HF readmissions drop after initiatives
Executive Summary
By analyzing heart failure readmissions and collaborating with post-acute providers and community organizations, Essentia Health-St. Joseph’s Medical Center in Brainerd, MN, cut its readmission rate from 18% to a low of 6%.
• An interdisciplinary team analyzed readmissions, interviewed patients who were readmitted, and developed the program.
• Initiatives include setting primary care appointments while patients are in the hospital, following up after discharge, and creating order sets that include best practices.
• The hospital staff meet regularly with post-acute providers and social service agencies to brainstorm ways to create smoother transitions and ensure that patients get what they need after discharge.
Team examined transition process
Before Essentia Health-St. Joseph’s Medical Center in Brainerd, MN, began its heart failure readmission program in 2011, the hospital’s 30-day readmission rate was 18%. Now, it’s been consistently less than 10% and had dropped to 6% in December 2013.
"Our goal is to continue our efforts to improve transitions and keep heart failure patients out of the hospital. Keeping patients healthy at home after a hospital stay is not only the right thing to do for patients to improve their quality of life, it’s also the right thing for the hospital as the Centers for Medicare & Medicaid Services (CMS) and other payers are penalizing providers financially when patients are readmitted," says Kathryn Miller, RN, BS, G-L C, director of quality and safety at the 162-bed acute care hospital.
Some of the initiatives the hospital adapted include making primary care appointments before patients leave the hospital, follow-up phone calls after discharge, creating admission and discharge order sets that list the standard best practices, medications, and issues that need to be addressed for heart failure patients, and developing a close relationship with post-acute providers.
The hospital began working with Stratis Health, the Minnesota Quality Improvement Organization (QIO) in mid-2011 to analyze readmissions and come up with a plan to reduce unnecessary readmissions within 30 days of discharge.
"We determined that we had an opportunity to reduce the readmissions for heart failure. We examined the whole transition process and learned the best way to impact the long-term recovery and health of the patient is to make sure the patient and the receiving provider have all the information they need to keep on track with recovery after the patient leaves the hospital," she says.
The hospital convened an interdisciplinary group of social workers, discharge planners, nurse directors, hospitalists, pharmacists, and other disciplines and reviewed data on readmissions. In addition, St. Joseph’s invited the directors of nursing from the three largest nursing homes in the area, home care and hospice representatives, and representatives from other community agencies to meet regularly. One agency that participated was the Senior Linkage Line, an organization that provides services for Minnesota seniors free of charge, including answering questions about Medicare, helping with prescription drug assistance, providing information on long-term care options, and a variety of other services. A representative from Stratis Health also attends the meetings.
A key to the success of the initiative was developing rapport with post-acute providers, and it took just one simple change to get them on board, Miller says.
At the first meeting, skilled nursing facility representatives informed the hospital that their regulations require that every medication dispensed be tied to a diagnosis and that it often took several phone calls and faxes to get that information after the patient arrived.
"We immediately educated the hospitalists to include a diagnosis-related reason for each medication in the chart. It didn’t take long to make that change, and the nursing facilities immediately realized how productive these meetings could be," Miller says.
The hospital has always provided an interagency transfer form along with key documents such as the discharge summary, progress notes, and lab and other test results, Miller says. The report includes the patient’s last medication and what time it was given and the last set of vital signs. In addition to providing the paper documents, the hospital has worked with the information technology staff to allow directors of nursing or social workers at the nursing homes to access patients’ hospital records on a view-only basis if they need additional information during the hospital stay.
When patients are discharged to another level of care, the nurse at the hospital calls the receiving nurse, gives an oral report and answers questions. If the patient is going to a provider who is not part of the hospital system, the attending physician also calls the physician at the receiving facility.
When the team spoke with heart failure patients who were readmitted, they found that many had not had a follow-up appointment with their primary care provider. "We know that patients who have a follow-up visit with their physician within five days are less likely to be readmitted because the doctor can identify and deal with any problems," Miller says. The team also determined that often patients weren’t able to get appointments because their doctor had no openings for several weeks. The hospital worked with the staff at the clinics to establish one to two available appointments every day for patients being discharged from the hospital, Miller says.
Now the ward secretary calls the physician practices and sets up timely appointments for patients who are being discharged. "We have found that if we make the appointment, patients are much more likely to go," Miller says. In addition, the discharge planners meet with patients before discharge to address any concerns the patients may have, such as lack of transportation to the doctor’s office for their follow-up appointment. If they do not have transportation or can’t fill their prescriptions because of financial hardship, the discharge planners may refer them to the Senior Linkage Line for assistance. The agency can arrange transportation by volunteers who will take patients to the pharmacy or physician office, or connect them with financial assistance programs that may be able to help with prescription co-pays.
Two days after patients with certain chronic diseases are discharged, a nurse calls to check on them. The nurse, who has access to the patients’ medical record, makes sure they understand their condition, that they have their medication and a follow-up appointment, and that they have transportation to the doctor’s office.
The hospital has a pharmacist in the emergency department to complete medication reconciliation for patients who are being admitted so the treatment team will have the most accurate list possible before the patient gets to the unit.
"It’s not always easy to get an accurate list of medications since some patients use multiple pharmacies and others are snowbirds who get their prescriptions filled while they are in Florida or Arizona for the winter. The pharmacist is the best person to get this information so that the physicians treating the patient are informed," she says.
