Thanks to a series of initiatives to focus on at-risk patients after discharge, Flagstaff Medical Center has avoided readmission penalties for four years and consistently has a 12% all-cause Medicare readmission rate.

  • Inpatient care coordinators assess patients in the hospital and refer those who are at risk to the outpatient care management team, which visits the patients in the hospital and determines the appropriate post-discharge interventions.
  • Depending on their risk scores, patients may receive home visits from coaches, telephone calls from care managers, telemedicine monitoring, or a combination of interventions after discharge.
  • Care coordinators who staff the ED 24/7 set up services including home health, skilled nursing transfers, hospice consults, and other interventions, when appropriate, to prevent a readmission. Utilization review nurses are a resource with physicians when they determine patient status.

Flagstaff (AZ) Medical Center hasn’t had a readmission penalty for four years, and consistently has an all-cause readmission rate for Medicare patients of 12%, compared to a statewide average of 16% and a national rate of 18.6%.

Following a challenge from the chief medical officer to cut the heart failure readmission rate in half, Flagstaff Medical Center, Northern Arizona Healthcare’s flagship hospital, reduced its all-cause 30-day readmissions from 23% to 12% by assigning patient care managers to stay in touch with at-risk patients through phone calls and telemedicine, says Lisa Brugh, MS, BSN, RN, ACM, system director of care management for Northern Arizona Healthcare.

That was in 2013. The next year, the care management leadership added pneumonia, myocardial infarction, chronic obstructive pulmonary disease, and total joint replacements to the program and staffed it with additional care managers. The program has also expanded to the system’s other hospital, Verde Valley Medical Center in Cottonwood, which has an all-cause Medicare 30-day readmission rate of 10.8%.

Flagstaff Medical Center is a major regional referral center and treats patients from a wide area, much of which is rural. “We are the only Level 1 trauma center in the northern part of the state and we’re often on deferral. We try to put patients in beds only if they need to be there and focus on moving patients through the continuum as quickly as possible and making sure they have what they need to prevent an unnecessary readmission,” Brugh says.

As part of the initiative to focus on transitions of care, a multidisciplinary team was trained on the Project BOOST (Better Outcomes by Optimizing Safe Transitions, developed by the Society of Hospital Medicine) program for preventing readmissions. The inpatient care coordinators and other treatment team members use Project Boost’s 8P tool to identify risk factors that could lead to readmissions. The health system’s electronic medical record includes a care management module and a readmission module, which automated the 8P data so the care coordinators could quickly identify patients who were at risk and implement appropriate interventions.

The care management department staff has developed a seamless program to meet the post-acute needs of all patients with staff who follow the high-risk patients through the continuum, Brugh reports.

The inpatient care coordinators assess patients in the hospital and refer the at-risk patients to the outpatient team. Care management assistants work with the inpatient care coordinators to implement the discharge plan. They set up follow-up appointments, arrange for durable medical equipment deliveries, and take care of other discharge needs.

“They handle the groundwork to get patients discharged so the care coordinators don’t have to spend a lot of time on the telephone or doing paperwork,” Brugh says.

The outpatient team, located in a medical office building on the hospital campus, includes a call center, RN care managers, social workers, and health coaches.

When the outpatient team gets a referral, an RN care manager visits the patient in the hospital, completes an evaluation using a risk adjustment tool, and develops a follow-up plan.

Depending on the diagnosis and the patient’s risk score, the care manager may suggest a telemedicine program, one or more home visits by a coach, telephonic interventions, visits by a paramedic in the community, or home health visits.

The outpatient care managers identify patients that could benefit from telemedicine and set it up while the patient is still in the hospital. They get the patients to sign the consent forms, provide them with the equipment, and teach them how to use it. The patients receive monitoring equipment such as scales, thermometers, oximeters, and transmit their metrics to the care management department every day.

The outpatient team’s health coaches work with patients who need extra education and help understanding and following their treatment plans. The coaches are patient care techs or medical assistants and are trained to make home visits, if needed, for additional follow-up.

Nurses in the outpatient care management department call every inpatient, observation patient, and high-risk ED patient shortly after discharge to review the discharge instructions, identify patients who didn’t get their medication or who didn’t understand their discharge instructions, and refer patients who need extra help to the care managers for follow-up.

Care coordinators, either nurses or social workers, cover the ED 24/7 and assess patients as they come in. A team of utilization review nurses also staff the ED seven days a week from 8 a.m. to midnight to serve as a resource when the physicians determine patient admission status. If patients do not meet criteria for an inpatient admission or observation services, the utilization review nurses refer them to the ED care coordinators to develop a safe discharge plan.

“The emergency department care coordinators can line up acute rehabilitation, facilitate a hospice consultation, or set up home health services and prevent a readmission,” Brugh says.

The care coordinators are alerted when a patient is readmitted within 30 days so they can assess the patient and revise the discharge plan and try to find out why the discharge plan failed. A team of care management staff performs a root cause analysis on every patient who is readmitted and presents the results to the hospital leadership.

“More changes are in the planning stage,” Brugh adds. She and her team are developing a post-acute resource center by moving FTEs from the care coordination positions to the resource center. The center will include case management assistants who will work with the inpatient care coordinators setting up equipment deliveries, making referrals to home health agencies and skilled nursing facilities, and other tasks that do not require a license.

By taking on the non-clinical tasks, the case management assistants will free up the inpatient care coordinators to work closely with the physicians and nurses to develop a progression of care plan, Brugh says. Once a progression of care plan is approved, the care coordinators will hand it over to the resource center staff.

The post-acute resource center includes care coordinators and may also include a social worker and nurses to handle whatever situations require their expertise. The center will be a resource for the bedside nurses who handle simpler discharges, for the outpatient surgery nurses, and the ED, as well as the inpatient care coordinators, she says.

“We are getting ready for the new discharge planning Conditions of Participation to go into effect. Since the proposed changes may require a discharge plan for every inpatient, observation patient, and outpatient, we’re taking a proactive approach with our resource center. The only alternative would be to locate care coordinators all over the hospital,” Brugh says.