Improving Care Coordination by Streamlining Patient Referrals

Regions Hospital, St. Paul, Minnesota

Increase acute myocardial infarction (AMI) heart attack patients’ participation in post-discharge rehabilitation.

Modified order set in electronic medical record (EMR) and made appointments for rehabilitation at the bedside before patient discharge.

Referral rates to cardiac rehabilitation are approximately 60 percent higher than the national average.

Regions Hospital
640 Jackson Street
St. Paul, MN 55101
Ph: (651) 254:3456

From the Experts:
“We are helping our patients transition more effectively to the outpatient setting. The slight changes we implemented will make a significant difference in patient outcomes.”

Gretchen Leiterman, M.B.A.
Vice President of Cardiovascular Services & Quality

Regions Hospital is a full-service, private hospital providing medical care, with special programs in heart, cancer, behavioral health, burn, emergency and trauma.

Clinical areas affected:

Staff involved:

  • Cardiologists
  • Nurse practitioners
  • IT/EMR staff

It took several months for the team to develop strategies to improve referral rates, secure buy-in, and work with the nurse practitioners and IT and EMR staff to implement.

Jon Schluck
Regional Manager of Cardiovascular Outreach Operations
Ph: (651) 254-2346

Innovation implementation:
Patients who have recently experienced heart attacks (acute myocardial infarction) benefit from the counseling and lifestyle modifications offered in cardiac rehabilitation. Research has shown that minorities are less likely to receive the necessary procedures and treatment for cardiac care. Nationally, experts say that only 18 percent of all patients who have experienced an acute myocardial infarction received referrals for rehabilitation after discharge.

Reviewing the existing process of patient referrals and identifying potential hurdles of compliance, the team at Regions Hospital discovered that discharge order sets were often not triggering recommendations for cardiac rehabilitation, and if they were, the responsibility to schedule rehabilitation sessions rested solely with patients once they returned home. Unfortunately, this often meant that none were scheduled and the patient did not participate in the necessary post-discharge rehabilitation.

To address these challenges, the Regions team decided that altering the first part of the discharge process was key. Modifying the discharge process required changes in the hospital’s electronic medical record. The team worked with the cardiac care department chair to raise the issue that the EMR needed to be modified to automatically recommend referrals for cardiac rehabilitation. The cardiac care chair raised this issue with executive-level staff and secured their buy-in to implement the new policy. By working with the hospital’s IT staff, the team was able to ensure the discharge order sets for cardiac patients included a pre-checked order for referrals to rehabilitation.

Next, the team informed nurses of the change by posting flyers that instruct them to notify rehab staff if there is a discharge order for rehabilitation when this happens. Cardiac rehab staff are summoned to the patient’s bedside to schedule rehabilitation sessions. At this time, patients are given all the information about their appointment, including the date, time and directions.

Advice and lessons learned:

  1. Having an electronic medical record is key. It makes the process easier to implement systematic change.
  2. Engage a physician champion. The ability to enlist a high-level physician leader as a champion helps speed up the process.
  3. Schedule patients for outpatient rehab while they are still an inpatient. Catching patients before they leave greatly increases your chances of scheduling them and that they will participate in the rehabilitation after discharge.

Cost/benefit estimate:
This simple change had no significant cost increase associated with it but had the effect of increasing cardiac rehabilitation referrals to levels well above the national average, which led to improved patient outcomes and reduced mortality rates.