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Successful hospitals share the strategies they have used to reduce readmissions.
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.
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:
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.
4. Use outside resources
Laura Adams, president & CEO of Rhode Island Quality Institute (RIQI), Providence, Rhode Island, notes the organization has found great success in helping hospitals limit readmissions through the use of RIQI’s Care Management Alerts and Dashboards (CMADs).
“RIQI aggregates clinical data from across the state within a central repository known as CurrentCare, Rhode Island’s statewide health information exchange (HIE), which is powered by InterSystems HealthShare platform,” she says. This HIE includes data from several settings, including hospitals, labs, pharmacies, primary and specialty care practices, alcohol and substance use treatment facilities, federally qualified health centers, community mental health centers, and long-term care.
The CMADs draw on this data to inform providers in real-time whenever their patients are admitted or discharged from acute care hospitals, EDs, or long-term care facilities in Rhode Island. The CMADs also provide aggregate risk scores, historical admission trends, drilled down clinical data, and updated demographics.
“With the right information served up at the right time, care managers and physicians engage immediately in coordination of care,” Adams says. “Recent analysis demonstrated a reduction in hospital readmissions by 18.9% during 2017. A reduction of 18.4% was also demonstrated for patients who visit an ED within 30 days of an inpatient discharge, with a 16.1% reduction in ED return visits.”
5. Get pharmacists involved
At Tandigm, pharmacists help assess the medication regimens of patients following hospitalizations.
“Pharmacists check patients’ medication lists to find duplicates, identify potential negative interactions, evaluate high-risk medications, confirm dosages, and more,” Goldblum says. “Tandigm also has a team of social workers who connect with our high-risk patients, if needed, to connect them with community resources that may address social issues that may be impacting their health at home.”
Additionally, Tandigm deploys a doctor or nurse practitioner directly to the home of a high-risk patient to address health needs and ultimately alleviate a readmission risk.
Goldblum describes high-risk patients as those who are the most likely to have complex care needs. “At Tandigm, we leverage a home-grown risk stratification process to help us identify these high-risk patients who need frequent, quality care or are at risk for certain conditions,” he says. “Our risk stratification process uses physician reports, admissions data, claims data and more to examine a range of clinical characteristics of patients in our network such as utilization, comorbidities, and hospitalizations. This data, coupled with expansive physician input, enables us to assign each patient a risk score that will influence their care process.”
6. Make it personal
OhioHealth’s Geskey believes patient education is the one aspect of healthcare that has been systemically underutilized. “Instead, at times, we deploy technological solutions instead of personal connections that employ clear communication, an understanding of the patient, and the struggles he/she labors under,” he says. This makes it difficult to build trust and decreases patient engagement.
Over the course of the Healthy Literacy pilot program, he has visited more than 100 homes and notes not one patient utilizes the Internet to manage their health condition.
He says effective education meets the patient where they are, assesses how the patient best learns information, assesses whether they understand it, and helps patients set goals and breaks down barriers in attaining those goals.
7. Consider all the patient’s needs
Care coordination and communication between providers keeps a readmission prevention plan together, says Buonocore. “We utilize [registered nurse] and [nurse practitioner] navigators to help with the care coordination,” she says. “We use interprofessional daily rounds to discuss readiness for discharge, focusing on whether the condition they came to the hospital for has been adequately treated and if their comorbidities are well-addressed.”
The nurses also identify social, spiritual, and palliative issues, and collectively come up with solutions.
“Care coordination is a key factor in assuring that all the right things are in place with each care transition,” says Buonocore. “You have to remember patients and families come to us with very complex problems-not only medical problems but also psychological and social issues. If you are not addressing the whole picture, you are more likely to end up with a readmission.”
As one patient told Buonocore, “I can’t even begin to think about medications, my first priority right now is getting a roof over my head.”
“It takes a village to accomplish this work. Keep patients at the center of it,” says Buonocore. “Ask your patients and families what they need, or what is keeping them from being well. They sometimes will be able to pinpoint issues, so collaboratively you can work on solutions.”
8. Consider the history
Saeed Aminzadeh, CEO of Boston-based Decision Point Healthcare Solutions, believes the secret to reducing readmissions is to identify and engage the patient as early as possible (ideally before they even have their index admission).
“Multiple, clustered admissions are a function of both clinical and engagement risk,” he says. “Members who are at high risk for multiple, clustered admissions typically have an undesirable disease trajectory as well as a history of engagement challenges, such as poor preventive behavior, sporadic visits to their doctor, excessive use to the ER, challenges with medication adherence, PCP switching, etc.”
Decision Point has discovered that when probed (or when data on social determinants of health is available), these members often have other socioeconomic barriers, such as limited home care support, undesirable nutrition, and poor health literacy, which further compound and elevate their risk.
“We have found that identifying and engaging these members prior to inpatient activity is key to creating sustained improvements in readmission rates,” Aminzadeh says. He adds that though health plans should have sophisticated post-discharge programs designed to ensure that members are educated on their discharge instructions, medications, and follow-up appointments with their doctors, “from our work with health plans, a proactive approach is really able to move the needle and has resulted in 25% reductions in readmission rates annually.”
Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.