Platte Valley pilots successful program to reduce length of stay and readmission rates

PVMC Kurt and Gentry

In the pursuit of enhanced efficiency and patient well-being, Platte Valley Medical Center launched an innovative pilot program that has significantly decreased the time patients stay in the hospital and decreased their likelihood to return.  

The pilot is part of the Hospital Transformation Program (HTP), which is a value-based program mandated by the state of Colorado for all hospitals that receive payments from Colorado’s Medicaid program. The goal of the program is to improve the quality of hospital care by transitioning hospitals to a pay-for-performance structure. Each hospital must select 10 cost and quality performance metrics based on their community health needs assessments. Length of stay and readmission rates are two of the metrics the Peaks Region is focused on. 

Roughly 30% of Platte Valley’s patients are on Medicaid or are medically indigent patients, meaning they don’t have insurance and don’t qualify for Medicaid, Medicare or private insurance. Since these patient populations are so large, Platte Valley launched two initiatives to address length of stay and readmission rates among this population. 

Platte Valley piloted a program where they created a discharge nurse position uniquely trained on how to get patients out of the hospital as timely as possible by addressing barriers to discharge. This position serves as a bedside RN, case manager and care coordinator. Gentry Johnson, director of IP Services, was a key driver of the program’s success, and Dana Knight, Maddy Talbott and Toni Thompson are critical members of the Discharge Navigation team. 

Through a system of daily interdisciplinary rounds, the discharge nurse, primary nurse, attending physicians and ancillary caregivers go through the entire patient census on a unit-by-unit basis and look for real-time barriers to discharge. 

“The discharge nurse focuses on factors that contribute to readmission and takes steps to ensure the patient was set up for success post-discharge,” said Kurt Gensert, chief nursing officer and chief operating officer at Platte Valley. “This included ensuring they have transportation, lining up a family member or friend to help them, educating the patient bedside with a family member present, discussing medication compliance, filling their prescriptions before they leave the hospital, and scheduling their follow-up appointments for them.”  

In addition, a complex case management nurse follows up with patients for 30 days via telephone after they leave the hospital. The nurse ensures the patients attend their appointments, take their medications, and follow their care plan. They also check in on the patient’s health, guide them if they’re not following their care plan, and answer any questions they have to help avoid readmission. 

“Medically underserved patients often have poor medical compliance, so they can be hard to manage,” Kurt said. “They're poorly incentivized to do everything they can for their health, so we make it as easy as possible for them to do the right thing and as hard as possible for them to do the wrong thing. We’re able to determine which patients are at high risk for readmission and step in to proactively help avoid that.” 

Kurt explained that a lot of Medicaid patients don’t have a primary care doctor or, if they do, they’re not able to get in to see them for months. “We’re able to work with third parties and community resources to ensure that these people don’t fall through the cracks,” he said. 

The team also looked at social determinants of health to reduce length of stay and readmission rates. This is done by screening patients for social needs such as whether a patient struggles with a lack of food, housing, transportation, or utilities, or with depression and other mental health challenges.  

“Some of the screening questions are very sensitive and difficult for the patient to discuss and difficult for caregivers to ask,” said Kurt. “It’s not something you can go through quickly since some delve into the patient's ability to make ends meet at home, if they’re having suicidal thoughts, or if they’re being abused, to name a few. Asking these questions is just as important as getting someone’s health history to properly treat and diagnose them. What we’ve done is assigned this role to one person who ensures no Medicaid patients are discharged without going through the screening.” 

There is a small group of well-trained caregivers adept at having tough conversations and getting patients to open up to them. If it’s indicated that there is abuse in the home, or housing or food instability, the team connects the patient with social programs and community resources to set them up for success after discharge. By asking patients the screening questions and providing them with additional resources, the patients don’t have to choose between filling their prescriptions and paying their rent or buying food.  

“Doing this is sort of a decompression valve for the neediest of patients,” Kurt said. “We’re helping to bridge the gap by connecting them with existing resources. Yes, we want to keep their readmission rate down, but ultimately, we want to improve their health-related quality of life and have better outcomes. Our caregivers have already seen the tremendous impact of this work and the difference we’re making in our patient’s lives.”