Look beyond hospital walls to avoid readmissions

Focus on what happens to patients after discharge

Case managers typically have concentrated on what has to happen before the patient can be discharged from the hospital, but now, to reduce readmissions, hospitals also have to take into consideration what happens to patients after they leave the acute care setting, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and health care consultant and partner in Case Management Concepts LLC.

"Hospital stays are episodic and are only part of the management of a patient. Transitional planning is not just about moving the patients into the hospital and out the door. Hospital staff must take responsibility for initiating coordination of care and ensuring a smooth transition to the next level of care," adds Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.

All patients need discharge planning, but not every patient's discharge needs must be addressed by a case manager, she says.

Every patient should be assessed on admission for potential discharge needs and reassessed during the stay for any changes in the discharge plan, Cesta adds.

"When patients are not assessed for discharge needs, there is no plan for follow-up care, and the patients move into the community unprepared to manage their own care and with no person responsible for helping them. If they go home without knowing how to manage their care or don't see a doctor in a timely fashion, they are likely to develop problems that result in a readmission," she says.

Hospitals should develop discharge planning criteria and use them to screen patients to identify those at high risk for discharge planning, Cunningham says.

Educate the nurses and frontline caregivers at your facility to identify patients who are at high risk for discharge needs, she adds.

"There are some patients who will definitely need discharge planning, and they can be quickly identified. But there are other patients who say they can manage at home but after discharge they can't take care of themselves," Cunningham points out.

Discharge planning should begin at the time of admission to the hospital and not at the time of discharge, says Hussein Tahan, DNSc, MS, RN, CNA, executive director, international health services at New York Presbyterian Hospital.

"The earlier case managers begin the process, the more opportunities they will have to talk to the patient and caregiver about discharge options and make sure they are active participants in the process, as well as in making decisions regarding their care after discharge. If we identify the caregivers and engage them early on, we can help them understand their roles and responsibilities toward the patient after discharge. We also will be able to determine whether they are capable of assuming such responsibility," he says.

Involving patients who live independently in the discharge plan gives case managers the opportunity to begin self-care management education early to make sure patients are capable of caring for themselves, Cesta says.

"If the case management assessment shows that patients may not be able to manage their own care after discharge, the case manager will have to incorporate that into the plan of care and look for alternative approaches," Tahan adds.

Initial assessment at admission

At North Hills (TX) Hospital, the case manager performs an initial assessment shortly after admission to look for the patient's potential for post-acute needs and collaborates with the social worker to make sure the needs are met.

"We determine if they live at home, if they are independent, if they have caregivers available in the home or close by, and other factors that might impact their ability to transition back into their pre-hospital setting," says Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management.

For instance, a 78-year-old man with multiple medical problems who has been getting along on his own with his daughter dropping by every couple of days may need more support when he goes home from the hospital.

"In that initial assessment, the case manager tries to pull all the pieces together and coordinate with the social worker to facilitate a safe transition to the next level of care," she says.

The social worker coordinates with the patient, the family, the physician, and the remainder of the treatment team to come up with a plan that will ensure a safe discharge.

"We involve the patient and family early on in the discharge plan. Medicare Conditions of Participation require that the patient have a choice in post-acute providers, but people are more likely to be adherent if they have a part in developing the discharge plan," she adds.

The hospital staff present the most viable options to the patient and family and work together so everyone is telling them the same thing.

"It can be difficult if there is an older adult who has been living independently and now can't go back to the home setting. The physician, social worker, case manager, and nursing staff work together to help the patient understand the risk to the patient," she says.

Ensuring that patients have a follow-up visit within seven days of discharge and medication adherence are the two biggest opportunities for reducing readmissions, Cesta says.

"Where case managers tend to fall short is counseling patients to prepare them for discharge. Today's patients are sicker than ever before when they leave the hospital and it's difficult for them to retain the information they need to transition safely back to the community," she explains.

Educate your physicians to help prepare patients for discharge, Cunningham says.

"At our hospital, we have asked the hospitalists to personally say to the patient how important a follow-up visit to their primary care physician is," she says.

Many patients don't have follow-up visits because it's difficult to make a call to a busy doctor's office, Lawson points out.

"Many times it's difficult to navigate the telephone system, or older patients don't hear well and can't understand the options so they just give up," she says.

The hospital is developing a pilot project with a senior clinic affiliated with the hospital to block out appointments so discharged patients can get in to see a physician in a timely manner.

"We want to help them get their appointments within seven days, the high-risk time for patients to be readmitted. A primary care visit shortly after discharge is a big key to minimizing readmissions," she says.

Lutheran Medical Center is asking its clinic to hold slots for appointments to ensure that patients can get in, Cesta adds.

Hospitals need to make sure the paperwork they give patients is simple and easy to understand, Cesta says.

"The discharge instructions are more for us than for the patients. They're not patient-friendly. Even if the patient can't read them, they don't understand them," Cesta says.

Many hospitals give patients a carbon copy of a written form and keep the original for the chart. The copy may be blurry and may include medical jargon that patients don't understand.

"Patients go home with a stack of papers, most of which are carbon copies filled with medical jargon. They either can't read them or, when they feel like reading them, it's too late," Cesta says.

As part of discharge education, case managers should include an explanation of each document they give patients at discharge, what information each contains, and how patients and their caregivers should use the information, Tahan suggests.

"Don't just tell them, write it down for them in a way they can understand," he says.

For instance, write down that the pink sheet tells them what to do after discharge and the yellow sheet is a list of their medications that they need to give to their primary care physician.

"Since medication adherence and reconciliation are of major concern and sometimes result in readmissions to the hospital, case managers need to do more education about medications, discuss the importance of filling the prescription, and make sure the patients know what to take and how to take it when they get home," he says.

Tahan recommends making post-hospital discharge calls within 72 hours to make sure the patient has filled his or her prescription, understands what medications to take and when, and has a follow-up appointment in place.

"This is necessary for the continuity of care and an approach that should prevent some readmissions to the hospital. The call is another opportunity to educate patients about their care and to make sure they can care for themselves and that the discharge plan was safe," he says.

(For more information, contact: Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management, Lutheran Medical Center in Brooklyn, NY, e-mail: tcesta@lmcmc.com; Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, e-mail: Beverly.Cunningham@hcahealthcare.com; Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management, North Hills Hospital, e-mail: Cynthia.Lawson@hcahealthcare.com; Hussein Tahan, DNSc, MS, RN, CNA, executive director, international health services, New York Presbyterian Hospital, e-mail: hut9001@nyp.org.)