MSN6612 – Triple Aim Activity Log Interviewees Todd Chester

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MSN6612 – Triple Aim
Activity Log
Interviewees
Todd Chester
Sacred Heart Hospital Director of Quality Assurance
Mary Loudsinger
Sacred Heart Hospital Social Worker
Bob Van Ness
Home Care Liaison
Trish Walstrom
Care Coordination Manager
Informational Interviews
Todd Chester
Sacred Heart Hospital Director of Quality Assurance
What are some of the major cost concerns for SHH?
Todd: Like many rural hospitals, we have some serious financial concerns. For
one thing, we are incurring way too many costs in relation to readmission rates. I
can’t emphasize enough how problematic this is from a quality assurance
standpoint. We’ve always had a problem with readmission, but because of the
Affordable Care Act, this problem has become especially costly for us–and I know
that Vila Health is highly concerned. Readmission rates are high for a number of
reasons. For one thing, I don’t think we’re doing a good enough job assessing
barriers to care–especially the barriers involving financial and logistical concerns.
We’re sending people home with instructions for follow-up care, and then people
don’t follow up because we’ve asked them to do things that they can’t. So for
example, we tell them to make a follow-up appointment with a provider who’s an
hour away in Fargo, and they don’t have easy access to transportation, so they
don’t ever schedule the appointment. That scenario happens quite a bit around
here, since we don’t have a lot of health care providers in the area, and there’s a lot
of poverty. And there’s just the simple fact that people can’t always pay for
medication and follow-up care–so they skip these things and then end up back at
the hospital. Insurance deductibles are higher than ever and people are really
struggling financially around here, and even with the Affordable Care Act, we have
a fairly high percentage of uninsured patients.
Also, with smaller hospitals like ours, you always get issues involving economy of
scale. We’re a small hospital, which means that cost per case tends to be higher.
And when you’re smaller, that means your financial position is less predictable,
which makes long-range planning and contingency planning difficult.
What are some of the major patient care concerns for SHH?
Todd: Considering the constraints we have as a rural hospital, I’m proud of the
care we’re able to provide. But there’s serious room for improvement. Like many
hospitals, one of our biggest problems is turnover. It’s very challenging to get talent
to come to a community like this one and stay, especially when we can’t compete
financially with the pay in larger cities. It’s a brain drain. We’ve had a heck of a time
retaining doctors–they come here, get some experience, and move to a bigger city
at a hospital that can pay more. Or if they want to stay in the general area, they
wait for something to open up at Valley City Regional Hospital, or in Fargo.
Turnover definitely impacts patient care, as does our ability to find new talented
people.
What are some particular challenges with the population of this area that relate to
your ability to achieve Triple Aim outcomes?
Todd: One of our biggest problems is that this population is not getting the
preventative care it needs. Part of that has to do with income. Part of that has to do
with education–this isn’t the most educated population, and that demographic
tends to know less about health care and use preventative services less often. But
a lot of it has to do with geography. For a lot of people, going to a doctor or a
specialist means driving to Fargo, which is an hour away. An hour drive might not
seem like a big deal, but for an older person who doesn’t drive much anymore, or
someone who doesn’t have access to a vehicle because of poverty? That hour is a
real barrier to care. And there are a lot of family farmers in this area, and they can’t
drive for an hour, go to a time-consuming trip to the doctor, and then drive for an
hour back, because they literally can’t get away from the farm for that long. They
have time-sensitive chores like milking the cows, and finding someone else to do
these chores might be an expense they can’t afford. And frankly, some of our
patients are simply stubborn, old guys who won’t go to the doctor because they’re
too self-reliant. They refuse to go to the doctor when they think they can take care
of things themselves–which is fine if they have a minor cut, but it’s not fine when
they have undiagnosed diabetes.
Mary Loudsinger
Sacred Heart Hospital Social Worker
What are some of the major patient care concerns for SHH?
Mary: I think we’re not doing a good enough job meeting the specific needs of this
community. There’s a lot of turnover at the hospital–I guess a lot of rural hospitals
have that problem–and one problem that creates is that the people in the hospital
don’t know the population well enough. They treat patients here the same way they
would treat patients in Minneapolis or some larger community, and that doesn’t
work. And to be completely honest with you… well, a lot of patients think that the
hospital staff is talking down to them. A lot of our patients are farmers or
mechanics, or they’re in the military, and most of them don’t have a college
education. And we get these doctors and nurses from out of the area who are here
to get some experience and move on–and they don’t always treat our patients with
the respect they deserve. And even when hospital staff is respectful, I think they
don’t always pay enough attention to the health care needs of this particular
community. They need to understand that there’s just not an established norm
around here for getting preventative care, and that a lot of people have real
obstacles that make it difficult to get to specialists in Fargo or even just to the local
clinics.
What are some of the major cost concerns for SHH?
Mary: There’s a lot of cost associated with readmission rates. We get people back
in the hospital because they don’t follow the care coordinators’ instructions. I hear a
lot of venting about this in the hospital, and the tendency is to blame the patients
for failing to follow through. And there’s something to that–I mean, it really is
frustrating when patients don’t take care of themselves — but I think we also need
to look at how care coordinators can do a better job so that patients can follow
instructions. Some of that has to do with addressing barriers to care–like working
with churches and community organizations to make sure older people have a ride
to the doctor, or helping people find ways to pay for their medication. And some of
that is just developing better relationships with patients so that they trust the people
who are giving them instructions about their care. I think we all need to take the
time to figure out what each patient specifically needs before we try to send them
home with a care plan. I know we definitely don’t do a good job of taking cultural
considerations into account. Obviously this isn’t a very diverse area, but we do get
people in here who have last names other than Johnson and Nelson! And
unfortunately our staff doesn’t always have enough experience to help them. Like, I
recently met with an older Vietnamese woman who lives in this area who was
recently diagnosed with diabetes, and the care coordinator gave her dietary
instructions without considering the fact that she doesn’t eat a traditional American
diet. The care coordinator told the woman to avoid rice and noodles–well, that’s a
major part of her diet. We could avoid having that kind of patient readmitted into the
hospital if we took the time to ascertain her needs better.
What are some particular challenges with this area’s population that relate to your
ability to achieve Triple Aim outcomes?
Mary: It’s really hard getting people around here to get the preventative care they
need. There’s a lot of reasons for that, including cost. But some of it is that going to
the doctor just isn’t something people do around here. People are very self-reliant.
They’d rather take the time to stock their first aid kits than to get a check-up. So if
you look at the Barnes County Community Profile, the numbers for things like Pap
smears and mammograms are really low. It’s going to be difficult to achieve Triple
Aim outcomes with numbers that are that low.
Bob Van Ness
Home Care Liaison
What are some of SHH’s major patient care concerns?
Bob: Getting patients the home health care they need is really tough. Part of the
challenge is helping people pay for their home care, and that’s a big part of what I
do–helping people navigate their way through Medicare and insurance, or finding
them alternative resources if they need it. The hardest part, though, is that there
aren’t enough home health care resources in this part of the state for the aging
population. That means that people who really need care right away get waitlisted,
or they can only have someone come to their homes a few times a week when they
really need more than that. Unfortunately, this is the kind of region where we need
more home health care, not less, because the population is older and because
transportation is harder for people in rural areas.
We also don’t have nearly enough assisted living or nursing home care in this area-
-or hospice either, for that matter–which means that people who really need
assisted living either have to leave their community and move to Fargo, or they
stay at home. That means we have to get creative, like making sure there’s a
relative who can look in on someone to fill in care gaps, or someone from the
neighborhood or a church. Or sometimes it means calling to check on people
ourselves. All of that is time-consuming and less than ideal, but we really do have
to make do. I think that the care coordinators need to be more aware of this home
health care gap and put more effort into helping to fill that gap. I do what I can, but
I’m just one person.
What are some of SHH’s major cost concerns ?
Bob: Well, what do you think happens when people don’t get the home health care
they need? They wind up back at the hospital! I can’t even tell you how many older
people get sent to the hospital with injuries related to falls. We can’t prevent all of
that, but we could definitely cut that down with better home health care. I don’t think
this will ever happen, but I think the hospital could save a lot of money if they
opened an adjacent facility – maybe in partnership with Valley City Regional
Hospital – that offered nursing home care, and possibly assisted living and
hospice as well. Then we’d have a place to send people who really shouldn’t be at
home.
What are some particular challenges with this area’s population that relate to your
ability to achieve Triple Aim outcomes?
Bob: I’ve already talked about some of the challenges of our older population.
They don’t have a lot of money, they live in remote areas, and we don’t have
enough health care resources for them in the community. But another population
I’m concerned about are returning vets. I don’t know if anyone else is particularly
concerned about these guys, but I’m a vet myself. I served in Iraq, and I count
myself lucky that I came back healthy both physically and mentally. Injured vets
have home health care needs too, and we don’t even have the resources in the
community to provide for older folks’ home health care needs, never mind a
population that people don’t think of as needing that kind of care. And on top of
that, we have many returning vets in this area who are depressed and who
sometimes take their lives. That’s a hard population to reach before it’s too late,
because there’s such a stigma associated with mental health care for a lot of them.
I don’t think we can achieve Triple Aim outcomes until we make sure the vets in
this area are taken care of better.
Trish Walstrom
Care Coordination Manager
What could care coordinators do better that would help control costs?
Trish: We absolutely need to get readmission rates under control. People are
coming back to the hospital way too often because they’re not following the care
instructions that we’re sending them home with–and I know that costs the hospital
a fortune. And it’s tempting to blame the patients for not following through. I know I
hear a lot of venting about this, and some of that is justified–I mean, we have some
stubborn old people around here that just refuse to go to the doctor and think they
can solve their problems by themselves! But I have to keep reminding myself and
my staff that venting does nothing to control costs.
We also need to find ways to update our care coordination process so that people
follow through as instructed. That means we have to do a lot of things differently.
First of all, we have to make sure patients understand the instructions we’re giving
them. Then we have to take the time to make follow-up calls with patients to make
sure they’re doing what we told them to do, and help them problem-solve if they’re
running into any problems. Follow-up calls just are not a part of our process, mostly
because we’re just so busy. And that has to change. We have to prioritize follow-up
calls or people are going to continue to end up back in the hospital. In addition, I
think we need to better address barriers to care–cost, transportation, and whatever
it is that’s keeping people from taking care of themselves. It’s a huge problem that
there aren’t a lot of specialists around here. We need to find ways to help people
get to Fargo who don’t have the time or the money or the vehicle to get there–
because that’s where the specialists are.
What could care coordinators do better that would help improve patient care?
Trish: Frankly, I think we need to build up a better sense of trust with our patients.
We have so much turnover at the hospital, so they don’t know us. They know me,
because I’ve been here a long time, but I’m the exception–and I’m often
supervising and not working directly with patients. In a small community like this
one, trust is essential. If we tell a patient she needs to get a follow-up test done,
she needs to believe we have her best interests in mind–and she needs to know
we know what we’re talking about. Maybe that means more community outreach? If
the people in this community felt like they knew us better, they would feel more
comfortable at the hospital.
What are some particular challenges with the population of this area that relates to
your ability to achieve Triple Aim outcomes – and to be effective care
coordinators?
Trish: You know, there are a lot of challenges, but there’s one that kind of creates
them all: Nobody in the process sees themselves as part of a bigger picture. The
health care department, the patients, us, the churches – we’re all doing our own
thing and seeing only our own turf, and the whole idea of working together seems
like a huge leap. But unless we get creative about working together, none of those
individual factors will ever get solved. There are always going to be transportation
issues and self-reliant, stubborn older folks in a place like this. The question is, how
can we get creative so that those things – which aren’t going to change – don’t
stand in the way of our attempts to change for Triple Aim?
Email Response
Email you sent
We need to develop a plan to decrease the readmission rates!

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