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If there was one number that told Milford Regional Medical Center (MRMC) CIO Nicole Heim and her team that the hospital needed to address reducing patient readmissions, it was 11.
That was the number of times one specific patient was admitted to the hospital over the course of one year – accounting for 58 hospital days worth of stays. The visits included 54 separate studies and 24 chest x-rays.
What Heim and her colleagues saw at MRMC – a 121-bed community hospital serving 20 communities – was a cycle of readmissions that had a lot to do with the complex and often confusing set of events that occur when a patient is discharged from the hospital and is provided with instructions for follow-up care. Multiple providers often assume care for a patient, including primary care physicians, family members, skilled nursing facilities, visiting nurses, home health care; each of those providers become part of the process that assumes responsibility for care instructions.
And when paper documentation is used to ensure the correct message gets to where it needs to go, important information often gets lost in translation.
“What we found was that printed discharge summaries and the instructions that we actually give those patients were often misplaced and they didn’t travel with the patient and weren’t given to the next care provider to continue that care and to continue the teaching we did here at Milford,” said Heim. “We gave those instructions, but they never followed the patient, so the patient came back for multiple admissions over the course of the year.”
In an effort to remedy the problem, MRMC decided to try an electronic approach to its discharge summaries. That meant teaming up with two health providers that often serve as the next care stop after being discharged from the hospital: Medway Country Manor and Care Tenders.
Medway Country Manor is a skilled nursing facility and Care Tenders is a home health agency. Over the course of 2012, Medway Country Manor had 289 admissions and 280 discharges from MRMC. Care Tenders agreed to be a partner to start the pilot program.
The three organizations are using a $75,000 grant dispersed by the Massachusetts eHealth Institute (MeHI) to create an electronic connection through the Massachusetts Health Information Highway (the Mass HIway). The Mass HIway is the Commonwealth’s first and only statewide health information exchange (HIE).
MRMC’s use case for the Mass HIway is to provide documentation electronically to those facilities and organizations that will assume care for the patient upon discharge. Additionally, the hospital wants to receive information from those facilities upon admission and have the information flow directly into its MEDITECH electronic health record (EHR) system.
“It’s of course our efforts to reduce readmissions, but we have done a number of things including the formation of an interdisciplinary patient centered transitions team looking at patients’ actual studies and looking for opportunities to improve communication between Milford and the outpatient settings and we’re also an active member of the state action on avoidable rehospitalizations initiative,” said Heim.
The project’s goal is to continue the work to reduce the avoidable readmissions and to improve that communication between MRMC, the partnering organizations and to assist families serving as care providers because they don’t always remember to bring the paper documentation to the next care setting.
“We’re very excited that we’ve been able to attest to Stage 1 for the past three years, and we’ll move on to Stage 2 starting in October,” said Heim. “We’re looking at using the Mass HIway as part of our strategy to meet the initiatives and objectives for Meaningful Use Stage 2, which will require us electronically to send that documentation on discharge.
“There’s endless possibilities of other partners to expand with us, and that’s the point of the Mass HIway.”
MRMC plans to continue to connect with multiple other facilities and organizations that are going to care for its patients upon discharge.
“We’re definitely excited to start this project and be on the pioneer end of the Mass HIway and share our story with other facilities that will come after us,” said Heim.