Medicare project focuses on readmissions

QIO, hospitals, nursing homes collaborate

Since DCH Regional Medical Center in Tuscaloosa, AL, and the Alabama Quality Assurance Foundation began collaborating on a Medicare demonstration project to determine the most effective ways to reduce readmissions for Medicare patients, the hospital has increased its referrals to home care, nursing homes, community resources, and medication assistance programs.

The project began in August 2008 in the Tuscaloosa Hospital Referral Region and involves seven hospitals, 13 nursing homes, and 12 home health agencies in seven counties, according to Sherrie Smith, RHIA, CPHQ, lead quality resource specialist, Alabama Quality Assurance Foundation with headquarters in Birmingham.

The Alabama Quality Assurance Foundation was one of 14 state Quality Improvement Organizations (QIOs) awarded a contract for the Medicare Care Transitions project.

The project's main goal is to reduce readmissions for Medicare patients hospitalized for all diagnoses, Smith says. The project also measures readmission rates for patients with heart failure, acute myocardial infarction, and pneumonia.

A key component of the project is increasing communication between post-acute providers and the hospital as patients transition to another level of care, Smith says.

"There are a lot of people who may impact whether a patient stays out of the hospital after being discharged. When patients are transferred from one provider to the next, in many cases, neither provider knows what the other's issues and requirements are. Home care agencies and nursing homes have to be involved in any project to reduce readmissions," Smith says.

Before the project began, DCH Health System already had embarked on several initiatives to reduce readmissions, says Brian Pisarsky, RN, MHA, ACM, CPUR, director, case management services, DCH Regional Medical Center and Northport Medical Center in Tuscaloosa, AL.

"We are looking at readmissions of all patients with all payers, from self-pay to commercial insurance to Medicare and Medicaid," he says.

The health system began what it calls the Hospital-to-Home case management program to identify additional patients who would benefit from being discharged with home care.

A dedicated case manager reviews patients throughout the facility to determine which ones might benefit from a home health referral.

"She looks at all patients, not just those who might be expected to need home health because of their diagnosis. These include patients who had outpatient surgery and those who are receiving observation services and are sick but not sick enough to be admitted," he says.

The Hospital-to-Home case management program has resulted in a 32% increase in referrals to home health, which in turn is likely to reduce readmissions, Pisarsky says.

"The home care agencies are very concerned with helping patients avoid readmissions because one of their quality measurements is the number of patients who are readmitted. They have the same kind of incentives we have to make sure patients don't need to be readmitted," Pisarsky says.

The Medicare Care Transitions project expanded on several initiatives that were already in place at DCH Health System, Smith adds.

In an effort to improve communication as patients transition from one level of care to another, the health system was meeting regularly with representatives from nursing homes to discuss what kind of information needs to be shared and to collaborate on how the communications and referral process can be improved.

"In the past, we have talked on the telephone. By meeting face to face, we get to know each other, and now the case managers have someone to talk to at each facility," Pisarsky says.

Each facility brings a representative case to each meeting and discusses the issues that arose as the patient transitioned between facilities.

"Early on, the teams functioned to put out fires and focuses on the issue du jour. As time went on, we changed the focus to do a root-cause analysis to determine what the issues are and opportunities to improve the transitions in care. These meetings have helped each side understand what issues the other side has," Smith says.

The hospital holds similar meetings with representatives from home health agencies who collaborate with the hospital case managers on ways to improve the transition in care.

The home health improvement team is reviewing the educational materials patients receive at each level of care to make sure they are consistent throughout the continuum.

"It's confusing when patients get one set of materials in the hospital and a different set from the home care agency. They may say the same thing, but when they are worded differently, the patients may get confused," Smith says.

Since the project began, DCH Health System has implemented case management in the emergency department from 7:30 a.m. to 11:30 p.m., seven days a week. The department added an additional 1.4 FTE in staff in order to expand the emergency department coverage.

The emergency department case managers identify patients who are being readmitted as soon as they arrive.

"The case manager is aware that the patient has been recently discharged and intervenes to verify what we could have done better. The purpose is not just to stop patients from being readmitted. It's to help them find a medical home," Pisarsky says.

While assessing the patients who are readmitted, the emergency department case manager answers questions on the admission assessment screen to provide details on the reason the patient came back to the hospital.

The information on readmissions is reviewed by the multidisciplinary length-of-stay team, which is responsible for reviewing the cases of patients who have been in the hospital for more than six days.

The team examines each readmission separately and looks for trends and areas where the discharge process can be improved.

For example, analysis has shown that many of the patients are being readmitted because they did not understand their medication regimen, Pisarsky says.

As a result, the hospital has implemented a "time out" for its medication reconciliation and education efforts. Now, when a patient is about to be discharged, the medication orders are reviewed by the nurse. Then, a second nurse, a pharmacist, or case manager reviews the discharge medications and verifies that they have been reconciled and that the medication is appropriate.

The hospital has added one FTE to its staff to make follow-up calls to patients with pneumonia, heart failure, and surgical patients after they have been discharged.

The discharge follow-up case manager, an RN, makes several hundred calls a month to check on patients three or four days after they have been discharged.

"We're trying to find any way possible to ensure that patients don't have to be readmitted. We have instituted multiple processes to close any gaps in treatment that may have occurred after discharge," Pisarsky says.

The case manager reviews the discharge information in the patient's computerized medical record and asks a series of questions that are customized based on patient history.

She asks patients if they have a follow-up visit, if they have filled their prescriptions, and if the home care nurse has visited.

"We have found at times that our case manager sets up home care, but because of miscommunication, the nurse doesn't arrive. The same is true of durable medical equipment. We want to intervene and correct the problem as soon as possible," Pisarsky says.

The discharge follow-up case manager also asks patients questions about adherence to their treatment plan and answers any question or concerns, then takes appropriate action.

For instance, if the patient doesn't have a follow-up doctor's appointment, she sets one up. Sometimes patients can't afford their medication so she helps them get medication assistance.

If patients seem to be unable to care for themselves, the follow-up case manager can set up home care visits.

Sometimes patients refuse home care when they are in the hospital, but after they get home, they are uneasy about changing their dressing, are confused about their medication, or don't understand what to do when they have symptoms, Pisarsky says.

"A lot of times, patients who thought they didn't need home care find out that they do need help in adhering to their treatment plan. We are taking proactive steps to make sure they can stay safe and healthy at home," he says.

Since the project started just 18 months ago, it's too soon to have definitive data on reducing readmissions, Smith says. However, the hospital reports increases in referrals and other processes that are expected to affect the readmission rate.

Since the initiatives began, the hospital has experienced a 32% increase in home care referrals, a 7% increase in referrals to nursing homes, a 30% increase for community resources, and a 50% increase in referrals to programs that help indigent patients with their medication, Pisarsky says.

The QIO is working with community partners to ensure that the patients are educated on how to plan for their discharge and are trained and encouraged to assume responsibility for their health.

One staff member at AQAF is dedicated to working with community agencies, such as soup kitchens, senior centers, and organizations for the aging, Smith says.

The QIO has partnered with the University of Alabama School of Nursing on a project to measure patients' level of activation in taking responsibility for their own care.

As her school project, a student at the University of Alabama School of Nursing visits patients in the hospital and administers the Patient Activation Measure (PAM), which is used to determine which patients are at high risk for readmission and most appropriate for coaching.

The QIO is paying for a coach to visit the patients in their homes after discharge to go over the patients' health records, help them understand their medication regimen, ensure that they have a follow-up visit with a physician, and if necessary, goes to doctor visits with the patients.

"The coach encourages the patients to keep a personal health record updated and coaches them on what questions to ask their physicians and how to ask them," Smith says.

The coach makes three follow-up calls within 30 days of discharge to make sure the patient is managing his or her own care.

The project focuses on readmissions for Medicare patients but should have an effect on readmissions for patients with all types of insurance or no insurance, Smith says.

"The information we learn from this project and the processes that the hospitals put in place should reduce avoidable readmissions for all patients," she says.

[For more information, contact Brian Pisarsky, RN, MHA, ACM, CPUR, director, case management services, DCH Regional Medical Center and Northport Medical Center, e-mail: bpisarsky@DCHSYSTEM.COM.]