EXECUTIVE SUMMARY

The Children’s Hospital of Orange County (CHOC Children’s) in Orange, CA, has been recognized for its patient safety efforts that also have led to improved readmission rates.

  • The hospital reduced its readmission rate from 3.8 readmissions within seven days per 100 discharges in 2015 to 3.2 readmissions per 100 hospital discharges three years later.
  • CHOC Children’s divided the case management role between utilization review nurses and discharge planning nurses.
  • Discharge planning nurses/case managers round with medical-surgical teams.

A children’s hospital targeted seven-day readmissions, successfully reducing the rate after instituting a patient safety case management program.

In a value-based healthcare culture, ED and hospital readmissions for preventable health issues are considered a failure.

“With pediatrics, we focus on readmission within seven days,” says Patty Huddleson, RN, BSN, CPHQ, clinical quality manager at the Children’s Hospital of Orange County (CHOC Children’s) in Orange, CA. Huddleson and CHOC received recognition for their patient safety efforts in January 2019 by the Children’s Hospitals’ Solutions for Patient Safety (SPS), a collaboration that focuses on strategies for hospitals to improve safety and quality while reducing readmission rates. (See story about SPS in the April 2019 issue of Hospital Case Management.)

“The intervention that this collaborative decided to focus on had to do with keeping patients out of the hospital,” she adds. “Our readmission rate was 3.8 readmissions per 100 hospital discharges, within seven days, in 2015.”

Three years later, that seven-day rate was 3.2 readmissions per 100 hospital discharges, she says.

The hospital conducted a pilot program in 2016 with a case manager and social worker rounding with the physician medical-surgical teams. They were dedicated to that team, looking for case management and social services issues as they rounded, says Karen Pugh, MSN, RNC, director of case management and social services at CHOC Children’s.

Part of the hospital’s evolution was to change the case manager role. It had been a combination of case management discharge planning and utilization review (UR), Pugh says.

“Around 2017, we split up that role to make it distinct,” she explains. “We have utilization review nurses and discharge planning nurses, so it’s the discharge planning nurses that round with med-surgical teams.”

The UR nurses can work from home, using evidence-based guidelines and giving insurance payers all necessary information to expedite payments.

While rounding with physicians, case managers can send the UR nurses emails to answer questions about the physician’s discharge plans and timing. They keep communication flowing.

Here’s how the case management program works:

• Use team-based case management. Case managers touch base with patients’ families and connect them with needed services, making sure they are well-educated on what patients need at home, she adds.

“A year later, we attempted to spread that to more teams, meaning more teams in the med-surg unit, to have a case manager or social workers rounding with all the different teams — and the doctors loved it,” Pugh says. “They liked having the case manager and social worker there to bring up concerns they might not have thought about with the patient and family.”

• Assess risk. The next step is to develop a risk stratification tool that could identify patients who would most benefit from case management to prevent readmissions.

“Our organization hired a scientist a year and a half ago, who developed a tool to predict risk,” she says. “It puts patients in high, medium, or low categories to predict whether the patient would be readmitted.”

The tool was embedded in the electronic medical record. Initially, its goal was to categorize patients and look for reasons why patients were returning to the hospital.

At first, the case management team worked with the high-risk patients. But they found that most of those patients already were connected with the outpatient case management team, Pugh says.

“Now, we’re more focused on patients that are moderate risk,” she says. “We thought those kids could be prevented from coming back to the hospital.”

• Find out why patients return to the hospital. One strategy is to ask families questions from a reassessment tool, including

- “Why are you coming back to the hospital?”

- “When you left the hospital, how did you feel? Were you comfortable, slightly comfortable, uncomfortable?”

- “Were you prepared?”

- “Were you able to get your medications?” If the person says “no,” the case manager can ask whether the patient participated in the medication-to-bed program, which gives them medications to take home from the hospital.

- “Do you need help taking care of yourself?”

• Find solutions. One strategy for preventing readmissions is to ensure patients and families schedule medical appointments before leaving the hospital, Huddleson says.

Not all patients make these appointments, Pugh notes.

“We have a dedicated case manager to that process, to set up appointments at discharge, and we’re not at 100%,” Pugh says. “Sometimes they don’t want the appointment.”

Another strategy is to provide timely follow-up to discharged patients.

“We developed a post-discharge follow-up call with nurses,” she says. “Within 48 hours of discharge, we call to see if they have any questions, to reinforce the discharge instructions, and to make sure they have an understanding of what they’re supposed to be doing.”

The most frequent questions patients and families ask involve medical concerns. In some cases, nurses refer them to the right providers or advise them to return to the ED, Huddleson says.

• Collect metrics. “We keep metrics on whether patients completed their appointments after discharge,” Pugh says. “We have a dashboard and can show our team the work they are doing.”

The data include how many patients kept or did not keep their appointment.

“About 50% do not go to the appointment, and we’re trying to work with the team to figure out exactly why they don’t,” Pugh says.

“Some of the things we’ve heard back from families is the kid gets better and they don’t feel like they need to go to the primary care provider appointment,” she adds. “We’re working on a plan to increase the percentage of patients who keep their appointments, and case management is working on that, as well.”

Case managers also need to know why patients returned to the hospital. These readmissions and ED visits could be the result of worrisome signs and symptoms, such as being unable to obtain medication and schedule follow-up appointments, and not being comfortable with home care.

“Some would rather be at the hospital than at home,” Pugh says. “Or maybe their home health nurse didn’t show up or the durable medical equipment they needed was never delivered.”

• Provide telehealth as needed. Hospitals can schedule a post-discharge telehealth visit for patients who are discharged at high or moderate risk.

With telehealth, case managers and social workers can see patients in their homes. They can answer questions, ensure families understand the discharge instructions, and reinforce the importance of making it to a follow-up appointment, Pugh explains.

The case management program’s outcomes in reducing unnecessary readmissions have been positive, and there are other benefits: “Case managers love it because they feel their work is more streamlined without having to worry about the utilization review part; they’re more focused on the family,” Pugh says.