Encouraging patients to follow up with their primary care doctors within one week of discharge is key to Tandigm Health’s strategy of reducing readmissions. The population health organization based in Conshohocken, Pennsylvania, discovered that high-risk patients who followed up with their primary care physician (PCP) within seven days had a 10%, 30-day readmission rate. Those who didn’t see their PCP in that same timeframe had a 17% readmission rate, despite both groups having nearly identical LACE index scores. The LACE index identifies patients who are at risk for readmission or death within 30 days of discharge.
“Our value-based program is designed to engage doctors by providing meaningful incentives that ultimately reward them for improvements in the quality and cost of healthcare,” says Ken Goldblum, MD, chief medical officer, Tandigm Health. “As our data began to show the benefits of following up with a PCP post-discharge, we added a metric to our incentive plan and started to reward physicians for following up with their patients within seven days of a hospitalization.”
With that incentive in place, the hospital’s follow-up rate increased from 25% to 54% in just one year.
It is incredibly important for patients—and their care teams—to have a clear understanding of their needs and expectations following a hospitalization, says Goldblum. When care isn’t coordinated, important parts of a patient’s journey to improved health can fall through the cracks.
“Prompt PCP follow-up post-discharge is an important way to bring all the parts of the care process together, allowing PCPs to connect the dots and identify any potential issues that may have been otherwise overlooked,” he says. “It’s also important that a patient knows who to turn to when a problem arises.” That’s why Tandigm Health has a team of telephonic nurses that follows up with high-risk patients quickly and regularly after they are discharged from a hospital or nursing facility to educate and assist them with their transition of care.
This is just one of several strategies healthcare systems have employed to reduce readmissions. Here are eight more.
- Focus on health literacy
Discharge paperwork can sometimes be tricky to understand, especially for someone who has just undergone a health scare and wants to return home as quickly as possible. Joseph Geskey, DO, vice president of medical affairs, OhioHealth Doctors Hospital in Columbus, Ohio, says this is why the hospital prioritizes ensuring patients understand their discharge instructions.
“For example, every patient should benefit from having discharge instructions that are written at a fifth-grade reading level,” he says. “Hospital staff should ensure that patients can ‘teach back’ the instructions they have been given. This helps us to see that patients have understood them.”
Additionally, patients should know what problems to look for when they leave the hospital, what they should do if they encounter them, and who they should call if they have questions, says Geskey. Care coordination is critical in that the right care at the right time allows optimal stewardship of resources to be deployed to the individuals who need it most. This improves efficiency and improves equity and effectiveness, he says.
“With our Healthy Literacy pilot program, we screen patients for health literacy and how engaged they are in their care,” he says. “If they have limited health literacy, meet Medicare homebound criteria, and decide to use OhioHealth Home Health, myself and two other OhioHealth Home Health nurses visit their homes for one hour per week for four weeks.”
There, they work on everything from understanding medications to knowing what foods they should be eating based on their diagnosis. The program has led to a 40% reduction in readmissions for those patients involved in the pilot program, and has led to increased patient engagement in their medical care, says Geskey.
“We will never be able to reduce the cost of healthcare unless we can get patients to partner with us more effectively,” he says. “This builds relationships such that instead of looking at people as being noncompliant, or unwilling to help themselves, we are motivated in helping them creatively solve problems that allow them to be a person who has an illness like congestive heart failure rather than a congestive heart failure patient.”
2. Use a prediction tool
Michael Gentry, senior vice president and COO of Sentara Healthcare, the company that oversees Sentara provider divisions, including 12 hospitals, Sentara Life Care Corporation, and Sentara Enterprises, suggests utilizing HOSPITAL Score.
This tool identifies patients at the highest risk of avoidable readmissions before they are discharged, and it has helped tremendously with risk stratification, says Gentry. It predicts 30-day readmissions based on the following predictors at discharge:
- Hemoglobin level
- Discharge from an oncology service
- Sodium level
- Procedure during hospital stay
- Index admission type
- Number of admissions during the previous year
- Length of stay
The higher the HOSPITAL Score (0-11), the higher the risk of a 30-day readmission. Risk categories are considered Low (0-4), Intermediate (5-6), and High (7+).
“This process is only a year old for Sentara so there is not much data yet; however, our initial study shows strong correlation between a high HOSPITAL Score and readmission rates,” Gentry says.
Other ways Sentara has reduced readmissions include identifying and documenting the patient’s caregiver to ensure the continuum of care when a patient gets home and following up after discharge with phone calls to answer patient questions, check pain level, confirm medication adherence, and remind patients of follow-up appointments.
“Studies show that a follow-up appointment within seven days of discharge is associated with lower readmission rates among patients with the highest clinical complexity and risk for readmission,” Gentry says. “Our goal is to help provide warm handovers to all clinicians connected to the patient, as well as follow the patient through the entire process to ensure they have the necessary preparation to have a successful transition to the next level of care.”
3. Extend your reach
Denise Buonocore, MSN, RN, incoming chair of the AACN Certification Corporation, the credentialing arm of the American Association of Critical-Care Nurses, also serves as acute care nurse practitioner for heart failure services at St. Vincent’s Medical Center in Bridgeport, Connecticut.
Part of her responsibility is taking charge of the readmission effort for heart failure services.
“When I first started the initiative, I realized that at least half of what affected readmissions happened outside the hospital. In order to be effective, we needed to disrupt and transform the whole care continuum,” she says. “Knowing our patient demographics and population, we knew we had to create interventions that would minimize disparity in care and create the right transition for every patient every time.”
Part of her plan in reducing readmissions is getting all parts of the care continuum inside and outside of the organization, including patients and families, working toward the same goal.
“When we started our readmission journey, we engaged key leaders and staff inside the hospital and out in the community, including home care agencies, skilled nursing facilities, hospice agencies, medical practices, and patients, to help us understand the challenges,” she says. “We then created systems, processes, and expectations to overcome the challenges that patients and families face. This eventually evolved into a clinically integrated network.”
While she agrees that patient education is important, she says teaching patients to be empowered as full participants in their care and decisions is equally important. For example, she says you can teach patients the signs and symptoms of worsening disease and explain what to do. But unless you are using teach back to ensure they understood and have a well-thought-out plan for what to do next, who to call, and when to call, they will probably end up back in the hospital.