Look beyond your hospital walls to prevent readmissions

It takes a 'village' to ensure a successful discharge

As a hospital case manager, you may think your job is done when you ensure that your patients have a discharge plan and have left the hospital. In today's healthcare environment, that is not enough. Hospitals have to extend their reach beyond the hospital walls and work with post-acute providers and caregivers to ensure a successful discharge.

"Traditionally, we have tried to optimize care within the settings in which we work. If we really focus on patients and caregivers, we need to think about the patient experience over time and keep in mind that the team is not just the people within the walls on the hospital. It's all the people who provide care for the patient at all levels of care who need to work together to improve patient care," says Pat Rutherford, RN, MS, vice president at the Institute for Healthcare Improvement, a non-profit organization based in Cambridge, MA, that focuses on innovation and collaboration in improving healthcare. (For Rutherford's tips on improving the discharge process within the hospital, see related article, below.)

Next month, the Centers for Medicare & Medicaid Services (CMS) is going to start penalizing hospitals for excess readmissions within 30 days of patients with heart failure, pneumonia, and acute myocardial infarction and has announced plans to add more diagnoses to the list. In addition, in fiscal 2015, Medicare spending-per-beneficiary will be added to the CMS Value-based Purchasing Program. The measure, designed to evaluate how efficiently care is delivered when patients are in the hospital and the effectiveness of the discharge plans they develop, includes every Medicare Part A and Part B claim incurred by the patient beginning three days before discharge through 30 days after discharge.

Both of these initiatives mean that hospitals need to shift from the concept that when patients leave their four walls, they are no longer the hospital's problem, says Robin Jones, RN, quality improvement coordinator at Valley Baptist Medical Center in Brownsville, TX.

"We can create the best discharge plan in the world, but if we didn't have a partnership with downstream providers to assure a safe transition and if there are not community resources available to meet patient needs, it is likely that patients will come back," Jones adds.

Everybody along the continuum of care — the office practices, skilled nursing facilities, home health agencies, and other post-acute providers — have a part in reducing hospital readmissions, Jones says. "We are all in this together, and it takes an effort on everyone's part to engender a collaborative spirit," she says.

To ensure that patients are not readmitted, hospitals have to open up the lines of communication with post-acute providers, says Bonnie Kratzer, RN, director of care management, home health and hospice at Charles Cole Memorial Hospital in Coudersport, PA, a critical access hospital in rural Northern Pennsylvania. "Everyone who is caring for the patient at all levels of care need to work together with a common goal in mind. If you work in silos instead of working together, the discharge plan could fall apart," Kratzer says.

She advises hospitals to take the first step and reach out to community providers. "We have to start somewhere if we are going to take care of the patients we serve and collaborate with all the providers in the community, even if they may be competitors in some way. We need to keep things open and put the patient first," she says.

Case managers often communicate regularly with their counterparts in skilled nursing facilities or home health agencies, but in most cases, they don't truly join efforts and work together, Rutherford says. However, since hospital case managers generally have good relationships with post-acute providers, they are in a good position to create the bridge between the hospital and the community providers, she says.

"Clinicians and staff can create cross-continuum 'teamness' by working together to promote individualized and coordinated care. The first step in developing this new level of collaboration is to identify problem areas and seek joint solutions without blaming or power-brokering," she says. Often, staff at home health agencies and skilled nursing facilities are reluctant to bring up problems because they count on the hospital for referrals, she says. "It is time for health care providers to join forces to create 'one team' to provide the very best care for patients in our care," she adds.

UConn Health Center/John Dempsey Hospital, Farmington, CT, had limited success when it invited post-acute providers to collaborate on a readmission reduction program, says Wendy Martinson, RN, BSN, QA specialist in the clinical efficiency and patient safety department. But now, providers are actually asking to join in the efforts, she adds.

Jones adds that collaborations with post-acute providers not only help improve transitions but they help the hospital learn about which providers have disease-specific programs and expertise in certain areas.

"We know that we have a better chance at a successful discharge if we give patients a list of facilities that have the expertise to meet their specific needs rather than giving them a generic list. If we know what services providers specialize in and if the facility is accredited, we can give patients the information they need to make an informed decision," she says.

Improving discharges starts within the hospital

Focus on patient-centered initiatives

According to Pat Rutherford, RN, MS, vice president at the Institute for Healthcare Improvement, hospitals can improve patients' discharge from the hospital by enhancing current discharge processes and by making the following changes:

  • Gain a deeper understanding of the comprehensive post-discharge needs of the patient through an ongoing dialogue with the family, caregivers, and community providers.
  • Gain a deeper understanding of patient and family caregiver comprehension of the clinical condition and self-care needs after discharge.
  • Develop a post-acute care plan based on the assessed needs and capabilities of the patient and family caregivers.
  • Effectively communicate post-acute care plans to patients and community-based providers of care.

Rutherford leads the IHI's State Action on Avoidable Rehospitalizations (STARR) initiative, which aims to reduce rehospitalizations by catalyzing a multi-state, multi-stakeholder approach to dramatically improve the delivery of effective care on a regional scale, working across organizational boundaries. "Our 'North Star' in the STAAR initiative is facilitate a safe, effective, and patient-centered transition from the hospital to the next settings of care. While removing waste and inefficiencies from our healthcare system is an essential task for reducing unnecessary healthcare costs, improving care transitions and reducing avoidable readmissions is first and foremost a patient-centeredness initiative," she says.

The frontline nursing staff, doctors, case managers, and social workers can work together to develop a comprehensive assessment of patients' home-going needs. Rutherford recommends asking patients and family caregivers what they are most worried about when they leave the hospital. "Including patients, family caregivers, and community providers in the discharge process takes more time but yields critically important information that enhances planning," she says.

She recommends using "teach-back" to supplement current patient education methods throughout the hospital stay. "The use of teach-back helps clinicians assess patients' and family caregivers' understanding of the discharge instructions and their ability to perform self-care," she says. She suggests that the hospital staff consider partnering with providers in all clinical settings to standardize patient-friendly educational materials.

Expand the scope of your multidisciplinary rounds to include in-depth planning to initiate services based on the needs and capabilities of patients and caregivers and to mitigate circumstances that could cause a readmission. The case managers and the discharge coordinator should have key roles in this initiative, she says.

Provide real-time critical information at the time of discharge to providers in community settings to make sure critical information is available to doctors and advances practice when a patient calls with a problem at 2 a.m. the day after the patient has been discharged from the hospital. "A simple one-page summary co-designed by the senders and receivers is ideal," Rutherford says. Make sure the discharge instructions you give patients and family members are clear and easy to understand.

Telephone follow-up is a common intervention to improve transitions and reduce hospital readmissions, Rutherford points out and cautions that "it takes a coordinated effort to effectively plan follow-up calls to be effective, and one-size doesn't fit all." She tells of one patient who said she preferred the post-discharge follow-up call from the doctor or nurse from the hospital and another one who thought it would be more helpful if his physician office made the call.

"Important considerations include: who is in the best position to reinforce the discharge instructions and to help with problem-solving; how the phone conversation is conducted; and what form of documentation and information sharing after each call to ensure care coordination," she says.


  • Robin Jones, RN, quality improvement coordinator at Valley Baptist Medical Center in Brownsville, TX. email: Robin.Jones@valleybaptist.net
  • Bonnie Kratzer, RN, director of care management, home health and hospice at Charles Cole Memorial Hospital in Coudersport, PA. email: Bonnie.Kratzer@CharlesColeHospital.com
  • Wendy Martinson, RN, BSN, QA Specialist in the Clinical Efficiency and Patient Safety Department, UConn Health Center/John Dempsey Hospital, Farmington, CT. email: wmartinson@uchc.edu
  • Melissa Scollan-Koliopoulos, EdD, APRN-BC, CDE, BC-ADM, Assistant Professor of Medicine, UMDNJ New Jersey Medical School in Newark, email: scollame@umdnj.edu
    IHI has published a how-to guide for hospitals: Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2012. Available at www.IHI.org.