Readmissions can never be low enough, so hospitals are constantly looking for better ways to reduce them. Some are finding that success depends on collecting good data, because you can’t reduce readmissions if you don’t know what’s bringing people back to your door.

Regions Hospital in St. Paul, MN, a 454-bed teaching hospital in the HealthPartners system, was concerned about readmissions two years ago and leaders there recognized that while they had a robust data collection system, it was not capturing patient perceptions, says Rory P. Malloy, MPH, senior performance improvement manager. The hospital averages about 150 readmissions a month, and when a quality improvement team looked at how to reduce those numbers, they found a weakness in their data collection.

Like many hospitals, Regions collects information on readmissions to help identify causes, but Regions found that for about two-thirds of their readmissions the reason was listed as “other.” The patient’s response to a brief query on readmission didn’t fit any of the options listed on the form.

The hospital developed a process for in-depth interviews at the time of readmission, delving much deeper than the usual list of reasons for the patient returning. The results have been enlightening and revealed areas of concern, such as a high rate of patients not attending follow-up appointments and not following drug and nutrition recommendations.

“In 2017, we’re hoping to integrate the feedback results directly into the electronic record and into the actual caregiver’s process,” Malloy says. “We want to integrate the information in team rounds and the discharge planning that the case manager might do at the patient level. As we start to see trends and themes emerge, that’s going to be what helps us drive our strategy for all patients.”

Pursue Multiple Strategies

The key to reducing readmissions is to operationalize several strategies and ensure accountability for each strategy, says Donna Hopkins, MSN, RN, CMAC, vice president with Novia Strategies, a healthcare consulting firm based in Poway, CA.

One such strategy to reduce readmissions focuses on the discharge plan — and specifically on the inclusion of the patient and his or her caregiver throughout the entire episode of care as part of the discharge planning process, she says.

“Too often, we see that the care team thinks the discharge plan is in place through daily rounds, only to discover at the time of discharge, the patient or caregiver hasn’t been prepared or educated on what they need to do once they get home,” Hopkins says. “To reduce readmissions, we recommend proactively including the patient and caregiver into daily conversation during their acute episode, so they know what they need to do after discharge to foster full recovery.”

Another strategy to reduce readmissions focuses on discharge follow-up. Best practice is following up with the patient and caregiver within 48 hours — ideally in person, and essentially by phone — to reinforce education and confirm the patient has the resources and support needed to follow the discharge plan, Hopkins says. Another best practice is to secure a home health agency screen for all patients discharged to home — not only the obvious ones.

“We see situations where a patient doesn’t appear to need a home health screen, yet that patient might have less optimal home conditions that may compromise their recovery,” she says.

An emerging trend is the incorporation of transition coaches or patient navigators within care management models, Hopkins says. The transition coach or patient navigator is a higher-level point person for the patient and family with the knowledge and skills to manage a patient’s care throughout the entire episode. This navigator takes care management outside the four walls of the hospital, coordinating the patient’s care prior to admission within the acute care setting, and post-discharge for 30 to 90 days.

“This approach ensures patients are ready for surgery, transition appropriately from one level of care to the next in a timely manner, receive appropriate discharge planning to that least restrictive environment, and are followed after discharge to minimize readmission,” Hopkins says. “Early demonstration projects are showing positive results, as evidenced by such metrics as increases in patient satisfaction, decreases in surgical cancellation rates, decreases in 30-90-day readmission rates, and increases in discharge to home.”

The optimal period for analyzing discharge data is being questioned, with a recent study suggesting that a shorter interval will yield data that more accurately reflect hospital quality and factors that can be controlled.

Don’t Restrict Focus Too Much

Hospitals most often go wrong when studying and trying to reduce readmissions by focusing their efforts on a narrow patient population, says Patricia Hines, PhD, RN, a managing director with Novia Strategies. Many organizations have historically placed their readmission efforts on the high-risk, high-dollar patient populations targeted by CMS that are associated with financial penalties, such as pneumonia and, more recently, total joint replacement.

“They have not applied their readmission strategies to all of their patients, especially those at high risk who do not cleanly fall within those diagnoses. Patients don’t always fall into specific categories, and narrowing the focus tends to support a task-oriented approach to care delivery,” Hines says. “In our work with hospitals and healthcare systems across the country, we see more success when they adopt a comprehensive care planning approach that includes all high-risk patients as well as their caregivers.”

The Improving Medicare Post-Acute Care Transformation Act, or IMPACT Act, of 2014, is intended to improve many quality metrics, including readmissions and ED re-visits from post-acute settings, Hines notes. The IMPACT Act is stimulating post-acute venues to ramp up efforts to identify patients at risk and establish efforts to prevent readmissions, she says, and the risks imposed on hospitals for accountability for entire episodes of care, whether through bundled payments or Medicare Spending per beneficiary (MSPB), will affect readmission rates.

For hospitals, the threat of penalties better justifies their investment in initiatives to reduce readmissions, Hines says. Thus, hospitals are becoming more motivated to coordinate care and reduce fragmentation not only within their own acute care setting, but also beyond to the post-acute services, she says.

Address Transition Earlier than Discharge

Ideally, the healthcare team should position the patient for the next level of care along the course of the hospitalization and not in the last few hours prior to discharge, Hopkins says. As a safety measure, hospitals should adopt a “Discharge Time Out” process prior to a patient’s discharge, like a surgical procedure time out, where the healthcare team would reassess all the processes essential for a smooth transition of care have occurred. If not, the application of teach-back methods, medication reconciliation, and further patient education is best saved for the transition coach or navigator role to follow-through post-discharge.

“What is absolutely essential is what is termed ‘survival education,’ encompassing whom to contact for problems, medications for the first 24-48 hours, and the expectations for follow-up by someone from the transition care team the day after discharge.”

Every readmission is a learning opportunity even if the cause was beyond your control, says Thomas Mathew, MD, a hospitalist for 10 years and corporate medical director of health systems for naviHealth, a post-acute care management company based in Nashville. Good data will reveal information that can be applied to individual patient care, he says.

Healthcare professionals from many areas need to work together, and with community resources, to address readmissions rather than seeing the issue as primarily the hospital’s responsibility, he says.

“The financial penalties have us focused now not on just a 30-day risk period but the 90 days, and that pushes all the various providers and environments where patients journey over 90 days to start aligning a little bit differently,” Thomas says. “We can’t just say we’ll blame it on the home environment and leave it at that. Let’s try to understand it because we’re all at financial risk, but it’s also about the quality of care in a community.”

Data collection should be widened so that instead of a simple checklist, the provider asks open-ended questions such as, “What would have helped you avoid coming back to the hospital?” he suggests. Seeking information from the original treating clinician, asking what could have been done to avoid the readmission, also yields valuable information, he says.

Readmission history also is not captured well during intake, Thomas says. Emergency physicians and others can add a question about readmission history to the standard history questionnaire, he suggests, possibly identifying issues that can be addressed in the treatment process.

Significantly reducing readmissions will require a change in mindset across the entire healthcare community, Thomas says.

“The new model says patients shouldn’t be managed in a silo but rather connected along an episode of care, and that’s a strategy that will help align folks along the continuum to start aligning their efforts more,” he says.

Telemedicine is a strategy with great potential for reducing readmissions, says Richard Kimball, managing partner of HExL, a consulting company based in New York City.

Some of the most immediate benefits come when using telemedicine to monitor patients with congestive heart failure, which can begin with simply having the patient step on a scale every day. If the patient’s body mass goes up 5% in a short period, this is a warning for fluid retention probably caused by failing to take medications or manage diet.

“You can get an alert from that measurement and intervene immediately before the problem gets out of control and the patient comes back to the hospital,” Kimball says. “The same can be done with glucose monitors and a number of other monitoring devices. The ability to get that heads-up before the patient starts spiraling down can make a significant difference in reducing readmissions, as long as you’re also prepared to provide the necessary intervention in a timely way.”