheduled prior to discharge • Utilized Readmission Risk Score incorporated in Epic to guide interventions such as discharge medication reconciliation by Pharmacy • Referred to outpatient systems such as Duke Well Population Health (for expedited follow-up calls and outpatient wrap around patient services), project HOPE (Skilled Nursing Facility transition team), and Duke Health System Resource Center (for continued support of discharge plan) • Improved handoffs by ensuring consistent discharge summary routing occurred to outpatient providers using electronic reminder within the EHR to the discharging provider • Streamlined discharge summary formatting so most relevant information is highlighted for outpatient providers • Increased follow-up care pathways via telehealth use and engaging the complex care primary care nurse Outcomes and Impact- While the project is still ongoing, the team has seen the following trends (percentages represent relative changes): 1.5-day reduction in LOS (18% improvement), 16% improvement in the 30-day readmission rate through the Emergency Department, 7% increase in enrollment for patients in their EHR Patient Portal to improve communication, 51% increase of referrals to our DukeWell Population Health Care Managers, 22% improvement in the discharge summary routing to PCP, and 90th percentile performance on the HCAHPS Discharge Information section. Provider-level data was also distributed for physician leadership to monitor individual performance measures (e.g. discharge summary routing). In addition to the quantitative results, there was positive qualitative feedback from the care team. The daily multi-disciplinary huddle enhanced teamwork and communication while also focusing the team on the planned discharge date. A front-line nurse shared this feedback, “I try to attend the discharge huddles every day; they give me the big picture for the patients’ care. After learning of the plan, there is a chance to express concerns with the physicians, as well as the case management team. I will continue to try and go to these as frequently as possible.” Moving forward, data will continue to be monitored to fine-tune interventions through iterative process improvement cycles. In-depth chart reviews and readmission interviews were performed with results shared back with the project team to inform them of needed changes to workflows and processes. Future collaborations are currently in the design phase for enhancing education modules for caregivers, integrating a post-discharge clinic, and other models for this COVID population. Expansion of this pilot to other high-risk populations with complex needs will continue to also be explored as data is collected and analyzed. Uniquely Innovative- The COVID-19 pandemic created opportunities to reinvent and expand support for COVID patients. New and unconventional interventions were developed to discharge and transition these actively infectious patients to a safe home environment. For patients still under isolation precautions upon discharge, arranging access to timely outpatient services (dialysis, infusions, and routine labs) required coordination and collaboration not only within the Duke system, but also with community health partners. The flexibility and innovation required for iterative process improvements also launched new ways to treat patients and adjust to evolving patient needs with a responsive and agile care team working together.

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Author David Michael Gallagher Medicine, General Internal Medicine