| Objective 1: Identifying and documenting the sepsis diagnosis |
| Care coordination - Barriers |
| “Yeah, I mean I think the hard part is, number one, the identification … you know, if their diagnosis inpatient is sepsis, does that then correlate to a discharge of sepsis because we know a lot of these people have a lot of other comorbidities. They come in as a UTI, their CHF gets in the way, and then we all get jumbled in what our focus of care is…so we do not even know about them until they are already on their way home, and I think that that’s a challenge.” (acute care, dyad 2) |
| “I’m not sure diagnosis in general or sepsis is adequately communicated. I think we have a working DRG that pops up in- we have a column in our electronic health record for a working DRG, which is you know a moving target. I think there’s competing diagnoses. Sometimes if someone’s here and they are listed as sepsis, they have a procedure or something else crops up it bumps sepsis lower on the list. So, [for] I think identification of the patient, I think there’s probably opportunity to improve it.” (acute care, dyad 1) |
| “A lot of times, whoever, and some of this is really just playing with ongoing physician education and provider education is to try to use sepsis as the diagnosis it that’s really the main diagnosis because we often see that a patient might be listed as UTI or pyelonephritis or pneumonia, bacteremia instead of really having that keyword sepsis.” (acute care, dyad 2) |
| “I was just looking at many charts that I knew had sepsis and the identification just wasn’t there. Because that’s not what the problem was. The patient came in with lower back pain and they ended up having sepsis due to hardware. So up front the sepsis identification was not there.” (acute care, dyad 5) |
| Definition of sepsis - Barrier |
| “It would align with the sepsis three [Sep 3] definition and it would acknowledge the clinician’s documentation failure, which is quite common that we as clinicians recognize infection, we separately recognized organ failure, but often in the heat of the moment of a daily medical record do not call it sepsis. The usual approach would be someone writes pneumonia and then at some point theyA navigator tab write acute kidney injury, but they do not link them in some clear and consistent and transparent sort of documentation method.” (acute care, dyad 1) |
| EHR - use of the problem list - Barrier |
| “So, the problem list is usually very off track. Sometimes it says no problems and the patient has been here for 10 days. Sometimes it says epistasis and the patient is here for AKA. It’s just not accurate.” (acute care, dyad 5) |
| “…you know-[EHR brand], which we use, is definitely designed to run from documentation from problem lists. Our system chose not to use that approach, and it’s for good reasons. It’s bulky, it’s- it’s hard to categorize which problem is more important. So, we do not document in the problem list in [EHR brand]…So, if I come in with sepsis, but then I also have COPD and they are both high, where do they line up? …and looking at the note, it looks ugly. And that’s why people are hesitant to use that. But that would solve most of these problems because you are forced to identify it as sepsis or not. But we do not document that way. That could be- if we were forced to use that-probably solves about 80% of the problem.” (acute care, dyad 1) |
| “Something we have done is to add that sepsis diagnosis in to [an] order set to go on the problem list. So that’s kind of how we identify it. We do know that we are not that great at- from a problem list standpoint, we are not that great because we miss it on both sides. The screening, I would call it, is very sensitive for sepsis. Some people we name sepsis end up not being coded for sepsis. And then on the other side, sometimes, even though we are treating appropriately as in the documentation ends up being coded for sepsis, it’s not on the problem list. So, we are not that great from a problem- problem list to call it sepsis. We missed it on both sides. Although, we are much better at documenting. So, in the notes … we are very good at calling it sepsis in our notes. That’s how it gets coded. But from a problem list in [EHR brand] standpoint, a lot of things rely on that. We’re, you know, we are actually better than most of the places. We’re still not that good.” (acute care, dyad 1) |
| “I cannot tell you the number of times I open a new H&P [history and physical] and there are no problems documented in the problem list, and so I have to take it on myself to actually, actively document, some of the things that are going on with that patient. This patient has sepsis, this patient has hyponatremia, for example, and I try to document those things for the record, not just for us, but, as we all know, for continuity sake, for the next provider of care whether that’s a home health care person, primary care doctor or another healthcare facility, if that patient gets readmitted.” (acute care, dyad 1) |
| EHR - Facilitators |
| “So, we have a definition of sepsis that we follow. And we have some predictive models and EHR that suggest that a patient may have sepsis. And it currently- it’s basically based on SIRS [systemic inflammatory response syndrome], etc. And in [EHR brand], we have a sidebar and a checklist that kind of says ‘This patient may have sepsis’. And it starts early in the emergency department” (acute care, dyad 1). |
| “It did take some time to actually get this as a checklist within [EHR brand] but I’m hopeful that it will kind of target providers to thinking more about sepsis. Um and it does have a whole navigator tab where they can do certain documentation, as well as have access to the problem list to hopefully add sepsis to the problem list earlier on, because I think that’s the easiest way really to sort through [EHR brand] if Sepsis is not on the problem list. It’s very easy to generate a list of patients from the start.” (acute care, dyad 2) |
| Quality monitoring of service - Facilitator |
| “The way that this is handled in the back end is through what’s known as CDI team, the clinical documentation improvement team. We recognize that the inability to disseminate the information up front is a challenge, there will be a slow uptake and then the CDI team emails clinicians in real time, and both educates them and prompts them to use different terminology so there’s the back-end way to address this.” (acute care, dyad 1) |
| Objective 2: Identify sepsis patients for home health referral |
| Patient behavior, decisions, and preferences - Barrier |
| “Sometimes patients have co-pays and they do not want to pay. That’s a big barrier, the financial part.” (acute care, dyad 1) |
| Staffing - Barrier |
| “We do not have an identified individual who is the sepsis coordinator and down the line I think if work like this wants to be sustained and continued, I think that is a key role and kind of figuring out how to demonstrate the importance of that role not only qualitatively, but fiscally I guess to the institution is going to be something that we are going to have to think about.” (acute care, dyad 1) |
| “I have not had luck with the care coordinators, which is the reason why we went to the directors of med surg. I try [tried] to work with care coordination, so I just work around them. They were so busy.” (outpatient, dyad 3) |
| Care coordination - Barrier |
| “Education is provided to patients, but I would say that the amount of knowledge set of [acute care] nurses with home care agencies is little to none, and they, they are not really involved in that discharge process in terms of discussing home care or discussing sepsis at home, I would say.” (acute care, dyad 4) |
| Staff education - Barrier |
| “A lot of times, things have a lot of emphasis and then the emphasis moves, and so I actually think that the sepsis alert and just the whole sepsis issue, really, probably is kind of under-valued at this point. For example, in acute care we do some work with a lot of new nurses, and I’m really curious actually if they even understand what the narrator is, if they are ever formally trained on it, or if it’s assumed that the preceptor will discuss it. I’m actually wondering if my nurses even know what to do with the narrator. I actually do not think they do, to be honest.” (acute care, dyad 4) |
| “We’re seeing a lot of case managers leaving the case management world. So, I’m sure that the people who have been there, a long time, and that they know the drill, they probably are pushing that for the patients, but maybe some of the newer hired case managers just really have not had time to learn that is part of their role, so I’m sure it just varies case manager to case manager.” (acute care, dyad 5) |
| Staffing - Facilitators |
| “…initially we’d have the hospitalist sign the home care orders. And they usually will do that in the interim.” (acute care, dyad 1) |
| “If there’s a barrier or question, [they have] an on-site liaison here at our hospital for about four hours each day, Monday through Friday. He’s also available through Microsoft Teams that we can message, or he has a phone that he carries. So, we are in close contact with him throughout the day for any of those patients that are questionable or we are trying to work together to get services.” (acute care, dyad 1) |
| Acute care policies, pathways, and processes - Facilitator |
| “…it’s a tool that we use that’s in [EHR brand]. And it asks several different questions. We actually just did some recent enhancements to it. But it’s asking things like, what risk factors does the patient have at home? Do they live alone? Do they have support? How was their daily function? It kind of goes over all those areas to help us determine if they are going to have discharge needs. And that’s done just by chart review. And if they, what we call “Screen Positive” in any of those areas, then we have a nurse care manager or a social worker see that patient face to face. And at that point they do a full evaluation and create a discharge plan.” (acute care, dyad 5) |
| “The process by which they get referred to home health, I mean there’s- we have an interdisciplinary team meeting every day. We call it ‘care progression rounds’ in our hospitals. Care coordination is part of that, nursing is part of that, therapy is part of that. Occasionally, you have a provider, not occasionally probably 60% of the time, you have some sort of provider that’s part of that process. And we are reviewing the status of the patient, we are identifying what their needs are post discharge, and we are making decisions based on conversations we have with the family, with the patient. Whether there’s somebody that’s going home and is going to require home care, whether they are- or whether they need some other level of care. Once they have been identified as a potential home care candidate, we make a referral to our home care agency where their liaisons come in and do an assessment of the patient and helps us with the process from there.” (acute care, dyad 2) |
| Home health internal policies, processes, pathways - Facilitator |
| “For the appropriate patients we do try to get patients home as opposed to skilled nursing facilities. You know, I think we try to be judicious with this. I think there is a push to avoid going to nursing home if they can be taken care of well at home… And that’s one of our system goals and entity goals.” (acute care, dyad 1) |
| Objective 3: Refer patients to home health care |
| Information Transfer - Barrier |
| “I think on our staff’s end, our staff gets really frustrated because sometimes they get multiple messages- the same message four different ways. And sometimes then- sometimes I think we do not get any messages. So that’s kind of frustrating too” (acute care, dyad 1). |
| EHR - Facilitators |
| “It [software] helps me connect my patient in a county area with a home care agency that services their specific zip code. So, I will say it worked. It got me a home care agency.” (acute care, dyad 1) |
| “We use [EHR brand] with [HHC agency] so all our referrals come through as [EHR brand] alerts and requests. Discharge planning software called [software brand] facilitates referrals and information transfer. It’s been a big reduction in phone calls and voicemails if everyone keeps [software brand] up and running live.” (acute care and home health, dyad 1) |
| Care coordination - Facilitators |
| “Before we even call that patient, we will call the PCP and verify that the information is actually accurate, the appointment is there. We will call the home health agency and make sure that (A) they are aware that they were referred to them and then (B) we verify they have the orders, etc., … so there’s a certain level of follow up and accountability, with the referred agencies.” (outpatient, dyad 3) |
| Staffing - Facilitator |
| “We have our [HHC agency name] liaisons that are on site that work very closely, certainly with the care coordination team, as well as the multidisciplinary team, and they represent home health, infusion, hospice, and palliative care, and so very easily if they are told, then they will go ahead and do all the legwork to make sure the referral is pretty, packaged in a bow, and sent off and accepted and taken care of.” (home health, dyad 3) |
| Objective 4: Transfer clinical information to home health care |
| Care coordination - Barrier |
| “I think that if it’s resolved, they will not code it for sepsis.” (acute care, dyad 5) |
| Information transfer - Barriers |
| “We’ll also be looking at discharge information, but as anybody who’s looked at discharge information has seen it’s a ton of information. So, it makes it a lot harder to sift through if you are trying to determine if somebody is a sepsis survivor by looking at a hospital chart. It’s a lot harder to see that than if it just goes right into a referral.” (home health, dyad 1) |
| “I really do not think it’s continued after it’s been resolved, so if the patient is not actively in sepsis, you know, is [not] actively septic any longer, then I do not believe so, it would be more just communicated in the report and notes, and things of that nature, so it would just be part of the clinical understanding.” (acute care, dyad 4) |
| “But if you do not share the same chart system, if you do not have access to [EHR brand], then those folks do not know that that patient was even admitted and what they were admitted for. I will say like the hospital has been a challenge in that way sometimes for some patients where, you know, they were not even aware of one of my patient’s admissions from like a year ago. And so, I had to re- resend them records…this was relevant to this patient care. And you are the primary office. And either you are not believing what a patient is telling you, or you are not requesting records from us. And this is a problem.” (acute care, dyad 1). |
| “You know not only can we not code it, but now our coding, you know we switched the way we code in home health for I think it was October of last year. it’s trickier to have it in our ICD 10 codes.” (home health, dyad 3) |
| Staffing/Information transfer - Facilitator |
| “When reviewing the clinical chart and the clinician is going out, they’ll be made aware. The only other stop gap would be is if we are identifying that this patient has sepsis, we being [the] transitional care center, is verifying that, “oh, look, it’s on our sepsis query. They’re a sepsis patient.” When we call the home health agency to instruct them like, “hey we are just double checking, you know, you have these orders,” as well. We do verbalize that to intake, and it is, of course, on to intake to document that internally and take it from there. With [HHC agency name], certainly, it’s an internal system. It’s a little bit easier, I can go into their chart and document that myself for them, and they can see it, but more often than not, it’s verbalized to the partner companies.” (outpatient, dyad 3) |
| EHR - Facilitators |
| “But I know as far as patients that have that sepsis diagnosis in their problem list, … when we print out their discharge paperwork it gives them a sepsis awareness list of signs and symptoms to look for. “If you run into these symptoms, please contact your doctor” or “If so severe, go back to the emergency room” (acute care, dyad 1) |
| “The goal of the banner was just a visual cue for my team for both case management and social work so that when they did the handoff whether it was to home care or the skilled facility they were reminded to tell the next level of care that this was a sepsis survivor and put on the referral.” (acute care, dyad 1) |
| Objective 5: Making the outpatient appointment within 7 days of hospital discharge |
| Care Coordination - Barriers |
| “And it’s very hard when we discharge patients to get follow-up appointments. If we can do it and it’s hard, it’s 10 times harder for patients to get through to the call centers and everything. So, you know, ideally if we could have a centralized way to do this it would be lovely. But no one has the time to do it. Unit coordinators complain, social workers cannot do it, physicians and providers cannot do it. Nobody has the time.” (acute care, dyad 1) |
| “I know my social work colleagues have heard me say this for years, we do not make appointments for patients when they are leaving. I think that is one key, and this has been studied, if they have an appointment when they are being discharged, they are more likely to go and see the patient- their primary care doc.” (acute care, dyad 1) |
| “I believe that at our hospital when we- when they took on that initiative, it was done by the unit techs. They would schedule the appointments prior to a patient’s discharge. But it just ended up being that oftentimes the patient had to reschedule the appointment anyway because it did not work. The date and time did not work for them or what have you. So, I think it just ended up being it wasn’t worth the time to do that because it wasn’t working for the patient.” (acute care, dyad 2) |
| “It is the ambulatory team today that has that direct access [for scheduling]. So, while we have the inpatient team trying to make that appointment, on behalf of the patient, they still have to do it through the ambulatory team. …to me that’s a barrier, we need to remove.” (outpatient, dyad 2) |
| “My most disheartening was I was setting up a patient with the health clinic and it was a new patient follow up and they were not accepting new patients till the year 2022. So, what they do is they would have X amount of emergent appointments every day. But as far as for a PCP appointment, this new patient 2022 I was like you have got to be kidding me.” (acute care, dyad 1) |
| Staffing - Barrier |
| “I think the concern on our end, frankly, is our staff cannot be making appointments. We do not have the bandwidth. And that’s- you know, I think everyone’s going to say that. It’s just there’s only so many of us. And to make appointments, you know?” (acute care, dyad 1) |
| Patient behavior, decisions, and preferences-no-show outpatient - Barrier |
| “The doctor’s offices were complaining because patients were not showing up for their appointments, and they were blocking all this time for hospital discharges. And then they were not making the appointments. Patients were dissatisfied because they were not getting, you know- we were booking appointments, but they did not have transportation for that time. …and then they were not necessarily taking the initiative to change the time or that kind of thing.” (acute care, dyad 1) |
| Care coordination - Facilitators |
| “We do have unit clerk secretaries on each of the units that assist with setting up follow-up appointments and placing it on the patient’s After Visit Summary. So sometimes those appointments are there, and sometimes it’s for the patient ‘please schedule an appointment with infectious disease [in] three to seven days.’ So, nursing will be able to share. I think there’s five units that are trialing that now with [what] they are doing the appointments.” (acute care, dyad 1) |
| Staffing - Facilitator |
| “I’ll reach out to that office myself and just say, you know, ‘This patient was just discharged, is required to have a post-hospital appointment with your office. Can I verify patient information with you? Can you as an outpatient provider contact this patient directly to schedule?’ And that way, it puts that onus on that provider.” (acute care, dyad 1) |
| “We used to have a scheduler, and they did a pilot for a year, and then they removed it, but there’s talk about having it again, where the person would just schedule appointments for them, but as of right now it’s just the physicians.” (acute care, dyad 4) |