Readmission rates respond to collaborative process

Working together multiplies benefits

There's not a healthcare organization around that isn't focused on reducing unplanned readmission rates. They cost money and are the focus of a variety of regulatory and payer organizations that are either no longer paying for care related to such readmissions or will soon stop. But as much as everyone wants to find some magic bullet that will work in multiple settings, the truth is that no one thing is going to solve the problem. Indeed, what works at one hospital for a particular type of patient may not work at another hospital 50 miles away for the exact same patient. That makes the idea of creating a state hospital association collaboration to work on the issue something of a head scratcher: If it all depends on where you are and the kind of patient and the time of day and phase of the moon, then really, shouldn't we all just figure it out on our own?

Absolutely not, says Alison Hong, MD, director of quality and patient safety of the Connecticut Hospital Association. She is working with hospitals in Connecticut on a multi-year collaborative to address statewide readmissions for congestive heart failure (CHF). People are forgetting one key aspect to the question — whether what any hospital does in isolation from the rest of the health care continuum does will make much difference at all. That's part of what makes this collaborative different: It involves not just association member hospitals, but also organizations outside the acute care setting who are involved in caring for these patients — nursing homes, home care, community physician practices large and small. All of the parties are working together, looking through data, doing chart reviews, and going through every possible process to find common factors that lead to unplanned readmissions among CHF patients. The group is using the Institute of Healthcare Improvement's (IHI) Transforming Care at the Bedside document as its QI template.

The collaborative started last year, meeting both in person and electronically to focus on five strategies:

  • delivering evidence-based care;
  • using enhanced admissions assessments of post-discharge needs — start planning for discharge as soon as the patient is on the unit, talking with family, discussing social issues, medication issues, and logistical issues that might arise;
  • engaging family and patients — identifying the right caregiver, asking patients why they think they returned to the hospital, using advanced teach-back methods;
  • medication safety;
  • post-acute care follow-up — requiring patients to have an appointment with a community physician or clinic made before they leave the hospital and see they get to that appointment within seven days of discharge, with no outstanding issues to address, including transportation to the appointment.

The latter issue has been critical, says Hong, and involved developing relationships with physicians and their office managers to ensure that seven-day window was met. Some offices opened heart failure clinics to deal with the need. Others changed staffing to ensure that if a hospitalist called at 4 p.m. on a Friday to make an appointment for the patient the next week, someone was there to answer the phone — or they changed the rounding so that the calls did not happen that late in the day, that late in the week.

Organizations that were used to looking within their four walls for ways to improve quality had to change their mindset and look outside for ways to improve efficiency and quality, too, she says.

There was increased telemonitoring and a move to do medication checks at home; organizations worked together to find the least amount of paperwork possible to meet various regulatory requirements and still provide all the information needed to ensure continuity of care. "Sometimes it was small issues, like remembering to put the weight of the patient when they were discharged from the hospital," Hong says. "Or it might be a change to call the physician first, rather than sending the patient from the nursing home right back to the emergency department. It was a matter of looking outside the organization and learning to work together."

Every single one of the ideas used was brought up at one of the consortium's monthly webinars or quarterly meetings. And what works for one may not work for another, but they are all willing to share. At the most recent meeting in early November, 138 people were present, Hong says, all taking notes, asking questions and sharing solutions. "The boon of working together is hearing the stories of what worked and what did not. You can pick and choose, you can get together and hash out new ideas."

Sometimes they bring in people from out of state or researchers to discuss the latest research and innovations. They keep an eye on IHI whitepapers. "Everyone is working on readmissions, but it can be hard to know where to start," Hong says.

The heart failure component finishes up in February. Data will be released in the summer, but already organizations have seen improvements from their baseline readmission rates. The program has been so successful that they are expanding it to all-cause readmissions and continuing with the group. Some will leave, others will join, says Hong.

This is the fifth collaborative that the membership of the hospital association has worked on, says Hong. There is a lot of interest in it, and in using the team dynamic to create traction. Even those with fairly low CHF readmission rates are working on this and seeing an effect. "We all know that this is important to community health and the patient. We all know that this is going to be our parents in a few years, or us."

A STAAR turn

A year before the Connecticut collaborative started, four states — Massachusetts, Washington, Ohio and Michigan — began a collaborative initiative to reduce readmission. Called the State Action on Avoidable Rehospitalizations (STAAR) initiative, an interim report was released in the July 2011 issue of Health Affairs1.

No data have been released yet, but the report notes that there are more than 500 partners across the continuum of care working on the project, including 148 hospitals. Of those hospitals, all of them now have teams that include people outside the hospital itself working to routinely review cases where a patient has an unplanned readmission.

Funded with a $5 million Commonwealth Fund grant to the IHI, researcher Amy Boutwell, MD, MPP, says what made this different was the emphasis on looking outside one particular care setting. "All QI projects are focused on what I need to do in this particular setting. What is interesting here is looking beyond that. Evidence shows that the handoffs, discharge processes, and transitions of care are a big issue in readmissions."

Participation in the project was predicated on committing to bring a cross-continuum team to the table. They had to include elder services, skilled nursing, visiting nurses, home care, and community physicians — whatever the organizations were that were most commonly involved in either "sending" or "receiving" patients. Patients and family representatives also had to be part of the cross-continuum teams. In addition, participants had to agree to collect data for all-cause 30-day readmissions and perform chart reviews and interviews of five recently readmitted patients to get their perspective on how to improve transitions.

"It's not just one provider who takes care of the patient, but a whole community," explains Boutwell. "The senders and receivers of those patients need to learn to talk to each other and figure out whether what they are doing works for us all, or for any of us."

The project runs for another two years, and anecdotal information shows that there is a lot of learning going on among participants. They purposely focused on all-cause readmissions because, says Boutwell, "we do not think that readmissions will be solved with a disease-specific focus." The average Medicare patient has more than one medical issue, so how do you know which one to focus on for readmissions? "We think if we do some basic things better, it will help all patients we serve. And we think that there is less risk of over-medicalizing it. The way we read the literature is that it is not about treating a disease or clinical condition better, but about helping patients navigate the system better."

The patient interviews were particularly helpful for participants, too, Boutwell says. "It was not about chart reviews or being statistically significant, but to get them to focus on the patient stories, the logistics and economic issues they face." Thus far, the issues that are arising probably sound familiar to the folks in Connecticut: getting post-discharge appointments in a timely manner; better communication with physicians, between providers, and with patients; and better patient education. "This is not exciting stuff. But it is all supported in the literature. We all think we are doing it, but if you study the process, you find out we aren't all doing it. They may think they do something 90 times out of 100, but it's really 50 or 60."

Along with the nearly complete participation with cross-continuum teams — something that no one was doing before STAAR — a recent survey of participants showed that 90% of them are working on using teach-back techniques with patients and 76% are working on using enhanced assessments to find out more about why patients think they came back to the hospital. "That says to me that we are providing meaningful recommendations," Boutwell says.

Boutwell notes that some participating hospitals have already reached their stated goals of reducing readmissions by 30%; Tufts reported a 50% decline in heart failure readmissions. Bay State Health System expanded its program from heart failure to the general medicine ward.

The improvements are often based on different endeavors. For example, Evergreen Hospital in Kirkland, WA hired patient educators, while Bay State made following up with discharged patients part of the job description for newly hired unit secretaries. "That was clever — not adding to the work burden of someone already there, but raising the bar for new hires," Boutwell says.

There is not likely to be a single protocol that works, Boutwell says. "But I think what will make a difference is bringing public and private entities together to make progress on systemic changes."

In the end, Hong says it all comes down to better communication — within the hospital community, but also within a particular healthcare community. There was a move in the 1990s and early part of the new millennium toward faxes, pagers, and electronic data, but sometimes, calling someone and talking in real time works better, says Hong. "It helps make the patient safer. We have to remember that those other things are tools, not replacements for real-time communication, and a call from the nursing home to the doctor might be the thing that keeps that patient from becoming a frequent flyer."

For more information on this topic contact:

  • Alison Hong, MD, Director of Quality and Patient Safety, Connecticut Hospital Association. Telephone: (203) 294-7266. Email:
  • Amy Boutwell, MD, MPP, President, Collaborative Healthcare Strategies, Lexington, MA. Telephone: (617) 710-5785. Email:


  1. Boutwell A, Johnson MB, Rutherford P et al. An early look at a four state initiative to reduce avoidable hospital readmissions. HealthAff. 2011 Jul;30(7);1272-80

10 ideas to reduce CHF readmissions

Among the ideas put forward and tried by members of the Connecticut Hospital Association's collaborative on reducing readmissions for heart failure patients are:

  1. heart failure coaches;
  2. expanded palliative care;
  3. unit-based hospitalist medicine;
  4. incorporating teach-back methods to education;
  5. starting teach-back simulation training (the audience seems to learn more than the simulators);
  6. ensuring post-discharge appointment in three to five days;
  7. using advanced practice nurses to see patients faster post-discharge;
  8. using an opt-out rather than an opt-in system for automatic home care visits — patients all get them unless otherwise specified;
  9. follow-up phone calls within 48 hours of discharge;
  10. ensuring you have a specific project goal related to lowering readmission rates, not a general idea to decrease it.