Study: Interventions help prevent readmissions
CMs follow patients before and after discharge
In a study by the Bronx Collaborative, patients who received two or more interventions by a dedicated care transition manager had a 17.6% readmission rate compared to a rate of 26.3% for patients who received the current standard of care.
• Three hospital systems and two health plans collaborated to develop the pilot project.
• Care transition managers, whose only job was facilitating transitions, visited patients in the hospital and followed up within 48 hours after discharge and again 14 days after discharge.
• The care transition managers educated the patients on their treatment plan, gave them a personalized booklet with details of their treatment plan, and followed up to answer questions and concerns and make sure they were following the plan.
Only 17.6% of patients who received two or more interventions by a care transition manager were readmitted to the hospital within 60 days, compared to 26.3% of patients who received the current standard of care, according to a pilot study by the Bronx Collaborative, a group of three hospital systems and two health insurers. Patients who, for a variety of reasons, received one intervention had a higher readmission rate, raising the overall 60-day readmission rate to 22.8%.
The collaborative includes Montefiore Medical Center, Bronx Lebanon Hospital Center, St. Barnabas Hospital, EmblemHealth, and Healthfirst. "The results of the pilot study show the value of making personal contact with patients before and after discharge and ensuring that they see their doctors for follow-up to help prevent problems that frequently contribute to readmissions," says Anne Meara, RN, MBA, associate vice president for Network Care Management at Montefiore Medical Center in Bronx, NY, who led the project design team.
The program has been continued at two of the four campuses where the pilot was conducted, Meara says. "Each hospital continues to work internally on incorporating the best practices identified in the pilot into the usual care so we can scale the intervention to all the patients in our hospital," she adds.
Participants in the pilot program were covered by the two health plans and identified by a predictive modeling program that assigns patient risk scores based on clinical and other information.
Many patients in the population served by members of the collaborative have socio-economic issues as well as multiple chronic diseases and/or psychiatric comorbidities. "We believe, based on the overall socio-economic profile of the area we serve, that our patients are more at risk for readmission than the average patients," Meara adds.
A key element of the readmission reduction program is care transition managers, experienced RN case managers who work only with patients in the program and have a caseload of about 35 patients at a time, a mixture of new patients and those who need follow up after discharge. The care transition managers conduct intensive education while patients are still in the hospital, ensure that patients have a follow-up appointment with their primary care provider, and call patients after discharge to go over the treatment plan and answer any questions or concerns. They are supported by care transition analysts, who are not clinicians but help with setting up transportation, arranging for durable medical equipment, and other non-clinical tasks.
"A concentrated focus is important to prevent readmissions, and it’s difficult to integrate that kind of focus into the jobs of people who have other tasks," Meara says.
The care transition managers meet with patients while they are in the hospital, perform an extensive assessment that includes the patient’s living situation, support system, financial issues, and other information necessary to develop the right discharge plan. During the pilot this information was recorded in a care transition record built into the platform of the local health information exchange, The Bronx Regional Health Information Organization. This made the information accessible at each hospital in the event that the patient presented at another hospital and was readmitted. "For the discharge plan to be successful, someone needs to have the time to sit down with patients and find out pertinent information that can assist in setting up a successful discharge. Unfortunately most case managers don’t have the time to do this and, furthermore, the concept of sharing this type of information is in its infancy stages," she says.
The care transition managers spend time educating patients in the hospital and make sure they have food in the home, have transportation to the pharmacy, and make sure they have a follow up appointment with their physician. They give patients a personalized booklet, written in easy-to-understand language, that lists their medication, how and when to take it, any medical red flags to look for and what to do if they occur, and the time of the follow-up appointment.
The care transition managers call patients within 48 to 72 hours of discharge and go over the discharge instructions, identify any questions or concerns, review symptoms and medication, and verify that patients have a follow-up appointment with a physician within 14 days of discharge.
"This is a critical phone call because there is so much going on during a hospital stay that patients may forget the information they received," she says.
They call again 14 days after discharge to follow up on the physician visit and see if there are other problems.
The care transition managers set up whatever services the patients need, including home care, durable medical equipment, or medication assistance. If patients need help at home, they may reach out to a family member, a neighbor or a church group. "They make sure everything is in place to make sure patients can manage at home," she says.
They follow patients for as long as 60 days if they have ongoing issues and work closely with the case managers at the health plans if they need longer-term follow up.
Members of the Bronx Collaborative developed the research project using grants from the New York State Health Foundation and the New York Community Trust. "We’ve worked together in the past, and this gave us an opportunity to look across organizations at high utilization and readmissions. Since each hospital takes financial risks in some form and the health plans are struggling to reduce readmissions, our incentives were very much aligned," Meara says.
Clinical representatives from all five organizations researched the literature and a number of readmission prevention models to design a model that would work in the Bronx community, where residents face social and economic challenges. "We looked for elements that are included in all the models, such as face-to-face meetings with patients, medication reconciliation, and scheduling follow-up appointments and designed a program we hoped would work in our community," Meara says.
The clinical design workgroup is continuing to meet to discuss the next steps in the process. "This includes standardizing the capture of psychosocial indicators that we believe contribute to readmissions so that we can factor that into our predictive model and share it through health information exchange," she says.