Published by: Jeff Critchfield on 9/27/2011 2:51:48 PM
During the early stages of the Support from Hospital to Home for Elders (SHHE) project we enrolled a gentleman who received dialysis several times a week at San Francisco General Hospital (SFGH). During intake the SHHE nurse noticed a pattern; the patient had frequent ER visits that frequently occurred on the days of his dialysis appointments. The patient was calling 911 to get to the ER to receive dialysis. He readily acknowledged having difficulty with attending his dialysis appointments secondary to transportation issues. A friend whom he relied on to drive him, frequently would not show up on the day of his dialysis appointments. During his hospitalization with recurring coaching episodes, we were able to share information that allowed him to advocate for a transportation voucher and he identified strategies with his medical home social worker to arrange a ride. On subsequent dialysis appointments he would stop by the SHHE office to say hello, celebrating that he had successfully gotten himself to dialysis that day.
Circumstances like Mr. X’s are unfortunately common. Psycho-social-financial realities in people’s lives significantly affect their success interfacing with the healthcare system. While there is an expanding body of work examining hospital readmissions and interventions, there is a much smaller evidence base for transitional care models that have been studied in low-income, multilingual, patients seen at safety net hospitals. To address this, with support from the Gordon and Betty Moore Foundation, we established the Support from Hospital to Home for Elders (SHHE) Project, a 700-person, randomized controlled trial, to assess an intervention designed to reduce avoidable hospital readmissions and emergency room visits in English-, Spanish-, and Cantonese-speaking elderly patients. With me (Jeff Critchfield) and Sue Currin, the CEO at SFGH as co-principal investigators, the study is a collaboration between the University of California, San Francisco and the San Francisco Department of Health.
In collaboration with the Project Red group at Boston University Medical Center and drawing from the published work of Eric Coleman’s Care Transitions Program, we developed the SHHE Project to address the challenges of San Francisco’s safety net patients. Hospitalized patients over the age of 55 who are returning to the community and have access to a phone, are randomized to usual care or usual care + the intervention. Those randomized into the intervention are visited during their hospitalization by a culturally and linguistically concordant SHHE nurse who offers coaching to activate and educate the patient and caregiver(s). The coach also develops a personalized transition plan based on the patient’s self-identified goals which they take home. During the post-hospitalization, within the first 48 hours and again on days 8-10 patients receive follow-up calls from a SHHE NP who reviews the medications and follow-up appointments detailed in their personalized after hospital care plan. The phone calls are opportunities to assess the clinical needs of the patients, and as needed, coach patients and caregivers to identify resources and strategies to meet identified needs.
For RNs, working as a SHHE nurse has meant a shift in the nature of care that they provide their patients. Richard Santana, a SHHE Nurse, recalls one patient’s intervention in particular:
Mr. Y was a 65 year old Hispanic man. In Latino culture, it is customary for the wife to be identified as the primary support person for her husband. However, after speaking with the patient and his wife it was clear that the wife was unable to provide adequate support. Mr. Y and I were able to work together to identify his daughter was actually functioning as the main caregiver. The three of us worked to set goals regarding Mr. Y’s health post-hospitalization. I was then able to coach on Mr. Y’s condition, medications and how to navigate a very complicated healthcare system in the context of Mr. Y’s own wishes regarding his health. Through frequent bedside visits and personal knowledge of Latino culture, I was able to successfully provide a level of care above and beyond what I am able to give as a floor nurse.
So far we have enrolled 375 patients in the trial, with enrollment of a total of 700 patients scheduled to end March 2012. We anticipate having initial results by Fall 2012 to answer our primary aims of impact of the intervention on readmission rates at 30, 90 and 180 days compared to the usual care. The study will also provide key understandings for what factors most influence the prevalence of readmissions for safety net populations.
The SHHE project was designed with specific thought to patients disproportionately represented in safety net patient populations, we anticipate lessons from this work will emerge to inform all hospitals who aspire to provide excellent transitions in care for the culturally diverse patients they serve.
To learn more about the SHHE Project please contact Jeff Critchfield at jcritchfield@medsfgh.ucsf.edu .
This blog post was co-authored by Danielle Moulia and Jeff Critchfield (pitcured below).
Jeff Critchfield, MD
Chief, Division of Hospital Medicine
Medical Director, Risk Management
San Francisco General Hospital