2014 JQS Award Nominee, JQS2014

Kings County Hospital Center

by Mauvareen Beverley, Deputy Executive Director, Case Management • August 13, 2014 • 0 Comments

NOMINATION SUMMARY

In September 2011, Kings County Hospital Center (KCHC) implemented a Care Management Department that developed a culturally competent process designed to improve communication and collaboration with patients and families; resulting in improved outcomes of care and greater patient safety. To understand our patient population, research was conducted on migration histories, health disparities and cultural beliefs of the population served. Cultural competence and compassion proved to be the innovation that spawned understanding of our population and improved collaboration with patients and families. We reduced CHF 30 day re-admissions, decreased Emergency Room visits and hospitalizations for patients with complex or multiple chronic diseases.

NARRATIVE

Cultural competence is critical for effective communication and will lead to greater patient safety through understanding. Through patient interviews, we learned that 80-90% of our African American patients are from North and South Carolina. This information allowed us to better understand how past experiences may foster mistrust of the health care system, which may contribute to the perception that patients were non-compliant with their care plans. Improving our cultural competence allowed us to address past negative experiences and engage patients more effectively. We identified Caribbean Islands from which our patients migrated and identified language resources needed for effective communication. We developed an innovative approach to educate staff on the “historical baggage” that can affect patient beliefs and trust. For example, the Tuskegee Study and Jim Crow Laws may have impacted some elderly African-American patients. The herbal medicines used in the Caribbean population were given high importance as well as a comprehensive social history that goes beyond “No Toxic Substance.” A patient from South Carolina said, “I don’t trust you doctors.” Rather than involving Psychiatry for paranoid ideation, we should ask, “Why don’t you tell me about your health care experience?” If the patient’s story is horrible, apologize for what happened because of the importance of removing the patient from the past and place them in the “here and now.” KCHC staff is trained to understand that the word “patient” is not the sum total of the complexity of an individual, and there are health and financial costs associated with negative terminology. We eliminated the use of negative language, such as frequent flyers, non-compliant without “why” or drug seekers, as it creates a culture of callous disregard. The Care Management team transformed each patient experience by designing the interventions based on what was learned about the patient with the following questions: Who is the individual? What are their fear factors? What is important to the individual? Where is the individual in the acceptance of the disease? Armed with the answers to these questions, the team works with patients, families, health plans and home care services to improve care coordination and to successfully transition patients back to their homes through the use of the following interventions:

Congestive Heart Failure (CHF) Task Force: Weekly CHF interdisciplinary meetings are held. Patients and families are invited and given the option of phoning in if they cannot attend in person. Example Patient Voice: 23-year-old, African-American male, employed as an assistant chef, uninsured, without previous medical problems, newly diagnosed with CHF due to viral myocarditis. Parents were devastated and patient wanted to know what he needed to do to live. The care management team focused on decreasing fear factors. Patient was discharged with homecare and dietitian services. We utilized his skill as a chef to prepare his meals appropriately, secured health insurance inclusive of heart transplant provision, and within 6 months, he lost 100lbs, Ejection Fraction increased from 10-15% to 35-40%, and grandmother described him as more outgoing and social.
Emergency Department (ED) Care/Case Management: An interdisciplinary team identifies patients who are “Avoidable Admissions.” Care managers are contacted to coordinate safe discharge, inclusive of home care visits, 48 hour phone calls, early follow-up appointments and communication with primary care providers.
Pharmacist Home Visit: Staff pharmacist and Visiting Nurse piloted a home visit to conduct the ultimate medication reconciliation. Findings included:

  • Some medications were not prescribed by KCHC physician
  • Herbal medicine
  • Prescription not filled by pharmacy even though dosage was changed
  • The intervention was a new process requiring documentation of home medication reconciliation.

RESULTS

According to Consumer Report in 2012, KCHC CHF 30-day readmission for the first time is in compliance with the national norm and has a low projected penalty percentage .26% for readmissions in 2014. In-hospital data- CHF 30-day readmissions for 2011 and 2012 were respectively 23.9% and 21.1% ED data- 7-day revisits for 2011 and 2012 were respectively 10.2% and 7.3%

ED Care/Case Management Initiative Patient Voice: 48-year-old Jamaican Rastafarian presented to the ED for dizziness and headache which resulted from uncontrolled hypertension. He usually does not take prescribed medicines; instead, he uses herbal remedies as he does not believe in Western medication. Care manager asked, “Did the medications we gave you help your symptom?” Patient responded, “Yes.” Care manager told the patient, “Maybe your body is telling you something and not us.” Result: The patient agreed to take the prescribed medications for 2 months and to use the clinic; however, if he found no improvement in his condition, he would return to using herbal remedies. In this example, the care manager respected the patient’s cultural beliefs and was able to employ a patient-centered approach that enabled him to collaborate on his own terms. Non-compliant language was avoided.
Process Improvement Uncovered Medication Discrepancies Due to the pharmacist home visit, a subsequent pilot with Visiting Nurse Services (VNS) Homecare Services was launched, which focuses on medication reconciliation for 84 patients. Twenty-six percent of patients had medication discrepancies, which resulted in Homecare being required to submit all medication findings in the home. While not quantified, this result may have also contributed to KCHC’s decrease in readmissions. Care Management collaborating with physicians has proven to improve patient and family engagement, decrease readmission and ED visit, thereby decreasing the chance for patients to experience error. Other departments including Nursing, Residents and Human Resources have requested training on cultural competence and patient engagement.