Group seeks the root cause of readmissions

Interventions keep patients out of the hospital

Faced with high readmission rates and patients who made multiple visits to the emergency department and were hospitalized frequently, a multidisciplinary team at Lehigh Valley Health Network began analyzing the cases of frequent utilizers one at a time, getting to the root cause of the readmissions, and developing a plan to keep them out of the hospital and emergency department.

The High Utilizers Group (HUG) team began meeting in the fall of 2011. “We don’t currently have any hard data to report but we are working on development of a standard process to collect data. We do know that in many cases, we’ve made a huge difference,” says Maureen Sawyer, MSW, LSW, ACM, director of case management for the three-hospital system with headquarters in Allentown, PA.

Initially, the team reviewed the cases of the top 36 patients who made frequent use of the emergency department and had numerous short inpatient stays, looking for patterns in readmissions. “We found interesting tidbits, but we didn’t determine any one thing we could do to make the problem go away,” Sawyer says. Participants in the HUG team included people from across the continuum, including representatives from inpatient hospitals, behavioral health, home health, and palliative care to collaborate on solutions. “We did a lot of talking, but we didn’t get that far until we brought in the line staff people who work directly with the patients,” Sawyer says.

The expanded committee includes emergency department case managers, inpatient case managers, transition coaches, pharmacists, home health social workers, payer representatives, and representatives from the county mental health department and Area Agency on Aging offices.

“With that mix, we had people who were close to what was going on with the patients and could identify the real barriers to care. We got very personal and discussed each individual in depth to determine what they needed. We stopped rolling our eyes and assuming that frequent utilizers are noncompliant, and we have begun drilling down to find the root causes of the utilization,” she says.

As the group continued to meet, several physicians have joined and provided medical background that the rest of the team doesn’t always have. “These physicians are willing to dedicate a lot of time to the cases. They don’t just come to the meetings; they prepare by reading the charts to determine the prior treatment and are able to give advice about consultations or changes in the treatment plan,” she says.

Physicians who participate include a gerontologist who consults with skilled nursing facilities; a hospitalist who treats a lot of the patients being discussed; the medical director for home care and the system’s short-term skilled facility; and the president of the medical staff, who is a family practice physician in the community.

The team meets for an hour twice a month and discusses two to four cases. The team started working off the list of the 36 highest utilizers. Now the team sends an e-mail before the meetings to a wide variety of clinicians throughout the continuum asking if they have a case they would like to discuss. “Often, we don’t have to ask. Someone has a patient they are concerned about and asks to be put on the agenda,” Sawyer says. Many times, more than one person on the team is familiar with the patient being discussed and has been frustrated with lack of progress.

The group discusses each situation and comes up with a recommended care plan that one team member shares with the people who are working with the patient. “It works very well when the patient is in the hospital and we get information back to the treatment team. After patients are discharged, we go through the primary care provider office,” she says.

One challenge to the collaboration is that some team members use different computer systems, although the hospital system is in the process of merging the information technology across the system. “But when we sit around the table, we can swap computers and see the documentation for inpatient care, home care, and other providers. It helps us pull everything together,” Sawyer says.

The meetings have developed a strong connection between the inpatient setting and behavioral health, Sawyer says. “They historically operate in two different worlds, but now they share information and participants bring the information back to their areas,” she says.

The team developed a simple template that presenters fill out before the meeting. Information includes name, age, brief medical history, number of admissions and emergency department visits, community services received, and the patient’s primary care physician.

Many of the patients are referred to palliative care or connected with behavioral health services.

“A lot of the time, we refer patients to our palliative care team to discuss the goals of treatment with patients and families to identify the patients’ wishes. A high percentage of patients have a behavioral health comorbidity that causes them to struggle with their complex medical conditions. In these cases, we get them reconnected with a behavioral health provider who can help them,” she says.

It’s not unusual for patients to be a topic of discussion several times over the course of a year.

Sometimes, it’s a matter of the patient seeing their primary care provider for follow up after an emergency department visit. Some patients go to the emergency department and leave with a month’s supply of pain medication, then go back to the emergency department when that runs out. “We make sure they have an appointment with their doctor and make sure they are following up, and then alert the emergency department to make sure they’re not enabling the patient,” Sawyer adds.

The team looks for successes in small increments, Sawyer says. “One of the things we learned early on was to lower our expectations. We wanted to keep the patients from coming back, but we realized that if someone was coming in weekly and we were able to get it down to every six weeks, we were helping everybody, and especially the patients,” she adds.