Charleston Area Medical Center (CAMC), a 956-bed academic medical center in Charleston, West Virginia, has been able to leverage interactive patient engagement and education technology to improve patient outcomes—specifically to reduce readmissions for causes related to chronic illnesses. The four-hospital system in West Virginia reversed a trend of rising readmissions. CAMC leaders have reduced their readmissions for congestive heart failure (CHF) by more than 22 percent, and for chronic obstructive pulmonary disease (COPD) by almost 30 percent in early 2016 compared to the previous year. Readmissions have also been reduced for pneumonia. CAMC has one of the largest heart programs in the U.S., and the only kidney transplant center in West Virginia, according to hospital executives.
In this initiative, the CAMC leaders have partnered with this success is a comprehensive strategy supported by the TIGR interactive patient engagement and education system from the Raleigh, N.C.-based TeleHealth Services.
Recently, Beverly Thornton, R.N., education division director in the Education and Research Institute at Charleston Area Medical Center, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding this patient education and patient engagement initiative. Below are excerpts from that interview.
How long have you been in your current position?
I’ve been a nurse for a number of years, but I have a love and appreciation for patient and family education. That’s what drew me into this area. And so I am an advocate for this. I landed in the Education and Research Institute, working with patients and community health activities, and also with our continuing education staff and medical professionals. I’ve been doing this portion since 1995; I’ve been in nursing for 42 years.
How big a staff do you have at the Education and Research Institute?
We have a continuing education department for CME, and I have two people who do that. And I have a media department and TV studio, and graphic designers and TV producers and those kinds of folks; so that’s about four or five staff members altogether; but they all have a wide variety of responsibilities, including running our learning management system for employees’ routine and required education for working in the hospital. Altogether, about a dozen people have some involvement in our continuing education, learning and management, processes. And we do education and training around the EMR as well.
And who on the team focuses on patient and family education?
That would be me. We don’t have a department, per se; we have a multidisciplinary council. Patient and family education is everyone and everywhere—it’s the responsibility of all the clinicians and everyone who touches the patient and family. We have a multidisciplinary council from all four hospitals and from all disciplines that I chair, to develop policies and procedures. There are about 35 on the council. We meet once a month. We also have ad hoc members; a lot of our physician membership is ad hoc; we will bring physicians in to speak on specific topics; it’s a two-hour meeting every month, and some online meetings as well.
How would you articulate your overall approach or strategy towards patient and family education?
I would say it’s around patient and family engagement around that education process. We can just be giving them things and hold them accountable for behavioral change. It’s a cultural thing, too, in our Appalachian state; it’s very cultural. So we have to engage the primary care provider, because our folks still listen to their primary care providers, they do what they tell them to do. So we have to engage them as a component to their care process.
And all of this is particularly important in the context of the low health status of the population, poverty and unemployment, in West Virginia, correct?
Yes, and there are additional social factors, too, including the aging of the population, and smoking.
What are the biggest gaps or areas you work on?
Access to follow-up care, making sure that that happens; and that they have the ability to get there; that they have the resources, so for example, a set of scales in their house to weigh themselves, with CHF, as well as to medications, and those kinds of things; and then the medication compliance issue. I don’t think it’s anything new or that anyone else isn’t experiencing. And then it’s the general engagement, so that they are central to making the difference—getting them to realize that they can make a difference in the outcome of their health by making lifestyle changes.
How did you achieve those strong readmission reductions for CHF and COPD in a year?
Starting at the beginning, we are a hospital that’s been working for several years on the Baldrige Awards application process. And Working in Baldrige, you are really, really challenged by process. So that means coming together in an interdisciplinary way and working on issues. So we had a multidisciplinary planning group that said, how do we work on these chronic illnesses? So we began to look at strategies. It’s not one, it’s not two, it’s five or six strong strategies that we were putting in place. And once we began to use the TIGER system, the TV telehealth system… Our culture is that we don’t just go in and tell people; TV is an important part of their lives. They use it daily and aren’t afraid of it. So that was a natural way for us to engage the patient that this a part of your care plan. You’ll watch these videos, we’ll talk about them. And you can assess how good a teacher were we in teaching them? So we evaluated what they learned, though we didn’t call it a test. So the TIGER system, as we call it, provided us that avenue for getting into the patient/family room, and letting engage.
Do CHF patients and their families readily understand the extent of the dietary and lifestyle changes they need to make?
No, they don’t get it readily. If you’re diagnosed, your brain kind of turns off, and you have to go through those stages of denial and acceptance—that’s why the follow-up is so important. When they go to our clinics, we continue to provide video education. And if they go home, can they continue to access the same programs, so they can be reinforced? And 20 years ago when I started doing some of this, I found that to own the information, you have to express it something like six different ways at six different times. So people don’t get it right away; it has to dawn on them. And I have countless stories of how that happens, and you see the lightbulb go on. And as an educator for patient advocacy, it’s great when you make the breakthrough. And they don’t’ get it every time—it’s like an 80/20 kind of thing. But our challenge was to find out what was impactful. That’s when we discovered that video and the TIGR system became one of the top five things that turned the corner for us.
How was the readmissions reduction accomplished over time?
That’s where our quality folks, our data collectors came in. We had a process by which we piloted on one unit that had 40-50 patients whom we followed. We followed them through inpatient stay and diagnosis; they were provided five strategies; they were given an education plan; they were given what’s called “teach-back.” In that methodology, you talk with the patient and evaluate their learning. Once we identified those patients and followed them to see what the 30-day and 60-day readmission rate was, and which patients were readmitted. So we developed prescriptions around a standard of care, so that every patient coming in with heart failure must receive certain types of education, including video and paper handouts. And it’s required; it’s a standardized education plan. Because hospitalization is all about consistency of process, that every patient gets something every time. So we developed that. And that’s where the difference came, and we made a movement on the HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores, where patients felt they were taken care of; and those scores also went up by 10 percent.
With regard to the 22-percent reduction in CHF reductions and the nearly-30-percent COPD reductions, were those across your entire health system?
Yes, that was the entire system. And that was 2015-2016. This all happened prior to November 2017.
What should CIOs and CMIOs know about this kind of work?
I think it’s important for CIOs to know the importance of technology in the personal growth and development of healthcare education and of quality of care; and it’s not they don’t know that. I know they do. But the integration of the care components is so important, to not just get the technical piece, but how do you relate the personal connection, while still using technology?
Are you working with the physician practices directly to avert readmissions?
Oh yes, we have to; it impacts us so much. That’s the whole focus around readmissions. And we employ more and more physicians, and those physicians we can really pull into the process, and we can make sure that the CHF patient sees their cardiologist within seven days. We’ve found that if they’re not seen by a cardiologist within seven days, their rates of readmission skyrocket. And how do we do that with non-employed physicians? So we send them to our congestive heart failure patient, to make sure they’re on track to make sure they’re seen by their cardiologist. You have to find those gaps. And that gets back to access to their physicians. Because you know, in the mountains of West Virginia, we have patients who may live 100 miles from their cardiologists. So we’re looking at telemedicine and other options, because we’re trying to make sure to make the connections.
What mechanism is involved to trigger or prompt those actions?
We make their appointments prior to their discharge. We make sure that they have an appointment prior to discharge. If they’re unable to get in within a week, they go to our clinic, and then go to their cardiologist. So that’s an important piece—you have to make sure they have that connection before they ever leave us.
And you believe that your initiative is widely replicable, correct?
Yes, it is replicable. One thing I will say that we do use is nurse navigators. These are LPNs, and we only have two of them for the whole system. What they do is that they get a report—there’s a risk stratification formula that’s used. So they’re given that list, and they have a one-on-one session with those patients while they’re still inpatient. And this isn’t new, either. It was actually brought back by one of our vice presidents from a conference he attended. Another hospital had been using RNs, but really, an LPN can do that. And they make sure the high-risk patients get the education, and they reengage with them as needed. So I wanted to mention that nurse navigator program; that’s been a key piece in that personal touch.
So it really is everything, all together—people, process, and technology—then, yes?
Absolutely. You can’t just depend on one. It’s like we have our five senses; you have to touch each one, to make it stick.