2014 JQS Award Nominee, JQS2014

Griffin Hospital


As a Planetree hospital, Griffin Hospital is committed to engaging patients and families with access to information and education. In 2012, we identified a lack of consistent patient disease education with teach-back which contributed to a high readmission rate for Heart Failure. We introduced “Here To Home,” a program to address communication and patient education within the hospital and across transitions of care. Utilizing bedside rounding, education with teach-back and a community collaborative with other providers, we reduced readmissions by 35 percent, increased HCAHPs discharge information score to 89.7 percent and maintained core measure composite of 100 percent for FY 2013.


In 2012, Griffin Hospital identified a high readmission rate for Heart Failure. A hospital wide education summit was held to evaluate the current state of patient education. The need for more comprehensive patient centered disease education, medication education, and discharge education with teach back was identified. A multi-disciplinary group consisting of physicians, nursing, case management and Clinical Informatics began to meet weekly to develop a program to increase patient access to information and education. The initiative was called HERE TO HOME. Internally, we created bedside rounding by the healthcare team to involve patients in care decisions and to improve their confidence with their after hospital care plan. Hospitalists were re-assigned geographically to be more accessible to patients for shared decision making and to the rest of the health care team. Through innovative software, we engaged patients in an interactive disease education process through an electronic touch-screen program that patients could repeat as often as desired. A color coordinated patient friendly “After Hospital Care Plan” was created which included patient’s primary care physician, pharmacy and important telephone numbers. A discharge medication list with purpose, administration and dosage is displayed in fourth grade literacy as well as a calendar of follow-up appointments. Through the “Med to Bed” initiative, new prescriptions are filled in our retail pharmacy prior to discharge. An Advanced Care Planning Team has been created as well to provide patients with options regarding advanced directives, palliative care and direction of care issues.

Patients are offered an “Education Menu” of after discharge programs to best meet their individual post discharge needs. These include a 30 day telephonic coaching program, free weekly Wellness Clinic appointments, and traditional home care (HHS) and short term rehabilitation (SNF) referrals to providers in our community collaborative. Patients are provided a community resource list that includes SNF and HHS readmission rates for the past year as well as the Medicare Hospital Compare star rating for skilled facilities for shared decision making.

Skilled facilities and home care agencies in the community were invited to become part of a collaborative to reduce avoidable readmissions for Heart Failure. Members of the collaborative agreed to use a shared teaching brochure and committed to provider-specific heart success indicators. Monthly meetings were held to drill down reasons for readmissions. Although it was difficult at first for collaborative members to speak openly about care issues, everyone eventually became more comfortable and improvements began to occur. A total of 23 touch points were identified for improvement. Some of these improvements included the skilled facilities sending patients home with prescriptions to complement their “bubble packs” to ensure that patients have enough medications to last until their next physician appointment. Hospital transition of care hand-offs to facilities improved and skilled facility hand-offs to home care agencies improved. Home Care Agencies ensured that patients had transportation for follow-up appointments, had adequate social support and performed careful medication reconciliation with patients and families.


For Fiscal Year 2013, Griffin reported:

  • 35 percent reduction in Heart Failure readmissions, from 25.8 percent (59/229) to 16.7 percent (30/180)
  • Heart Failure Core Measure Composite Score maintained at 100 percent
  • HCAHPS Discharge Education score increased to 89.7 percent from 88.1 percent

Of other education menu options offered:

  • 70 patients enrolled in our 30 day health coach daily check-in program; 45 patients have completed the program with five readmissions for a readmission rate of 7 percent.
  • Patient satisfaction rate with the health coach program has been 94 percent.
  • Of the 83 patients enrolled in our Heart Wellness Clinic to date; there have been three readmissions, two of which were unrelated to Heart Failure.
  • Patient satisfaction rate with the Wellness Clinic was 95 percent.
  • Overall, the community collaborative has been instrumental in decreasing our total Heart Failure population by 21.4 percent during the fiscal year.

Going forward in 2014, Griffin will expand its education, coaching and clinic programs to include pneumonia, COPD and AMI. We are currently identifying preferred providers among our collaborative members to partner with to create shared care pathways across transitions of care. These pathways will then be shared with all collaborative members for same page care from HERE TO HOME.

Lessons learned:

  • There is a need for greater advanced care planning at each level of care especially in regard to advanced directives, palliative care and what matters most to the patient. Education in this area will be a priority in 2014.
  • Further engagement with patients is critical as a significant number of referred patients to the Wellness Clinic and Coaching Program enrolled but canceled before starting the programs.