Enhanced discharge planning by phone yields results

RUMC tries telephone intervention

Telephone intervention can improve discharge planning when it is done in the right way, by the right people, according to the results of a program at Rush University Medical Center in Chicago.

Discharge planners know that simply having a nurse call after discharge to see if the patient is faring well will have limited effectiveness, but the program at Rush goes far beyond that, with specially trained social workers and an algorithm of risk factors and potential interventions.

The program, first implemented in 2007, succeeded in reducing readmissions within 30 days for seniors and mortality, although specific numbers are still being compiled.

The program targets seniors 65 years of age and older who are discharged to their homes and have multiple prescribed medications, plus other risk factors, notes Robyn Golden, LCSW, director of the older adult programs at Rush. Within 48 hours of discharge from the hospital, the patient receives a call from a Rush social worker, whose responsibility is to ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around any issues that might arise once the patient is back in the community. Those issues may range from transportation to meals and in-home care.

Over the three years of the Rush program, the social workers involved have found several common themes in post-discharge care, Golden says. Patients reported difficulty getting around after discharge, particularly if their illness affected their mobility. Patients also reported difficulty scheduling medical appointments and getting to their physicians' offices, as well as delays in home health care services. Caregivers were often overwhelmed.

Most patients required attention

A study of the program found that issues requiring attention occurred in 83% of the cases, says Madeleine Rooney, MSW, LCSW, liaison, Older Adults Program at Rush University Medical Center. Rooney spearheaded the development of the enhanced discharge planning program.

For 74% of these individuals, the problems did not emerge until after hospital discharge, Rooney says. The study also found that those who received services, versus those who did not, were significantly more likely to follow up with their doctors after discharge, which is an important contributor to positive health outcomes.

The enhanced discharge planning program was developed in response to recent trends that complicate the continuation of care, Rooney says.

"Patients are leaving the hospital in shorter periods of time, and often, they are leaving with multiple chronic conditions or more complex care needs, especially for older adults," Rooney says. "We saw that we could meet an unmet need by making contact with patients identified as being at risk for complications or problems after discharge to do a follow-up assessment."

Social workers ideally suited

In other programs to help patients transition from hospital to home, nurses coordinate the after-hospital care, but Golden believes that social workers are ideally trained for the role.

According to Golden, research has shown that 40% to 50% of hospital readmissions are linked to social problems and lack of community services — issues that social workers are trained to address.

"Social workers possess extensive knowledge of community resources, expertise in navigating complex social systems, experience using a framework of practice that focuses on the person in the environment, and training in case management and care coordination," Golden says. "Social workers are also able to use psychosocial assessment skills to explore family dynamics or resources that may affect the success of the discharge plan."

The program initially was targeted at patients older than 65 in four units of the medical center, Rooney explains. Case managers on those units identified at-risk patients using subjective criteria. For instance, the case manager might have made a referral to the Department of Aging but wasn't sure what the status of the referral was, or the patient was referred to home health — but the case manager was worried about the home health provider's ability to follow through and wanted Rooney and her colleagues to ensure that care was provided promptly. Financial difficulties also could trigger a referral.

After two years, Rush studied the data on referrals and what the social workers determined when they made the initial contact to the patients after discharge. During the two-year pilot period, a total of 1,248 referrals and 4,350 phone calls were made, and social workers connected with more than 1,400 older adults and/or their caregivers. The findings also show that 67% of pilot participants were not receiving necessary community services, following through on discharge recommendations, or coping with care demands. Sixty-one percent of patients required more than one call to resolve their identified issues, and the average number of calls per person was 3.49.

Algorithm of risk created

Using that information and risk factors identified in the literature, Rush developed an algorithm of risk in 2009, when the program was expanded to all units at the medical center. The algorithm used fields already available to clinicians in the hospital's electronic medical record system, typically completed by nursing and case management.

The risk factors include items such as admitted within the previous six months, number of medications, high-risk medications, and specific diagnoses, such as congestive heart failure, chronic obstructive pulmonary disease, HIV, and diabetes. Depression, mental health issues, substance abuse, and family conflicts also were identified risk factors.

"Interestingly, our research showed us that going home with home health was itself a risk factor," Rooney says. "There were problems and gaps with the provision of services by home health providers. So, we added that to our risk factors and will soon be adding pain, as well."

At about the same time, Rooney and her colleagues developed a template of intervention that included the most common problems found with post-discharge patients — transportation difficulties and financial problems, for example — and potential interventions to address those problems.

"One of the things that makes this model different is that it is a very bio-psychosocial approach to assessing discharge," Rooney says. "When we prepare to contact a patient, we're looking in our electronic medical record to see what was the clinical picture, what was the discharge plan of care, who were they supposed to follow up with, and so forth. But equally important to us was the many psychosocial and environmental issues that we know impact health outcomes, which often get minimized in the typical model. Discharge planning is usually practiced with a very medical model of care."

Team discusses discharge daily

Rooney notes that the enhanced discharge planning program meshes well with the federal government's drive to require a more effective and comprehensive care plan for patients, and the likelihood that reimbursement will be tied into rehospitalization rates. With that pressure in mind, the administration at Rush is studying the effectiveness of discharges at the hospital and piloting a program on one medical/surgical unit that involves a multidisciplinary team that meets every day at 10 a.m. to assess patients and plan for discharge.

The core team includes direct care nurses, case managers, hospitalists, clinical pharmacists, and an enhanced discharge planning social worker. Others join the team occasionally, Rooney says, including chaplains, dietitians, and physical therapists.

All of the patients on the unit are assessed using the discharge planning risk algorithm, and a report is generated for the team each day. Patients with one or more risk factors prompt the team to discuss potential interventions to improve the post-discharge plan, even from the patient's first day of admission. For instance, the team may identify that a patient will need to be educated about post-discharge medications, so that task is assigned, and then the team checks the next day to confirm that it was completed.

Rush also addressed the fact that a home health referral was a risk factor. Rooney and her colleagues met with many of the home health agencies in the community to discuss standards and quality of care, then created a set of expectations for the home health provider. For instance, a nurse must visit the patient within 48 hours, and any required physical therapy visit must occur within 72 hours. In a pilot with five agencies, Rush now requires the home health provider to file a regular report that tracks how well it has met those expectations — and to notify case management immediately if it identifies that an expectation cannot be met for a patient.

In its efforts to find new ways to help patients transition from hospital to home, Rush is also participating in Project BOOST (Better Outcomes for Older Adults through Safe Transition), a national project involving 30 hospitals to redesign the discharge process. Rush is the only hospital in Illinois included in the project. Like Rush's enhanced discharge planning program, Project BOOST, sponsored by the Society of Hospital Medicine, is aimed at reducing readmissions.

In December 2010, Rush received a two-year, $400,000 grant from the federal Administration on Aging and the Centers for Medicare & Medicaid Services to provide transitional care to older adults and people with disabilities. The grant will help extend Rush's enhanced discharge planning program to a new population.

(Editor's note: Rush offers guidance to other hospitals interested in replicating the enhanced discharge planning program. For more information contact Rooney or her fellow social worker in the program, Gayle E. Shier, MSW.)


• Robyn Golden, LCSW, Director, Older Adult Programs, Rush University Medical Center, Chicago. Telephone: (312) 942-4436. E-mail: robyn_l_golden@rush.edu.

• Madeleine Rooney, MSW, LCSW, Liaison, Older Adult Programs, Rush University Medical Center, Chicago. Telephone: (312) 942-6995. E-mail: madeleine_rooney@rush.edu.

• Gayle Shier, MSW, Social Worker, Older Adults Program, Rush University Medical Center. Telephone: (312) 942-8182. E-mail: Gayle_E_Shier@rush.edu.