Analyze readmission rates to see why patients return
Analyze readmission rates to see why patients return
Use the information to improve your discharge plans
If hospitals are going to avoid penalties for 30-day readmissions, they need to start now to identify their own patterns of what caused the readmissions and use that information to improve the discharge plan, suggests Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Health Group, a Newton, MA, health care technology and services firm.
Start by reviewing every readmission to determine the most common DRGs and the most common reasons for readmission, adds Brenda Keeling, RN, CPHQ, CPUR, president of Patient Response, a Milburn, OK, health care consulting firm.
Talk to patients to get information about why they were readmitted. Gather the statistics and use them in the performance improvement process.
"It may be an issue with funding or the family may not have cared for them after discharge or the hospital may have discharged them prematurely," she says.
Analyze more than 30-day readmissions
In addition to reviewing the readmissions within 30 days, look further and analyze those who are readmitted within seven days or the same day, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.
"If patients are readmitted 30 days after discharge, it's not as likely that the admission is related to their prior stay, but within seven days, it's more likely to be related," she says.
"If patients who are readmitted received post-acute care, drill down to determine what happened during the previous level of care," says Birmingham.
Look at patients who are readmitted after receiving home health services. Did the home health agency discharge them too soon?
"If case managers see a pattern in readmissions of patients receiving services from a particular home health agency, they should meet with them and make sure that the patients being referred to the agency are appropriate for what the agency can provide," she says.
Look at patients who are nonadherent and look for the reasons why.
Was it that they didn't understand the medications? Did they take an over-the-counter medication that made their prescription drug ineffective? Did they have multiple doctors who prescribed the same medication? Did the home health agency discharge the patient prematurely?
Since studies have shown that one cause of readmissions is lack of follow-up, case managers should make sure that patients have an appointment to see their doctor for follow-up within seven days of discharge and should make sure they understand the importance of keeping the appointment, Cesta says.
The challenge is ensuring that these patients get a follow-up visit, Cesta points out. In the case of patients who go to a hospital clinic, it is virtually impossible to get an appointment within a seven-day time frame, she adds.
Make a follow-up phone call shortly after discharge to make sure the patient is taking his or her medication, has a doctor's appointment, and is not having problems, she says.
Many patients, particularly those with serious conditions, can benefit from one home health visit during the first days after discharge to help with the transition from hospital to home, Cesta adds.
"Another weak link in discharge planning is the educational piece. So many times, case managers simply do not have the time to make sure the patient and the family understand the discharge instructions," Cesta says.
Nurses, social workers, and others who are involved in coordinating the post-acute care of patients should be accessible to patients and family members and get their input on discharge plans, Birmingham says.
At the time of discharge, give patients specific prompts for what they need to do if certain symptoms occur, and follow up with them 24 hours after discharge, she says.
Some organizations have a program in place that supports follow-up with patients 24 hours after discharge, she says, adding that the program must be organized through the quality improvement process.
"There is no such thing as a simple follow-up call. The case manager needs to track the volume and issues raised during the calls and be able to help direct patients to appropriate resources, such as their physician, and hopefully avoid the advice of returning to the emergency department," Birmingham says.
Make sure that post-acute providers receive timely and complete information on patients in order to assure that they can provide the post-acute care the patient needs and to provide continuity of care once the patient is admitted to their organization, she adds.
Case managers need to make it a habit to use the discharge screens in the hospital's level-of-care criteria set to ensure that patients are stable enough for discharge and can be appropriately treated in an alternative setting, Keeling says.
"When case managers are looking for continuing medical necessity, they may not be consistently comparing the discharge screens to the patient treatment plan," she says.
Many patients don't meet discharge criteria at the time they are discharged because the case managers don't assess the discharge screen to make sure they are stable, Keeling says.
"Case managers are under pressure to aggressively move patients out of acute care as quickly as possible, based on the DRG length of stay. Because of this pressure, the patients may not meet the discharge screens for discharge," she says.
Hospitals should explore establishing a community case management program to coordinate care for high-risk patients and help them navigate the complex health care system after discharge, Cesta suggests.
"Some patients are simply lost when they leave the hospital. They don't see the doctor for follow-up. They aren't taking their medication because they didn't get the prescription filled or they get confused about what to take. They don't get their home care appointments and don't let anybody know," she says.
Then the patients show up in the emergency department where they are likely to be admitted because the emergency department doctor doesn't have any other options at 3 a.m., Cesta says.
"Community case management programs for high-risk patients can help hospitals meet their goals of reducing emergency department visits and readmissions by helping the patients follow their treatment plan and stay out of the hospital," she says.
If hospitals are going to avoid penalties for 30-day readmissions, they need to start now to identify their own patterns of what caused the readmissions and use that information to improve the discharge plan, suggests Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Health Group, a Newton, MA, health care technology and services firm.Subscribe Now for Access
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