Blocking the Revolving Door

March 4, 2011
Rochelle Nataloni

MDNG Hospital Medicine, February 2011, Volume 5, Issue 1

Through organization-wide initiatives, electronic tools, and simple teach-back methods, hospitals around the country are taking major steps to keep patients from coming back, and making open-door policies a thing of the past.

By Rochelle Nataloni

Reducing the rate of hospital readmissions has long been a goal among hospitalists dedicated to improving quality of care, and now healthcare reform legislation has added fuel to the fire behind this ambitious objective. “Given that about one in five Medicare fee-for-service patients are rehospitalized within 30 days and some experts cite an estimated cost of $44 billion per year overall for rehospitalizations within 30 days of hospital discharge, healthcare reform legislation identified reduction of avoidable rehospitalization as a target for health care cost savings,” explains Mark V. Williams, MD, FHM, professor and chief of the division of hospital medicine at Northwestern University Feinberg School of Medicine.

This mandate to reduce avoidable readmissions makes the adage, ‘discharge planning begins at the time of admission,’ truer than ever. “To avoid a financial penalty for higher than expected rates of rehospitalization and reduce the personal toll on patients, hospitals can optimize the discharge transition process through implementation of Project BOOST,” says Williams, who is the principal investigator for BOOST (Better Outcomes for Older Adults through Safe Transitions), which is sponsored by the Society of Hospital Medicine.

Project BOOST provides users with tools that focus on discharge management, data collection, education, and team management, all aimed at reducing readmission rates by improving patient satisfaction, identifying high-risk patients, and improving patient and family education. Similar programs include the Agency for Healthcare Research and Quality-funded Project RED (Reengineered Hospital Discharge), and the CMS-sponsored Care Transitions Project, which aims to reduce preventable hospital readmissions for Medicare beneficiaries.

What can hospitals do?

Piedmont Hospital in Atlanta, GA, has adopted several tools from the BOOST program—including a patient-friendly discharge form, a risk identification tool, and a discharge checklist—since implementing the program more than two years ago. Among patients who received the BOOST intervention, readmissions for those under age 70 declined from 13% to 4%, and readmissions in those over 70 years of age decreased from 16% to 11%.

Matthew Schreiber, MD, Piedmont’s chief medical officer, suggests that the first step in reducing readmissions is to accept that hospitals and hospital-based providers must take ownership of the ‘space between’ discharge and follow-up with community physicians. He points out that historically, most of the interest in readmissions has come from community service providers attempting to reach into the hospital as opposed to hospital providers looking to extend out into the community.

“Hospital leadership must believe that reducing readmissions is a priority from both a quality and financial risk standpoint, and take on this challenge with a willingness to dedicate resources and a belief this is just the right thing to do," says Schreiber.

Schreiber stresses that reducing readmissions goes beyond simply decreasing the number of all-cause readmissions within 30 days. “Usually readmissions are defined as patients leaving inpatient status and returning to inpatient status, but the right attitude is to look to decrease the number of times any patient leaves the hospital and returns to the hospital within 30 days,” he says. For him, this means that if a patient leaves ‘Observation’ status and returns to the ER a week later, there are important lessons that can be learned. “This is a quality improvement process with financial implications, not a financial risk-reduction program with quality implications,” he says.

For hospitals that are just beginning the process of trying to reduce readmissions, Schreiber recommends forming a multidisciplinary team to evaluate the magnitude of the challenge. Key participants, he says, should include—but are not limited to—a data analyst, chief financial officer, finance representative who can agree to data definitions and benchmarks, hospitalist leaders, case managers, ER leaders, and representatives from home health, primary care, nursing, and pharmacy. “This group can develop a data dashboard, review cases, and commit to implementing new strategies,” he explains.

Communication breakdown

SSM St. Mary’s Medical Center in St. Louis, MO, which relies on a multidisciplinary, team-based approach similar to the one espoused by Schrieber, has experienced measurable success since implementing Project BOOST in a single 32-bed unit. “We have been able to maintain a 30% readmission (within 30 day) reduction over a two-year period,” says Philip Vaidyan, MD, director of hospital medicine at St. Mary’s. During this same time, patient satisfaction has risen by approximately 25%, says Vaidyan, who describes the experience of implementing BOOST as a complete cultural change. It’s not just a matter of using checklists to make sure that issues have been addressed, it’s a matter of committing to communicating with all of the key stakeholders, he says.

Vaidyan points out that avoidable readmissions are typically due to faulty discharge processes, which are often tied to a breakdown of internal communications. St. Mary’s works to avoid this with daily hospitalist-led multi-disciplinary team meetings designed to address each patient’s vulnerabilities. “We discuss if the patient has support, if they have insurance issues, and if they have general literacy issues or health literacy issues and once these vulnerabilities are identified we know what intervention needs to be taken,” he explains.

Because lack of follow-up with a PCP is often linked to unnecessary readmission, St. Mary’s hospitalists have partnered with Integrated Health Network (IHN) to ensure that patients who don’t have a PCP, or even lack insurance or are underinsured, are able to make an appointment with a health care provider at a clinic. They also address transportation-related barriers that prevent patients from getting to follow-up appointments. According to Vaidyan, the referral intervention has resulted in a 70% increase in the rate of patients who show up for follow-up appointments.

“All of the components that lead to avoidable readmissions are addressed in the hospital by the multidisciplinary team,” he says. “So by working as a team and communicating, all of us have a better understanding about the patient and their vulnerabilities.”

The importance of education

A number of hospitalists believe that the teach-back method is crucial to a successful discharge, especially in patients who have literacy or language challenges. Vaidyan points out that when patients are told about their condition and or medications, studies show that there is generally a 10% to 15% rate of retention. This, he says, improves dramatically when teach-back is employed. When patient can repeat key information about their condition and explain what medications they need to take and when they need to take them, it goes a long way toward preventing unnecessary readmissions, he adds.

Another area in which education can be leveraged to cut down on readmissions is in sharing information about home health care eligibility. Both Schreiber and Vaidyan pointed out that too often, patients don’t know they are eligible for home health services. “At Piedmont we quickly realized than less than 25% of our patients who had six or more admissions during a 12 month period had received home health services at the time of their most recent discharge,” said Schreiber, so he and his team cultivated a strong relationship with Visiting Nurse Health System (VNHS). “We work with them to review in detail what services patients are receiving, when they received them and what we or they could have done differently for patients who were readmitted.”

The new process, he says, has been incredibly fruitful. “I think many hospitals will realize that they need to reduce the total number of providers that they deal with in order to achieve better command and control over the experience of their patients. This likely means increasing the number of patients under the care of hospitalists, using a network of primary care physicians, and using a small number of companies to partner with for home health services.”

IT’s role in reducing readmission

The Catch-22 with readmission reduction initiatives is actually implementing the recommended quality improvement bundles in an effective, consistent way. Manually using these checklists introduces variability, not to mention increased workload. This, says health care IT consultant Siva Subramanian, PhD, is where automated solutions come in. “IT can help to reduce the implementation costs of readmission reduction programs and reduce staff effort required to implement these programs. When you rely on manual processes, they are subject to variability over time and across people. IT allows for scalability of the initiatives and sustainability of the outcomes,” says Subramanian.

Subramanian’s company, CareInSync (http://hcp.lv/fDUO94), markets a web and iPhone/iPad software tool called Carebook, which he says incorporates proven, evidence-based checklists, such as those used with Project BOOST and Project RED. “This is a real-time collaborative tool that can be customized to suit an individual hospital or department’s needs,” he says. Physicians, specialists, nurses, case managers, and other members of the care team can use the tool to collaborate on care transition plans for patients. “It keeps the entire care team along with the patients and their caregivers in sync on discharge and aftercare plans as they transition from one care setting to another,” he explains.

Another example of the role IT can play in reducing readmissions is through the use of remote monitoring technology, which many home health providers use to assist with patient care. “This has been highly successful in our experience with VNHS,” says Schreiber, noting that IT plays an intrinsic role in Piedmont’s readmission reduction initiative. “We use an electronic sign-out tool for the hospitalists to send daily information to PCPs. The hospitalists are required to call the PCP if a patient is going to have home health orders that will need follow-up, and we provide home health a copy of the BOOST paperwork as well. We also document the follow-up phone calls in the PCP's EMR,” explains Schreiber.

In addition to being able to capture and share patient information with the ultimate goal of reducing readmissions, IT makes it easier to track and measure changes, and to ensure that improvements are maintained, Subramanian adds.

Subramanian predicts that given the Health IT stimulus bill and impending policy changes, implementation of IT solutions aimed at reducing readmissions will be mainstream by early 2012 as hospital IT staffers start looking beyond their current EMR implementation projects.

10 Ways to Keep Patients out of the Hospital

There are 10 basic steps that hospitalists say can reduce avoidable readmissions.

  1. Communication: It is critical to keep an open line of communication, not only with the patient, but also with the primary caregiver, who must be informed about the patient’s status and empowered to carry out the discharge plan.
  2. Preparation: Patients and families need to be made aware of the estimated length of hospitalization so that they can sufficiently prepare for a safe and timely discharge.
  3. Medication reconciliation: Nearly two-thirds of all readmissions can be attributed to medication reconciliation issues. If discrepancies are not identified at the time of admission, the likelihood for errors increases.
  4. Medication education: It’s crucial that the patient and family be made aware of any high-risk medications, such as anticoagulants, digoxin, insulin, or narcotics, and be properly instructed in the use of respiratory medications, antibiotics, and cardiac medications.
  5. Patient education: The teach-back method or similar methods can be used to ensure that patients actually understand and retain information about their condition, medications, and follow-up care. This is particularly important in congestive heart failure patients, who are told to be on the lookout for red-flag symptoms such as leg swelling and weight management.
  6. Risk assessment: Clinicians should use a risk assessment tool to help identify patients at highest risk for readmission, and provide specific, goal-directed interventions to mitigate the risk. This assessment should include environmental factors such as whether patients are able to navigate the stairs at their home and have access to and the ability to prepare food, as well as intrinsic factors such as dementia, substance abuse, mobility issues, and finances.
  7. Transfer of information: A detailed plan must be formulated for communicating important information to the patient/family, home health representative, and PCP, as well as providing the patient and family with a discharge summary or high quality discharge instruction form.
  8. Follow-up appointments: Appointments with PCPs and key specialists should be made prior to departure from the hospital.
  9. Follow-up phone call: Patients should be called within 72 hrs of discharge to determine their clinical status and their understanding of the disease process; confirm follow-up appointments; and assure that the patient has contact information for their home health provider, PC, and pharmacy. Clinicians should ask if the patient was able to get their medications successfully and intervene in real time when necessary. The ideal post-discharge scenario includes getting the information from the follow-up call into the PCP’s chart.
  10. Final Checklist: Finally, hospital staff members should use a checklist to ensure that all of the above steps have been completed.