All the tools in the box and no one to use them
Underused methods to cut readmissions
You join a collaborative because you want access to data and ideas. Together you might find something out that individually you could not. That's the theory. And it works. Over and over in healthcare there have been successful collaborative efforts on everything from heart attack data to surgical infections. But according to a study in the November 2013 issue of the Journal of Hospital Medicine, hospitals aren't using tools available to them in collaboratives designed to reduce rehospitalizations.1
The study looked at hospitals that were enrolled in one of two collaboratives: the State Action on Avoidable Rehospitalizations (STAAR) initiative, launched in 2009 by the Institute for Healthcare Improvement that operates in four states — Massachusetts, Michigan, Washington, and Ohio — and the Hospital to Home (H2H) project, sponsored by the American College of Cardiology. The STAAR project was designed to leverage community organizations and hospital leaders, while H2H focused on specific patients — heart failure and myocardial infarction — and used a series of challenge projects to engage participants.
The study in question received completed surveys from 599 hospitals, says Leslie Curry, PhD, a senior researcher at the Global Health Leadership Institute at Yale and one of the study authors.
The surveys asked hospitals about the strategies they were using from the collaboratives, and the results were startling. Only just over half of the hospitals in both groups reported having quality improvement teams devoted to reducing readmissions; half or fewer of the hospitals reported that they monitored how quickly discharge summaries were sent to primary care providers or whether patients had appointments with primary care physicians within seven days; less than 20% in either initiative measured if patients were being readmitted to another hospital; most of the hospitals in both programs did not have a pharmacist in charge of medication reconciliation; most patients did not get discharged with an appointment already made for follow-up care; and less than half the hospitals in either program had anyone follow up on pending test results that come in post-discharge.
The authors note in the paper that these strategies have been in the literature as good ideas for a few years now, so what gives? Curry thinks that part of it is that the evidence base is not as clean as it could be. "Something like how to reduce your door-to-balloon time is a lot clearer than how to reduce your readmissions," she says. She also notes that these are two very different collaboratives. STAAR is the big innovator, and it's focused on what's going on in four states, not four walls. It's looking across stakeholders, so it could be that what this survey asks might not be applicable to the way these particular people are thinking.
She doesn't want to take away from "great, well-meaning people" who are doing this work and finding progress slow. "Some people are seeing readmission rates falling, but maybe it's hard to see what is considered statistically meaningful change. But there is still room for improvement. We have to figure out why, with all this effort, that is."
A lot of the problem may be time and manpower related — getting all the things done that recommendations suggest with the people on hand in the time required; it could be too much except on the slowest of days. "Nurses and pharmacists and social workers know what they have to do, and if they have time, they can do it. But this is very complex, to coordinate all the communications and all the paper," Curry says. "And there is still uncertainty about what works. The evidence is not compelling. If there are two things you should do, which two? And are they the same two that the hospital across the street should do?"
So if you don't know which two items are silver bullets, should you do nothing? No, she says. Choose three or four items from the list and you'll probably improve your performance. Remember too that readmissions are not all about what happens in the hospital, but about what happens in the community. Increasingly, hospitals will have a financial stake in what takes place out there as well, so while Curry says it's "kind of nebulous how to connect in a way with those other folks in other parts of the continuum," it's worth your while to start thinking about that now. In the not-to-distant future, you'll come out ahead for having done so, and so will your patients.
"Look at the 10 strategies and think about your facility," says Curry. "Focus on a few that you think will work best where you are. More is better, but be gentle, and pick something where you can do some internal tracking and get an easy early win. That boosts your ego so you can tackle some of the harder stuff."
Lastly, Curry says if you have not made really good friends with everyone who works in the emergency department, do. They should be the quality departments' best friends because no one knows better about the patients who come back into the hospital when they should not, "and this is an area for contribution and reaching out."
- Bradley EH, Sipsma H, Curry L et al. Quality collaboratives and campaigns to reduce readmissions: what strategies are hospitals using. J Hosp Med. 2013 Nov;8(11):601-8. doi: 10.1002/jhm.2076. Epub 2013 Sep. 6.
For more information on this topic, contact Leslie Curry, PhD, MPH, Senior Research Scientist, Global Health Leadership Institute, Yale University. New Haven, CT. Email: [email protected].