Team helps hospital avoid readmission penalties

Initiative includes post-acute follow-up

Bassett Medical Center’s readmission reduction project has resulted in a reduction of up to 70% among highest-risk patients. The hospital is one of only 20 hospitals in New York State that is not incurring penalties from the Centers for Medicare & Medicaid Services for excess readmissions for heart failure, acute myocardial infarction, or pneumonia.

The 180-bed Cooperstown, NY, hospital began its readmission reduction program in 2009 to provide the best possible care for patients, says Ronnette M. Wiley, vice president, performance improvement and care coordination.

“CMS had not yet announced financial penalties for readmissions, but we knew that New York state was among the states with the highest readmission rates in the nation,” Wiley says.

The hospital developed a readmissions model based on the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) and later adopted the entire Project BOOST model.

Cornerstones of the program include making sure patients go home with an expedited follow-up appointment, instead of relying on them to make their appointment, contacting high-risk patients within a day of discharge, setting up a toll-free number that patients can use to contact the case management department if they have questions after discharge and before their follow-up physician appointment, and working with care coordinators in primary care practices that have them.

In addition to the case managers and social workers on the floor, care for high-risk patients is coordinated by a patient service coordinator who works with the case managers to set up post-acute services and calls high-risk patients after discharge, and in some cases, by continuing care coordinators located at some primary care practices in the Bassett Healthcare Network.

“We used the BOOST criteria to screen patients for the potential for readmission when they are admitted. Those who are determined to be of highest risk receive extra education and support,” says Margaret Kiss, RN, BSN, director of case management. Many of the patients who are at highest risk take multiple medications, are isolated with little or no support system, and have other issues such as problems with transportation and getting their prescriptions filled.

The hospital started its initiative with patients admitted with heart failure, acute myocardial infarction, or pneumonia and expanded the program to all high-risk patients.

Every morning, each service line has a multidisciplinary team huddle during which the staff review all patients who have been admitted and those who are at highest risk. The multidisciplinary teams include case managers, social workers, the patient service coordinator, and an administrative assistant who takes notes. Representatives from physical therapy, lead clinical nurses from the acute care medical units, and representatives from pastoral care and palliative care also attend.

When patients have been readmitted, either the patient services coordinator or social worker visits the patient to find out why he or she came back to the hospital. Case managers hold their huddles Monday through Friday and also cover the hospital on Saturday. The hospital is moving to seven-day-a-week case management coverage.

The case managers round with physicians and collaborate on care for new admissions and those who have complex discharge needs. Patients who require long-term care, who have issues such as dementia, or financial problems are referred to a social worker for interventions.

“Case managers identify the needs of patients, verify coverage, and pull in social work to assist with any financial barriers,” Wiley says. They make sure that any post-acute services are in place when the patient is discharged. If patients will need home health care or physical therapy, the case manager alerts the home health agency, which sends a representative to complete an assessment before discharge.

The patient service coordinator assists the case managers in arranging post-discharge needs for the patients. She calls high-risk patients within 48 hours after discharge and uses an electronic tool that provides a script for the calls. She makes sure the high-risk patients have follow-up appointments and have transportation, that they have filled their prescriptions and are taking the medication as prescribed, and that any post-acute services, such as home health or durable medical equipment, are in place.

If the patient has questions or needs further follow-up, the patient service coordinator alerts the appropriate discipline to call the patient. In addition, the case management department has a toll-free number that patients can call during business hours with questions and concerns.

The continuing care coordinators, who work in some primary locations, also attend the inpatient multidisciplinary huddles to learn about the patients and coordinate with the hospital case managers about the plan for discharge and the discharge day.

“We notify them when patients are admitted to the hospital and when they are ready for discharge. We communicate the plan we have put in place, set up an appointment with their primary care provider, and check in after discharge to make sure all the services arranged have been provided,” Kiss says.