Application of a Learning Health System Approach to Hospital Discharge Transitions in Care

From the 2023 HVPA National Conference

Meghan Rockey MSN, RN, ACM (NYU Langone Health), Christine Truiano RN, MBA,  Michelle Palazio RN, CPN, MSEd,  James Carroll MPA,  Agustin Castaneda MPH, Tony Mei MS, Christina Wong BS, Gary Kalkut MD, Matthew Penziner BA

NYU Langone Health’s (NYULH) world-class patient centered care is supported by Care Coordination programs to help patients receive the right care at the right time with cost-effective outcomes for the health system. Since 2017, nurse Clinical Care Coordinators (CCCs) have conducted post hospital discharge calls under the Transitions in Care (TIC) program.

The TIC program has existed in several iterations, but measuring its impact was challenging. Seeking process improvement, Care Coordination nurse leadership collaborated with NYU’s Center for Healthcare Innovation and Delivery Science on rapid-cycle randomized testing in 2018. Conclusions from this study indicated that calls were ineffective at either reducing readmissions or improving patient satisfaction. Thus, meaningful adjustments were necessary. A high-risk population, primarily consisting of patients discharged home with home health services, was identified as needing additional support. We set out to identify reporting metrics that shifted focus to outcomes that could be measured and directly improved upon within the department.

Expectations for the TIC program shifted towards efficiently identify problems on calls and resolving them independently when possible. The updated target population presented an opportunity to re-design workflows and reporting to capture quantifiable, achievable and meaningful outcomes.

The nurse’s revised workflow pinpoints universal problems that might occur upon hospital discharge and reports that quantify efforts to resolve them. The streamlined assessment focuses on five domains common to all hospital discharges within the population:
-Discharge instructions
-Clinical signs and symptoms
-Follow-up appointments
-Homecare agency, equipment & supplies

Care Coordination nurse leadership and Epic analysts designed a unique care plan to quantify the actionable “task” taken to rectify the problem once it was identified in the assessment. Outcomes feed into a Tableau dashboard to display trends.

Dashboard data can be shared with stakeholders across NYULH sites seeking opportunities for discharge planning process improvement. On average, 29% of cases assessed require CCCs extra work efforts to uphold the discharge plan. Scheduling timely recommended follow up appointments and establishing timely homecare start of care comprise the most common work efforts thus far. New reporting captures both the problem encountered and the CCCs work to resolve the issue. Applying best practice standards, CCCs keep patients, their caregivers, and providers informed of status updates in real time.

A learning health system tests its programs with the goal of revising ineffective processes or reallocating resources. The TIC program now sheds light on lapses in essential components of hospital discharge for real-time course correction. Furthermore, the revised workflow quantifies efforts to resolve problems uncovered, thus revealing priorities to optimize for process improvement. While leadership continues making valuable partnerships across the health system and gathers tools to enhance capabilities, nurse CCCs work to improve overall quality and consistency of the calls. We aspire to help reduce hospital readmissions and improve patient satisfaction, but we focus on how to deliver individualized patient care for better outcomes overall. Our workflow and reporting now aligns with that focus.

Clinical Implications:
The process of reviewing outcomes and lapses in the discharge process can satisfy expectations for HRO accountability standards. Patients discharged home with homecare tend to encounter more delays than expected.Efforts to ease challenges of booking recommended follow up appointments within expected timelines are worthwhile. Untimely and inconvenient ambulatory follow up appointments are a significant hindrance to successful transitions home from the hospital.

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