The power of collaboration

A guest post from our Vice President of External Affairs, Janice Sullivan:

This blog has recounted the VNA of Boston’s continuing efforts to ensure our outcomes exceed both state and national benchmarks. Many of these outcome measurements (found on medicare.gov/HomeHealthCompare) are intended to improve care for chronic diseases and to keep people out of the emergency rooms and hospitals. One of the indicators we pay most attention to is the re-hospitalization rate for our patients and I’m proud to say we beat state and national benchmarks here.

Our referral partners at acute hospitals around the state also are diligently working on initiatives to prevent unnecessary hospital re-admissions. Not only is it better for the patient, but hospitals won’t be paid for these readmissions very shortly. It all ties back to providing value in the health care system. More efficient and high quality providers will be rewarded, the others…not so much.

Work on this initiative can range from improving the discharge process and paying attention to smooth transitions of care to implementing comprehensive clinical processes to insure better care for patients with certain chronic diseases. And, we’d contend, successful initiatives will have a strong home health care partner at the planning table to see real progress in reducing unnecessary readmissions. Our hospital partners are acknowledging this as well.

At a recent joint meeting regarding these initiatives at one of our acute care teaching hospitals, Dr. Eric Coleman, a national expert on care transitions, facilitated a discussion of a patient and the patient’s history of readmissions. The selected patient had received services from the VNA of Boston. The hospital discussed their perspective of the patient’s care and the VNAB team discussed it from their point of view.

There was a rich and thoughtful conversation with many on the hospital side of the table and Dr. Coleman expressing their admiration for the work being done by the VNAB to have kept the patient out of the hospital for as long as we did. They were also struck by the fact that we grounded our treatment plan not only on what was best clinically but what was best from the patient’s point of view. The meeting ended with more in-depth understanding and learning by both the hospital team and by the VNAB team…with commitments to follow up individually and as a group.

Bottom line, this type of collaboration will lead to value for the health care system, better processes to ensure smooth transitions and most importantly, better care for the patient. My congratulations to the VNAB team of clinicians. They have persevered to improve the health and well being of a patient who is facing a myriad of complex health challenges in a complex and fragmented health care system.