Team follows at-risk patients after discharge

Interventions start during hospital stay

At UNC Hospitals in Chapel Hill, NC, a dedicated team of inpatient case managers, emergency department case managers, and pharmacists evaluates all patients who are potentially at risk for readmissions, makes sure they have everything they need for a successful transition, and follows them for 30 days after discharge regardless of their discharge destination.

The hospital began its readmission reduction program just as the Centers for Medicare & Medicaid Services (CMS) was starting to discuss levying penalties for excess readmissions, says Jay Pomerantz, MD, medical director for clinical care management at the 830-bed academic medical center. “We began our initiative during the measurement period, although we didn’t know it at the time because CMS announced it later,” he adds.

Patients identified as high risk for readmissions have three chronic conditions or were admitted three times in the past year, and are taking 10 or more medications. Moderate-risk patients have 3 chronic conditions or two admissions in the past year.

In addition, the case managers on the floor alert the team if they feel patients are at risk or if patients who have been identified as moderate risk escalate to high risk. “Clinical judgment is important in identifying patients for the readmission reduction team to follow. We have identified a lot of patients, particularly patients who are new to us, with the help of the clinical team,” says Marie Bossert, RN, BSN, CCM, MBA, director of clinical care management.

Working with medical team

The team begins its interventions while the at-risk patients are still inpatients—if possible, while the patients are still in the emergency department. One of the case managers and a pharmacist visit patients at the bedside, inform them about the program, and enroll them. They work with the medical team and the inpatient case manager to ensure a smooth transition.

“They focus on medication issues, ensure that patients have a follow-up appointment and go to it, and make sure that the recommended post-acute services are ordered and are in place when the patient is discharged,” Bossert says. After discharge, a team member checks on the high-risk patients regularly to make sure they understand their medication regimen, have had a follow-up visit with a primary care physician or specialist, and are following their treatment plan, and to answer any questions and concerns. If one of the patients in the program comes into the emergency department during the 30-day period after discharge, the emergency department case manager alerts the team to intervene.

Patients who are at moderate risk receive telephone calls after discharge from experienced nurses who staff the hospital’s call center. The nurses conduct an extended assessment to find out if the patients understand their discharge instructions, conduct medication reconciliation, and help with questions or concerns. The nurses also call to remind patients of their follow-up appointment and to find out if they have transportation to the appointment or if they need to be referred to transportation service. They check back after the appointment to make sure the patients kept their appointment and reschedule the appointments if the patients did not.

Patients identified as low risk also receive calls that are shorter and less detailed than the calls to patients at moderate risk.

The readmission reduction team meets quarterly with representatives from skilled nursing facilities to collaborate on how to improve transitions between the post-acute facilities and the hospital. The team alerts the skilled nursing facility before patients are transferred, advises the nursing staff on what the patient is likely to need during the stay, and follows up weekly with the facility’s nursing staff and discharge planner. “We work closely with the skilled nursing facility staff and collaborate with them on the discharge plan,” says Katie Flanagan, LCSW, assistant director of clinical care management.

The team has worked closely with medical directors for the skilled nursing facilities to develop ways to avoid readmissions, Pomerantz says. For instance, hospital representatives and the medical directors at the nursing facility have collaborated on creating standing orders for diuretic adjustments when patients gain weight rather than automatically bringing them into the emergency department,” Pomerantz says.

The hospital system began its readmission reduction efforts with a heart failure pilot project that provided intensive case management follow-up after an acute hospital stay. “We began to look at what we could do while the patient is still in-house,” Flanagan says.

The team worked with cardiologists to develop a best-practices order set to be used when patients were transferred to skilled nursing facilities and long-term acute care hospitals. The case managers met with the teams on the medical units to introduce the order sets and get questions and suggestions. Core measures nurses are part of the team and identify patients who are admitted with heart failure, then put an alert in the case management system. The care of patients with heart failure is managed by the primary inpatient case manager, assigned to the physician team, and the heart failure case manager, who works with heart failure patients being treated by all medical services.

Clinicians work in triads

“In the beginning, we focused on standardizing care and following the best practices for heart failure, regardless of the service that was caring for the patients,” Bossert says. The team reviewed all the educational materials available and created an education booklet. If patients don’t have scales, the hospital provides them. They shared the booklet with the skilled nursing facilities to ensure that the patients get the same education throughout the continuum. The team is working on an educational booklet for patients with chronic obstructive pulmonary disease.

Clinicians at the hospital work in triads, a team that includes a physician, a nurse, and a case manager on each service. The teams meet regularly and develop projects that focus around care transitions. In addition to individual meetings, leaders from each service meet on a regular basis.

The hospital recently launched a transition oversight committee, made up of inpatient and outpatient providers. “We were doing a lot of things independently of each other without communication. We all have the same goals and now are working together to get the message across,” Flanagan says.