Readmission rates plummeted after a multidisciplinary team at Baylor Scott & White Health in Dallas began following elderly patients for 30 days after discharge.

• Patients targeted are hospitalized with pneumonia, heart failure, and chronic obstructive pulmonary disease and are stratified into three risk categories.

• All patients receive follow-up calls from a nurse, pharmacist, and social worker, and participate in automated telehealth calls.

• Advanced practice nurses make one visit to medium-risk patients at home, and weekly visits to high-risk patients for 30 days.

Readmission rates dropped from 19.9% to 13.5% when Baylor Scott & White Health in Dallas launched a program to follow up with elderly patients hospitalized with pneumonia, heart failure, and chronic obstructive pulmonary disease (COPD).

“Our goal is to get readmissions down to 10%,” says Alexis S. Early, LMSW-IPR, ACM-SW, social worker on the transitional care team.

Components of the program include follow-up telephone calls, home visits for high-risk patients, and automated telehealth calls. The patients are stratified into three risk categories and three flexible protocols that can be adjusted according to their preferences.

Patients in the program are 65 and older who are hospitalized for heart failure, pneumonia, or COPD. A multidisciplinary team follows patients discharged from nine hospitals in the Baylor Scott & White system for 30 days after discharge. The average patient in the program is 85 years old with five comorbidities.

The program is part of Baylor Scott & White’s House Calls program, which has been providing primary care visits to homebound seniors for 20 years.

“Going forward, Baylor Scott & White will focus on all-condition, all-cause readmission prevention. To better support this goal, the program is expanding to include diagnoses of hypertension, diabetes, sepsis, and urinary tract infection and will open up to patients 18 and older,” Early says. Plans also call for including community health workers in the program.

The transitional care team coordinates transitions for about 180 people at a time.

The team includes a master’s-prepared social worker, a nurse, a pharmacist, three advanced practice nurses, and a healthcare coordinator who manages the telehealth program. A physician office representative reviews the referrals from the hospitals, checks the patients’ insurance, and acts as the coordinator of operations, Early says.

The nurse makes follow-up calls to the patient after discharge and intervenes when needed. The social worker conducts follow-up calls, screens for depression and anxiety, provides emotional support, and connects the patients with appropriate community resources. The pharmacist makes follow-up calls to patients, reinforces the importance of adhering to the medication regimen, conducts medication reconciliation, and coordinates with the patients’ primary care physicians to make sure they are aware of the prescriptions the patients received while in the hospital, and that none of the medications cause adverse interactions. The advanced practice nurses visit eligible patients at home and are available for phone consultation if patients have questions.

“The entire team collaborates to assist the patients,” Early says.

Most of the patients are referred by the social workers and RN care managers embedded in the nine hospitals.

“Our team relies heavily on the social workers and RN care managers who work with the physicians to write an order for patients who are eligible for our services. They present our program to eligible patients and get their consent to be enrolled. When patients agree to participate, the social workers and RN care managers notify us by email and we enroll them,” Early says.

When older patients are admitted to hospitals in the Baylor Scott & White system, they are given a detailed geriatric assessment that gathers information on their medical, psychosocial, and functional capabilities and limitations.

The transitional care team inputs information from the assessment and other information from the patient chart into a software algorithm that risk-stratifies patients into three risk levels, each with a different protocol.

Patients at low risk still are active, newly diagnosed, or have been hospitalized only once for their disease. Many still are working. They receive a pharmacist call on the second day after discharge, and a call from the social worker after six days. The social worker conducts another social assessment, checking on family support, transportation to their physician office, activities of daily living, and social needs. The social worker conducts a depression screening and reminds the patient to call the nurse line if he or she has questions or concerns.

Low-risk patients receive an automated telehealth call every day for 30 days and answer questions that pertain to their specific chronic illnesses. If the patient answers “yes” to any question that indicates a problem, the nurse automatically is notified. The nurse calls the patient to get details and coordinates care with the patient’s primary care physician.

Patients at medium risk receive calls from the pharmacist two days after discharge, and the nurse on days five, 14, and 21. The nurse conducts an assessment, provides chronic disease-specific education, and answers questions and concerns. An advanced practice nurse makes one visit to the homes of medium-risk patients, conducts medication reconciliation, reinforces the education, checks vital signs, manages any clinical symptoms, and helps with advance care planning. The patients also participate in telehealth.

High-risk patients are those who have five or more comorbidities, multiple ED visits and/or hospital admissions, or have had a skilled nursing or rehabilitation facility stay. “These are complex patients, usually with difficult family dynamics and lack of support in the community,” Early says.

They receive calls from the pharmacist and the nurse, and participate in telehealth. An advanced practice nurse makes a home visit to the high-risk patients within 48 hours after discharge and follows up with a weekly visit. The social worker identifies the patients’ psychosocial needs, connects the patients with community services, and follows up to ensure their needs are met.

“Our program is very fluid and we try to accommodate the patients’ wishes. We have patients who don’t want a visit from an advanced practice nurse, so the office-based team follows them. If they don’t want telehealth, contact them through the nurse phone calls,” Early says.