Care Coordination Success Story: Rouse Warren County Home

This year, Quality Insights worked with facilities to reduce re-hospitalizations, emergency room (ER) trips, and adverse events that lead to them using care coordination strategies.

One participating facility — Rouse Warren County Home in Youngsville, Pennsylvania — said it has reduced its emergency department trips by 85.5% and re-hospitalizations by 38.41%, highlighting their dedication to improving outcomes for their residents.

Prior to collaborating with Quality Insights, the facility was working to mitigate their high fall rate and hospital transfers by forming a team to review its data related to ER trips, re-hospitalizations, and falls. The team created internal processes and were seeing improvements in their rates, but they wanted to get a second opinion to ensure they were headed in the right direction.

After attending an informational kick-off call, the team was encouraged to participate in the intervention led by Quality Insights’ Quality Improvement Specialist, Patty Austin, RN. The Rouse team met with Austin every week for 10 weeks and then moved to monthly meetings.

In these meetings, participants reviewed and assessed all hospital events from the prior week for any potentially preventable areas. Participants also reviewed all falls from the prior week to ensure good person-centered care planning was in place to prevent future events.

The team discussed both the individual event and the processes surrounding it, so the specific event and process gaps were evaluated.

The team developed a “watch list” at Rouse that is reviewed daily with the nursing home team and communicated to the floor staff. In doing so, the facility said they have been able to get ahead of significant changes, leading to fewer hospitalizations and fewer falls.

Each week of the intervention, the Rouse team participated in education surrounding a specific resource designed to help reduce hospital events. During the weekly review of individual events, they engaged in conversations and analysis of how each tool may have impacted the hospital event or fall.

Upon completion of the project, the team adopted the following tools provided by Quality Insights:

• Adverse Event QAPI Review
• SBAR for Post-Falls
• Post Falls Mini Root Cause Analysis
• Clinical Preadmission Ready Huddle

Following the weekly calls, the team at Rouse continues to hold monthly meetings. The facility reported that falls are at the lowest point since 2022.

Facility leaders at Rouse identified another unexpected outcome of this intervention: improvement in staff stability. They attribute this to the empowerment of their frontline staff to be more vocal and involved in the problem-solving process, thereby highlighting their value on the care team.

Rouse has been active with multiple interventions and workgroups with Quality Insights. Facility leaders said they strongly recommend facilities participate in programs offered by Quality Insights rather than try to work through issues on their own. Nursing home leadership says an outside perspective from others who have years of experience in the long-term care business can offer great ideas that they may not have thought of themselves.

Austin says she attributes Rouse’s success to the management team’s commitment to assessing current practices and incorporating departments other than nursing and frontline staff into the efforts to reduce adverse events that lead to hospitalizations and ER trips. Austin says she looks forward to tracking Rouse’s progress as they move forward.