Low-tech Efforts to Reduce Hospital Readmissions

As of Oct. 1, the Centers for Medicare & Medicaid Services (CMS) began penalizing hospitals for unnecessary hospital readmissions, but a range of efforts to reduce the 30-day readmission rate that draw from clinicians, IT staff and patients themselves have been in the works for years.

The issue of preventing unnecessary readmissions is “very complex,” says Gregory Maynard, MD, MSc, senior VP of the Center for Hospital Innovation and Improvement at the Society of Hospital Medicine (SHM). “This is a really tough nut to crack.” Fortunately, there’s been a concerted effort to improve coordination and offer better assistance to patients when they leave the hospital, as well as improve the inner workings of the hospital process. But, “we still have a long way to go,” he says.

Project BOOST (Better Outcomes by Optimizing Safe Transitions) is an initiative led by the SHM that involves mentoring hospital teams to map processes to create and implement action plans for organizational change. The project provides a suite of evidence-based clinical interventions each hospital can adapt and integrate into their environment.

Project leaders have partnered with many different organizations to disseminate the information, says Mark V. Williams, MD, principal investigator. That includes Blue Cross Blue Shield of Michigan, Illinois and South Carolina, as well as numerous academic medical centers. “It’s mostly hospitalists and primary care physicians who work with hospital staff to implement the toolkit, which includes a risk assessment tool to determine which patients have a greater likelihood of being readmitted.”

Williams has worked with hospitals on checklists for specific medical conditions that can be integrated into their workflow. The goal is to help hospitals optimize their discharge process and ensure patients have smooth care transitions.

There is room for improvement, however. “Medical centers are struggling to integrate screening tools and the intervention plans in EHRs because most of the documentation is designed to be specific to a particular discipline, rather than designed for teamwork and communication of common goals,” says Maynard.

In part, the EHR is making the flaws that already existed more transparent, while in other areas, the EHR interface is not intuitive and needs a lot of end-user training to get it right,” he adds.

No quick answer

Regardless of the technological challenges, success takes time, says Williams, citing a recent quality improvement project for reducing central line-associated bloodstream infections (CLABSI) among pediatric patients. The Comprehensive Unit-based Safety Program (CUSP), and CLABSI interventions are designed to improve safety and reduce the mean rate of CLABSI in hospital units. The effort showed a 40 percent reduction but not until the second year, he says. “There’s no quick answer. Hospitals have to work to change the process they’ve been using for a long time.”

Meanwhile, Project BOOST uses eight “Ps” to proactively detect high-risk conditions for readmissions and a coordinated plan to address them. The Ps include polypharmacy, poor health literacy and problem diagnoses such as heart attack and congestive heart failure (CHF). There are defined interventions for each high-risk condition, such as a checklist of items to  review. Is the patient on an ACE inhibitor? Does he or she have a scale and know who to call  about weight gain? Has he or she had an evaluation of ejection fraction with a recent echocardiogram?

“Basically, there is often protocol and guidance available for what should be done for a specific diagnosis, and the screening tool is just to make sure everyone is aware that the protocol should be triggered,” says Maynard. In other cases, the intervention is more general. For example, an early post-discharge phone call to ensure the scheduling of a follow-up appointment and extra efforts for patient education using ‘teach back’ techniques.

These efforts have helped to solve myriad problems. For example, a pharmacist learns the patient only takes some medications because of the expense, when cheaper alternatives are available. “A follow-up phone call, for example, may reveal that the durable medical equipment—perhaps a special bed—did not arrive as scheduled or the patient lost the follow-up appointment information. These little things can have a huge impact because they offer an opportunity to mitigate identified problems.”

Getting patients on board

Jane Brock, MD, MSPH, clinical coordinator for the Colorado Foundation for Medical Care’s Medicare quality improvement program, focuses on patient activation at the CMS Care Transitions project, which commonly employs a coaching technique pioneered by Eric Coleman, MD, MPH. “The premise behind coaching is that patients are often unable to be effectively engaged because they’re overwhelmed and don’t have a lot of confidence.”

The effort goes beyond educating patients to ensure they have the capacity to be meaningfully engaged, she says. The goal is to improve patients’ capacity to self-manage. “An activated patient will compensate for a multitude of sins on the part of providers.”

Patients may receive discharge instructions, but they often are focused on the acute event for which they were hospitalized. Then the person returns home and “has a large number of other burdens, both medical and nonmedical,” says Brock. “We really need a comprehensive view of care planning for people who have multiple chronic diseases. Instructions that dovetail with a much greater overall plan of care are not common.”

Standardizing the message

One component is a coaching program in which providers work to ensure they are giving standardized messages. “When everyone gives the same advice, it helps reduce confusion,” Brock says. The community decides which interventions to implement to help put everyone on the same page.

Increased awareness of this problem is helping the effort, says Brock. When she started working on this initiative six years ago, “it was considered innovative to get multiple providers in the same room to look at population-based data. Now it’s accepted as a normal way to work on reducing readmissions. There’s been a tremendous shift in the way people understand what causes readmissions.”

Penalties play a crucial role, she admits, but much of what causes people to return to the hospital is not strictly medical, she says. “Oftentimes, the difference when a patient gets released is transportation to obtain his or her medications and whether he or she has food at home. The nonmedical support functions of a community are important. Hospital readmissions help make the business case for community-based organizations.”

Based on her own hospital discharge experience, Jessie Gruman, PhD, founder and president of the Center for Advancing Health, would probably agree. After a gastrectomy for stomach cancer, Gruman spoke with her surgeon at 6:30am on discharge day. The nurse came in at 8 a.m. to say she could go home. She was given a prescription for pain medication, told she could get a flu shot and should call if she has a fever. “That was my discharge plan. I just had my stomach taken out and had a completely new digestive system that I had no idea how to operate.”

Fortunately, Gruman weathered her transition but “a little more guidance and direction would have been helpful.” Yet, other patients who “are fragile and complicated are likely to return.”

Since medical advances have allowed for patients to go home much faster, it means what we do at home is much more complicated. But, “there hasn’t been full recognition by healthcare professionals of just how much more complicated,” Gruman says. Just 10 to 15 years ago, patients stayed in the hospital much longer and professionals managed symptoms, wound care, rehabilitation, respiration therapy, nutrition and more. “Patients leaving the hospital need a lot more information and support than they’re currently getting, not just an appointment to see their PCP. They need help with not only performing the nursing and medical tasks, but with advice about how to adjust to changes in their functioning, whether they are temporary or permanent.”

Partnering with primary care

Williams and his team have learned it is “critical to engage PCPs.” Project BOOST makes a point of engaging PCPs for quality improvement. “We stress that the discharge summary should go out to the PCP at the time of discharge. Enhance communication and ensure PCPs know when their patients are in the hospital and what follow-up is needed.”

One health system calls recently discharged patients once a day for the first week. That’s when patients are at the most risk for readmission and probably have a lot of questions about their progress. “There is no way a checklist can cover every contingency that can occur,” says Gruman. “We don’t just need information. We need reassurance that we are doing OK and that we can handle these complex new tasks during this stressful time.”

Root-cause analysis is the basis of the hospital readmission reduction program in Nebraska. The statewide learning action network (LAN) is working to make care transition “better and easier,” says Audrey Paulman, MD, MMM, principal clinical coordinator for CIMRO, the Nebraska quality improvement organization.

They, too, emphasize patient engagement. “Patients have to live with the disease process, so we get organizations to involve patients in their own discharge,” she says.

A lack of standardized process and standardized information are two problems CIMRO is working on. “Communication always comes to the forefront. As hospitals and physicians become increasingly better at using health IT, they need to look at how downstream providers can receive that information,” Williams says.

While the current rate of 30-day readmissions is 26 percent, a readmissions rate of zero is not the right answer, says Paulman. But, “we are finding areas in which we can improve care.”

Going forward, Maynard says the most innovative health centers will bring others in their system along. “This is a journey,” he says. “We’ve been working on this for at least six years. It’s not something that gets done overnight. It requires culture change, workflow change and better communication with outpatient providers. Basically, you have to fix everything in your hospital to make this work optimally as well as things outside of the hospital walls to prevent people from getting readmitted.”

Everyone has either had an improper care transition or knows someone who has, Paulman says. “There’s a lot of interest in it, people can understand it and they can get behind it.” That should prove worthwhile as hospitals work to prevent penalties for unnecessary readmission.