Initiative cuts readmission rate to 15%

Improved communication was the key to success

When Valley Baptist Medical Center in Brownsville, TX, began a project to reduce readmissions in the fall of 2009, the overall 30-day readmissions rate was 23.3%. Last quarter, the 30-day readmissions rate for all diagnoses was 15%, according to Robin Jones, RN, quality improvement coordinator at the 280-bed hospital.

After the initiative was begun, the hospital's patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey improved, core measures improved, and medication errors and adverse drug events declined, Jones adds.

Working with the TMF Health Quality Institute, the Texas Medicare Quality Improvement Organization (QIO), the hospital conducted an analysis of readmissions to determine the top five DRGs and the root cause for the readmissions. Heart failure diagnoses made up three of the top five MS-DRGs that had the highest rates of readmission within 30 days. They included heart failure, heart failure with complications and comorbidities, and heart failure with major complications and comorbidities. The other diagnoses were kidney and urinary tract infections and pneumonia.

A multidisciplinary team determined that many of the reasons for readmission involved communication. Patients and caregivers often were not prepared for discharge or self-management. They didn't understand their medications, the need for follow-up care, or symptoms that could mean an exacerbation. Other causes included weak or fragmented discharge plans, inadequate follow-up care, and miscommunication or failure to communicate key information when patients transitioned to another level of care.

The analysis determined that the majority of patients being readmitted were those going home with no services and those who were discharged to skilled nursing facilities.

The team researched readmission reductions models and determined that Project RED (Re-Engineered Discharge) would best meet their facility's needs. Project RED, developed by Boston University Medical Center's research team, involves patient-centered education, comprehensive discharge planning, and post-discharge follow up. (For more information on Project RED, visit: http://www.bu.edu/fammed/projectred.)

Because there were so many heart failure readmissions, the hospital conducted a pilot on the telemetry unit for heart failure patients and over the next 12 months expanded the initiative to include all patients on medical units, Jones says.

"Reducing readmissions is all about communication. Patients and family members need to understand their disease, their treatment plan, and what to do if signs and symptoms indicate an exacerbation. It's not enough just to tell them. We have to make sure they understand," she says.

At Valley Baptist Medical Center, patient education is continual during the stay, rather than being concentrated as the patients near discharge. Whenever anyone on the treatment team gives patients information, he or she uses the teach-back method to make sure the patients understand it. "We've done a lot of education on the teach-back method and on tailoring teaching to the patient's level of understanding. In the past, we took it for granted that the patients could understand the information we were giving them," she says. The team reviewed the discharge materials and made sure they were simple and could be understood by people with a third-grade reading level.

The hospital surveys all patients in the target population on the day of discharge, using a questionnaire developed by the TMF Health Quality Institute, to identify areas for improvement. "We believe that how patients feel about what we are doing is important. It doesn't matter what we are telling them. What counts is what they understand," she says.

For instance, in the beginning, when patients were asked to explain in their own words what they had learned, scores ranged from 67% to 75%. After the TMF Health Quality Institute conducted an in-service on the teach-back method, patient response increased to 90% or higher.

To ensure that patients have follow-up physician appointments, the nurses make appointments for them. After the hospital began making the appointments, the number of patients seeing their physicians after discharge doubled, Jones says.

As part of the discharge process, members of the readmission reduction team make a follow-up call to patients two to three days after discharge to ensure they understand their discharge plan and medication list.

Before discharge, nursing compares the medication list the patients brought in with them with what they were prescribed in the hospital and educate the patient and family members on which medications to continue taking and which to stop.

The discharge team makes sure the downstream provider has the medication list and other discharge information. Instead of giving it to the patients and telling them to take it with them, the team faxes or scans the information. Community physicians who admit to the hospital can access the patient record through a physician information exchange.

The hospital created a new emergency department case manager position and discharge coordinator in case management to review the electronic health record and identify the cause for emergency department utilization and readmissions. She also reviews the previous care plan, medications, and post-discharge services and makes follow-up calls to assess their appropriateness. "It's easy to assess a patient and send them home with the same services they were receiving before admission, but we need to recognize that sometimes those services were not working and that's why they came to the hospital in the first place," Jones says.

Sometimes patients are readmitted because they are too embarrassed to say they can't afford their medication so they simply do not get the prescriptions filled, she says. "If we know this we can ask the physician to prescribe something cheaper. If that's not possible, we can refer the patient to a federally qualified community health center or other available community resources," she adds.

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