Hospitals can significantly reduce readmissions with a multilayered program tailored to the needs of individual patients, according to the experience of an Arizona health system.

One of the program’s strategies is to take some of the stress and responsibility off of case managers, says Debra Richards, MSN, RN, director of Sun Health Care Transitions, part of Sun Health, a nonprofit healthcare organization in Surprise, AZ, focusing on care for seniors. She previously worked at a hospital implementing the organization’s program for lowering readmissions.

As vital as case managers are to the discharge process and lowering readmissions, they can easily be overworked, Richards says. Prior to adopting the Sun Health strategies, her hospital depended on the case manager to send a referral to the care transitions team.

“A hospital case manager on an easy day has a ratio of 25 to one, so we found that the referrals really weren’t getting done. It wasn’t the fault of the case managers, because they were just so busy,” Richards says. “When Sun Health put a patient liaison in the hospital, that person could screen the Medicare fee-for-service patients and introduce the program to them in the hospital, so it’s not a cold call after discharge when they’re tired, have home health coming, and doctor’s appointments to be made.”

Patients are more receptive to the program when it is introduced well before discharge, Richards says.

“They remember the nurse in the yellow scrub top who came in to see them and explained what we were going offer them,” she says. “It makes a difference to have that connection well before the discharge process, when there can be so much information to absorb and things to do. Then, when that same face appears later, they respond much better.”

Nurse Calls and Home Visits

Nurses in the Sun Health Care Transitions program follow, educate, and support patients for 30 days following their hospital discharge, including conducting home visits and phone calls to help patients better self-manage their health conditions and, in turn, reduce the need to be rehospitalized.

The nurses review patients’ medication regimens, educate them on their conditions and potential red flags that could signal the need for medical attention, ensure timely physician follow-up care, and connect patients with helpful community resources.

At the time of discharge, the care transitions program is summarized for the patient, noting that a representative from Sun Health Care Transitions would contact him or her within 24-48 hours and provide a phone number to call with any questions. Nurses prepare a personalized plan for contacting each patient, with a typical plan proceeding in this fashion:

  • Prior to discharge: Bedside visit.
  • First day after discharge: Phone call to assess the condition and answer any questions.
  • Second or third day: Home visit.
  • Seventh day: Phone call.
  • 14th day: Phone call.
  • 22nd day: Phone call.
  • 30th day: Phone call.

The first phone call addresses general concerns, such as how the patient is feeling and whether he or she obtained the necessary medications, and whether the patient has made follow-up appointments with a physician. The caller also inquires about scheduling a visit from a nurse within the next 72 hours.

The home visit focuses on educating the patient about his or her particular needs and troubleshooting any problems that could interfere with healing.

“At the home visit, the RN goes over all the discharge paperwork, makes sure they’re taking all their medications and not taking duplicate meds because they got a new prescription with a different name. If they’re having trouble getting their prescriptions or getting through to their doctor’s office to get an appointment, we will help them with that,” Richards says. “We also provide them a binder of information for learning about their chronic diseases. They may have been admitted for a hip fracture, but it’s their chronic heart failure that’s likely to cause a readmission, so we help them learn how to care for that condition after a major surgery.”

RN Creates Action Plan

The patient is asked to have all of his or her medications out on a table when the nurse is scheduled to visit, to be assessed for any conflicts. This is particularly important with some patients who hold on to old medications, Richards says. Her own father always had a bag of current medications and a bag of old medications that he saved just in case he needed them again.

“We can help them dispose of those old meds so that they’re not hanging around and potentially having a bad effect when the patient confuses them for another medication or decides to start taking an old medication again without a doctor’s order,” she says.

The RN also develops an action plan that helps the licensed practical nurses who make the follow-up phone calls after the visit, guiding them to ask the right questions for that patient. For instance, the LPN might ask if the patient’s weight is increasing or whether there has been any progress in scheduling a doctor’s appointment that was proving difficult. If the patient has seen a physician, the nurse asks how that went and whether there was any change in medication.

It is important to have RNs make the house call, explains Jennifer Drago, MBA, MHSA, FACHE, executive vice president for population health with Sun Health. The LPNs are fine for making contact with the patient, but an RN is necessary for some of the key tasks during the home visit, she says.

“We’ve specially picked our RNs because of their backgrounds in chronic disease, and many of them have experience in home care so they know what to look for when they go into the home,” she says. “As RNs, they can do much more than a lay person or a volunteer — or even a social worker, in some respects — would be able to do in terms of educating the patient about chronic disease and addressing medication reconciliation in the home.”

The nurse making the call also asks about wound care, though that is not an issue that is specifically addressed at the home visit.

“Even though we don’t do wound care as part of this program, it’s useful to have someone reach out and ask that question because maybe they don’t have home health and don’t realize that it’s a bad thing when the wound is getting red and hurting,” Richards says. “We can direct them to the proper care for that and follow up to make sure they’re getting it.”

The program is different from what most hospitals do because the nurses are able to devote more time and attention to the patient after discharge, Richards says. Most hospitals simply don’t have the resources to see and contact patients regularly after discharge, she says.

“From a hospital’s point of view, they usually can accomplish one discharge call after the patient goes home, if they’re lucky enough to connect with them. It’s a one-time call and you’re not in the home,” Richards says. “Going into the patient’s home is what is really golden. The patient can tell the case manager about the home and living conditions, but the case manager really has no clue. When I go to the home, I can see that this person is a hoarder, or has throw rugs everywhere — all sorts of safety issues that we can address however necessary.”

The Sun Health Care Transitions program costs about $340 per patient to implement, but Drago says that expense is more than recouped by reducing readmissions. The return on investment typically is 150% to 200%, she says.

Patients participating in the program have rated Sun Health Care Transitions an average 4.74 on a scale of 5 in a satisfaction survey after the end of their transition programs, and more than 99% said they would recommend the program to others.

The Care Transitions program was launched in November 2011, and since then there have been 11,861 patients enrolled. The 30-day readmission rate for Sun Health Care Transitions patients is 7.72%, demonstrably lower than the national Medicare average, Richards notes.

In that period, Sun Health would have expected 2,111 readmissions without the transition program, but the actual readmissions were 916. That’s a reduction of 57%, yielding an estimated savings of $16 million, Richards says.

The good figures for 30-day readmissions continue, Drago notes, with 60-day readmissions at 15.2% (compared to 23.8% at partner hospitals not using the program) and 18.4% at 90 days (compared with 29.5% at the other hospitals).

“The reduction we had actually increased in that 90-day window, and we attribute that, in part, to the work we do around chronic disease, because they don’t usually get that kind of information, or they’re not very receptive to it. We catch them at a vulnerable time when they’ve just been discharged and they’re engaged because they want to know how not to go back to the hospital,” Drago says. “The work with medications also is important, and there is a significant impact from being in the home and looking for the social determinants of health that can impact the person’s physical health. We as healthcare professionals focus so much on the physical, of course, but if someone doesn’t have transportation or air conditioning or access to food, their health is going to suffer.”