Special action team for first hours of discharge

A "high risk for readmission action team" (HRRAT) could be the way to address one of the weakest points in the discharge process, the day or two immediately after the patient goes home, says one doctor in Texas.

Arun Mathews, MD, a hospitalist at Medical Center Hospital in Odessa, TX, says his hospital has a readmission rate of about 5%, and he is proposing a regional HRRAT to bring that number down and save money.

The team would be led by an inpatient physician, preferably a hospitalist, along with an outpatient physician, who would identify patients with certain high-risk conditions, such as end-state chronic obstructive pulmonary disease (COPD) or congestive heart failure, Mathews says. The HRRAT also would flag patients who are sent home with "gap measures," such as home oxygen, which increases the chance of readmission.

"This team would be the tip of the spear with home visits," Mathews says. "We're really talking about the 48- to 72-hour window between discharge and the first post-discharge outpatient appointment. That's when the bulk of our readmissions come from. So, this team would visit in that window to reduce readmissions and identify patients who are not doing well."

If the team discovers problems that could lead to readmission, it can address them either through direct intervention or referral to outpatient care, Mathews explains. The HRRAT team is still being developed, but Mathews says he expects it to be employed at the hospital — and perhaps on a regional basis — soon.

Discharge goal determined at outset

Medical Center Hospital already is improving discharge by encouraging physicians to create a "discharge goal" at the beginning of care, Mathews says. He has been studying the effect of work flow and processes on patients' post-discharge outcome and says he has identified a number of best practices.

"All good things begin with the end in sight," Mathews says. With that in mind, Mathews and his colleagues create a discharge goal for the patient using specific clinical targets for the optimal discharge.

"At the moment of admission, based on even a cursory understanding of the primary diagnosis, comorbidities, and the patient's demographics, one can start to develop an estimate as to what the length of stay should be," Mathews says. "We actively encourage our hospitalists to document this as what we call a discharge goal, and then to mention this in the daily progress notes to show what progress has been made toward this discharge goal."

For example, in a patient with a community-acquired pneumonia who is admitted with hypoxia and sepsis, the discharge goal would be dependent on a period of 24 hours with defervescence from fever, white cell counts trending down, no systemic inflammatory response indicators, and hypoxia is clinically improving. Those factors would be charted on the daily progress notes, providing a check-off list that shows how quickly the patient is improving.

"We also see that translating into more accurate and appropriate billable codes," Mathews says.

The next part of the process involves the hospitalists discussing inpatient management best behaviors, acknowledging that there is a right time and a right test for different pathologies.

"We acknowledge that a little bit of knee pain with a patient coming in [with] community-acquired pneumonia doesn't necessarily warrant an MRI in the inpatient setting, that there is a role for outpatient workups," Mathews says. "We also address consultant management. The hospitalist needs to take a role of leadership, keeping everyone on the same page, ordering consultations effectively."

Cut readmissions to zero?

Mathews is working with Ravi Shakamuri, MS, chief executive officer of Star Health Care & Star Care Health Services in Odessa, TX, to coordinate the outpatient and home health services that would make such a system possible. Shakamuri says the HRRAT could fill a need for post-acute care patients.

"There are so many resources within the hospital walls, but once they pass out into the community, these resources tend to get diluted and lost in the day to day life of the patients," he says. "Their families and physicians are not connected, and that lack of care in the first day of two after discharge can result in hospitalization again, whereas a relatively small amount of attention in those hours might make the difference."

By using the discharge goal and the HRRAT, Mathews hopes to sharply reduce readmissions. The two-pronged approach should ensure that patients receive the proper care while hospitalized and are not discharged until it is appropriate, and then the HRRAT can intervene with any problems that occur in the first, most vulnerable hours after discharge.

"I genuinely believe that hospital readmissions can be brought down to virtually zero with the implementation of such a process," he says. "That's a bold statement, but I think it can be done."


• Arun Mathews, MD, Hospitalist, Medical Center Hospital, Odessa, TX. Telephone: (432) 640-4000. E-mail: Arunmathewsmd@gmail.com.

• Ravi Shakamuri, MS, Chief Executive Officer, Star Health Card & Star Care Health Services, Odessa, TX. Telephone: (432) 552-1950. E-mail: rshakamuri@starcareonline.com.