Getting it right on readmissions

What didn't work is helping discover what does

If you say it out loud, people will agree intuitively: You can learn more from your failures than from your successes. But that agreement doesn't mean people want to trumpet what doesn't work. That caveat makes what's happening at Henry Ford Health System in Detroit so special: They are actively looking at what is still wrong as they try to get a handle on unplanned readmissions so that they can figure out what's right.

Long before payers started saying they'd stop paying for unplanned 30-day readmissions, the leaders at Henry Ford Health System decided to look at the topic, says Beth Anctil, RN, MSN, director for care coordination for the system. "Our CEO thought we should tighten up our processes for discharging patients," says Ancil, noting that over four years, the rate hasn't changed — or at least not enough, or not for long enough. "It will be down for three or four months, and then it pops back up again," she says.

Anctil says she gets that the reason is complex: part is culture and getting people to change the way they do things. Part of the reason is that every patient who bounces back is different, and figuring out which variable led to the readmission is difficult. "We study it, and it seems like everything we do is more complex than we thought initially."

Currently, there is a bundle that is considered standard of care, based on Institute of Healthcare Improvement suggestions. This bundle includes doing a risk assessment for readmission and flagging the charts of patients considered at risk; providing education for patient and care provider; providing a medication reconciliation and consultation; ensuring a follow-up appointment within a specified time; and providing discharge instructions and a summary to the patient and next provider.

"It's not rocket science, but it is different than what we did before, and there are barriers to it at every turn," Anctil says. She is trying to implement this system in five hospitals, including two community hospitals and one medical-group based hospital. "I don't have the same control at the community hospitals I do with the staff model hospital," Anctil says.

It has been particularly difficult to ensure that patients have a timely follow-up appointment with their community care provider. "There are four drivers to that: the hospital processes to facilitate the appointment and information flow, physician issues, patient/family issues, and financial issues," says Anctil.

Concerning the first reason, there was no place in the record to capture who the primary care provider is, nor was there an obvious place to flag patients who were deemed by assessment to be at higher risk for readmission, she says. Those omissions meant that high-risk patients either weren't having appointments made because no one knew who to call or because someone didn't realize they were at high risk. There also was an issue of ensuring a physician was available to see the patient in three to five days, Anctil says. If an appointment is made, how do you ensure that all the documentation — which in the past might have taken a week or more for a physician to complete — is done within the time period and delivered to the primary care physician?

"In the regulatory world, they have 30 days to proof and sign their notes," Anctil says. "Now we are telling them to do that on the day of discharge and to make sure that it includes information on pending test results and how the attending physician thinks the primary care doctor should proceed."

What happens if the appointment isn't kept? Who is supposed to follow up: the physician or the case manager? "We told them that until the handoff to the primary care physician is successful, they still have ownership of the patient," Anctil says. Not all the physicians agree. "Most would agree it's a good idea, but putting systems in place is hard," Anctil says. "What do we expect them to do? Drag the patient in?"

Furthermore, each of these items is variable depending on the physician, the patient, the patient's support network, and insurance. In the latter category, Anctil notes that some might provide an outpatient case manager, and some might not. "You have to get buy in, you have to know if they have transportation and whether they have money to pay the copay for their doctor," she says.

All of these areas of conflict and trouble have plagued Anctil's efforts to reduce readmission rates. But they keep plugging away.

They are asking every patient who is readmitted within 30 days of discharge why they think they were readmitted and what they might have done differently to avoid it. Often, the reason is medication-related. (For a related story about readmissions, see story, below.) "Patients won't take them, or they have a generic at home and a name brand here, and when they get home they take both, which is a double dose of something," Anctil says. "We have to spend a lot more time educating patients now. We ask them what their goals are. If they are on 15 medications, they might say they want to only take two, because that's all they can afford."

While the patient decision is based on money, that decision might not be the best one for their health. If they will only take two medications, it's better that a provider determine the two most important medications to take.

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For more information contact:

  • Beth Anctil, RN, MSN, Director for Care Coordination, Henry Ford Health System, Detroit, MI. Telephone: (313) 874-2490.

Profiling groups with chronic readmissions

Beth Anctil, RN, MSN, director for Care Coordination at Henry Ford Health System in Detroit, has taken a page from an article she read last year in The New Yorker that talked about hot spots: how a group of people who were falling and being readmitted to a hospital in Camden, NJ, all came from a single apartment building.

Thinking of the readmissions as some sort of cohesive group — hot spotters rather than frequent fliers — is allowing Anctil to better profile the group. She knows, for example, that a third of them have end-stage renal disease; two-thirds have some sort of addiction issue or mental health problem.

"That's only 92 patients last year who had six or more readmissions within 30 days, and probably more besides that. Those patients were responsible for over 2,000 admissions last year. And for all I know, they are at another hospital if they aren't here," says Anctil.

Even among that group of patients, only 4% are uninsured. "Our efforts with them will focus on end-stage renal disease, which should hit a third of the patients." One finding that research has shown is that some of those patients aren't receiving their full dialysis. They leave early or come late, dependent on someone else to drive them and at the mercy of that driver's imperative to be somewhere else. "We are actually working on a checklist to capture the reasons for under-dialysis," Anctil says.

They have also found a problem with how well they communicate dry weight changes to the dialysis center, she says. "We have a cross functional team now that is looking at solutions," Anctil says. On the table is mentoring and starting a primary care clinic in the dialysis center so that comorbidities can be addressed while the audience is captive.

The initial bundle includes a home care visit paid for by Henry Ford if the patient doesn't have insurance to cover it. "The reality is we have to be frugal, so I don't know that we will need a social worker at the dialysis center, and a mentor, and a home care visit. But I don't know which will work. We'll be able to evaluate some of it by looking at compliance and measures of other health status," says Anctil.

Shortly, Anctil says they will begin following a group of patients from home to dialysis — some who are compliant and some who are not. Patients on home dialysis will be monitored, too, so that they can see if those patients have something to teach about end-stage renal patients who can't stay out of the hospital.

As for that bump in the middle? Anctil knows something isn't working there, either. Part of the problem is that not all aspects of that five-pronged bundle have been implemented consistently, she says. "We want to flag those high-risk patients, but we couldn't find a good place to do it. On the chart? Where on the chart? On the board?" Anctil says that there are pockets of providers who do this well and always have, but others don't. The only thing that can be done according to Anctil is track it and publicly show who is doing well and who isn't. "We'll make it competitive, hospital to hospital. We'll tell Henry Ford Hospital that someone else is doing it better and they'll figure out a way to get it done."

They are also doing additional disease education in the hospital, and then doing it again post-discharge, she says. "It is the same education in all settings." A pharmacy consultation and home health referral also are provided, and if the home care visit isn't covered, Henry Ford will pay for at least one visit. "It costs less than a readmission," says Anctil.

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