Open! MBQIP 2 Outcomes: Improving Care Transitions

We did not forget about the MBQIP 2 Outcomes project for this grant year; it was in flux with the unknowns of “the coronavirus season” (as my 7 year old calls it).  In addition to the logistical complications a pandemic has, the staff leading this project – Jamie Schultz with the MT Flex Program and Casey  Driscoll with the MT HIIN – have moved onto different positions (Casey is still with us at MHA, just with Hospital Preparedness).

We are getting a later start this year and we are not able to implement face to face gatherings, but prior to their role departures, Jamie and Casey developed an impressive program that I would like to now introduce to you.

2020 MBQIP 2 Outcomes – Improving Care Transitions

Project Description:

Discharge planning and patient communication are frequently targeted in improvement projects, but most hospitals continue to struggle to show measurable or sustained improvement.

The MT Flex Program will provide an interactive approach for improving aspects of care transitions as well as development of a hospital and community services capabilities and resources list to aid the discharging hospital in meeting patient needs identified during the discharge process.

Project goals include: reducing readmissions, improving HCAHPS care transitions scores, improving patient outcomes, and meeting discharge planning conditions of participation (§485.642)

Project Objectives:

  • Hospitals share current discharge practices and identify gaps in practices using CMS’s conditions of participation & other identified best practices
  • Ensure all hospitals collect and communicate with the patient and/or patient representative the findings of the patient discharge evaluation including:  the discharge plan, treatment preferences, post-discharge goals and post-acute care provider
  • Compile a list of services and capabilities for each facility and resources available in their surrounding communities by identifying treatment options available that aid in the post-acute care of the patient (meets new discharge planning condition of participation)
  • Reduce readmissions through better discharge practices and improved patient communication

MT CAH Obligations and Expectations:

  • Bring together team members who commit to and are willing and excited to share discharge practices with CAH peers
  • Complete data collection on:
  • Readmissions & discharge processes
  • Hospital & Community Services, Resources & Capabilities
  • Attend and participate in virtual workshop(s) to analyze current discharge processes and discuss hospital and community services available regionally and through state partners
  • Complete simple project outline, including:  Current state analysis, issue identification, root-cause analysis, implement improvements & track results.
  • Share findings and experience during project webinars.

Linked here is a full project description, a very tentative schedule, and overview that includes a project registration form and the tool that is referenced.  Prior to the project registration deadline, we will provide a webinar or video overview of the tool; how it works, and how we hope your facility will benefit from it by participating in this project.

I am sure you have questions, so please feel free to shoot any over to me.

Jennifer Wagner, CPHQ

Rural Hospital Improvement Coordinator

Office: (406) 457-8000 |[email protected]