Program cuts 30-day readmit rate to 10.6%
Four-person team targets at-risk patients
Executive Summary
A readmission reduction program that begins while patients are in the hospital has cut the 30-day readmission rate by 37% at St. Rose Hospital in Hayward, CA.
• Patient advocates visit patients with diagnoses that put them at risk for readmission on Day 1 and conduct an assessment to determine discharge needs.
• Advocates collaborate with discharge planners, line up any services needed after discharge, and follow up after discharge and after physician visits.
• When patients are readmitted, the team drills down to determine the cause and recommends process changes.
After St. Rose Hospital in Hayward, CA, started its readmission reduction program, the community hospital’s 30-day readmission rate for all diagnoses dropped by 37% and the 90-day readmission rate declined by 43%.
When the project started in 2011, the 30-day readmission was 16.8% and the 90-day readmission rate was 28.3%. For the 12 months ending on Dec. 31, 2013, the average 30-day rate was 10.6% and the average 90-day rate was 16.2%.
When the hospital started its readmission reduction program using a grant from the Gordon and Betty Moore Foundation, a team of clinicians reviewed a number of model programs, chose Project RED (Re-Engineered Discharge) and modified it to fit the hospital’s needs. The hospital was a participant in the Avoid Readmissions through Collaboration (ARC) readmission reduction collaborative of San Francisco Bay-area hospitals and their post-acute partners. (For details, see related article on page 69.)
"The interventions start while the patient is still in the hospital, which has a big impact on outcomes. We think of our program as a supplement to what is already being done to prepare patients for discharge. We are adding another set of hands to the process and helping to give patients the tools they need to have a safe discharge and avoid coming back to the hospital," says Shogofa Zamon, Project RED coordinator.
Responsibility for the program is assigned to a four-person team that includes Zamon, a case reviewer, and two patient care advocates.
The program targets the diagnoses most frequently readmitted — heart failure, acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease. The patient care advocates review the hospital census each morning and identify newly admitted patients with those four diagnoses. "Those patients get top priority, but if the census is low, we include other patients as well, particularly those with other cardiopulmonary conditions," Zamon says.
The case reviewer, who is an LVN, reviews every readmission to determine what happened between the time the patient was discharged and the current admission and works with the readmitted patients to help them avoid another readmission.
On the first day of hospitalization, the patient care advocates visit the patients and complete an assessment. "They ask about their home environment, if they live alone, who provides their meals, if they have insurance and a primary care physician. We want to find out if there is a gap we need to fill when they leave the hospital," she says.
They give patients a note pad and pen and suggest that they write notes and any questions they have during the hospital stay as well as keeping track of their medications and doctor appointments.
The patient care advocates collaborate with the discharge planning nurses and case managers and help line up any resources the patients may need after discharge. They have a binder of resources they can share with the patients who need them.
These include wallet-size medication cards, recipes for patients who need a restricted diet, weight-tracking forms for patients with heart failure, lists of affordable caregivers, discount medication cards, and a variety of other resources. If patients need transportation assistance or services such as meal delivery, they help them access them. If they don’t have a primary care provider, the patient care advocates help them identify a provider in a convenient location.
Following up with patients
The patient care advocates follow up by phone with the patients within three days of discharge. They review the discharge instructions, answer any questions and concerns, and make sure they have a follow-up appointment. "Originally, we made the follow-up appointments while patients were in the hospital, but many patients couldn’t keep the appointments. Now, we give them the tools to make their own appointments at a convenient time and keep calling until they make an appointment," she says.
The patient care advocates call patients the day after their doctor’s appointment to see how it went and answer any questions. "When patients repeat what a doctor tells them, it helps them remember the information," she says.
The same person who saw the patient in the hospital makes the follow-up calls. If patients need more support, the patient care advocate keeps calling until the issues are resolved and the patient is stable.
The case reviewer works with the readmitted patients and follows the same assessment and follow-up process as the patient care advocates. The case reviewer accesses the patient history, talks to the patient to find out the reason for the readmission, and takes steps to help the patient avoid coming back. For instance, if the patient was readmitted because of a medication issue, the reviewer calls in a pharmacist for a consultation.
In addition, the case reviewer categorizes each readmission and looks for trends. "We analyze why patients are being readmitted and work with the rest of the treatment team to prevent readmissions in the future," Zamon says.
For instance, end-of-life issues are the reason for a large number of readmissions. "Many readmitted patients have chronic end-stage illnesses, such as end-stage renal disease or cancer, and need palliative care or hospice but instead they are readmitted to the hospital," she says.
The readmission reduction team met with social workers and case managers at the hospital as well as representatives from community skilled nursing facilities and home health agencies to raise awareness of end-of-life issues and alternatives to hospitalization.
"We know that this is a sensitive topic, but often the families and patients don’t know that they have a choice. The hospital doesn’t have a palliative care unit, but patients can receive the care at a skilled nursing facility or go at home with hospice services. Now, clinicians at all levels of care are starting to have this conversation with families, and end-of-life readmissions have started to decline," she says.
The team also analyzed the patients who were being readmitted because their chronic condition was getting worse and looked for resources to help the patients manage their conditions.
As a result, the hospital reached out to the American Lung Association and began offering Better Breathers Club classes for patients with respiratory problems, such as chronic obstructive pulmonary disease.
The two-hour monthly class is open to the community. The sessions include exercise for people with lung disease with a DVD demonstrating the exercise that patients can take home, a class on diet for patients with respiratory conditions, energy conservation techniques, education on medications, and other information about living with chronic obstructive pulmonary disease.
"The class is very interactive, and the participants love it. We started with one person and built up the class over time," she says.
"Once we analyzed our readmissions, we worked on determining what resources would help the patients the most," she says.
