By Sharon Silow-Carroll, Jennifer N. Edwards, and Aimee Lashbrook
Significant variability in 30-day readmission rates across U.S. hospitals suggests that some are more successful than others at providing safe, high-quality inpatient care and promoting smooth transitions to follow-up care.
Four hospitals had readmission rates in the lowest 3 percent among all U.S. hospitals during the fourth quarter of 2007 through the third quarter of 2008 in at least two of the three conditions reported by the Centers for Medicare & Medicaid Services (CMS): heart attack, heart failure, and pneumonia.
The four hospitals do not focus on reducing readmissions, but on improving clinical quality and patient care in the belief that readmissions will decline as a byproduct of their broader improvement efforts.
The four hospitals offer the following two lessons for healthcare organizations seeking to reduce avoidable readmissions.
Begin case management and discharge planning early. Planning for a patient's discharge should begin on the day of admission. Staff access the patient's risk factors, needs, available resources, disease knowledge, and family support shortly after admission-typically within eight hours.
The hospitals target patients who are likely to have problems following discharge for enhanced care coordination and/or case management. For example, at Mercy, social workers visit all patients over 80 years old to address their needs.
Technology is also used by the four facilities to assist them in assessing, tracking, or referring patients. At Memorial City, risk-assessment software helps case managers establish the appropriate level of care and assess patients' readiness for discharge. This tool also helps the hospital make the case with patients' insurance plans about needed care.
While all four hospitals coordinate with home health agencies and connect patients to available community resources, McKay-Dee and Mercy take an extra step by scheduling follow-up appointments for most of their patients prior to discharge. The two other hospitals are only able to make appointments on an ad-hoc basis for the neediest patients because of limited staff and resources. Scheduling appointments for patients can ensure they receive follow-up care and comply with recommended treatment.
The hospitals commit to regular communication across care teams and with patients and their families. Daily, interdisciplinary care coordination meetings-or rounds-are common, providing an opportunity to raise issues or concerns about patients, adjust the discharge date based on progress, and arrange for equipment or services that may be needed in the community. In some of the hospitals, whiteboards are located in patients' rooms to keep families apprised of the target discharge date and other important milestones.
Despite their successes, the hospitals noted some aspects of discharge planning are beyond their current capacity or could be improved, such as universal scheduling of follow-up appointments and developing a care plan with every patient.
Align the efforts of hospital and community providers to ease transitions across care settings. Collaboration and close communication between inpatient and outpatient providers can enhance care transitions and reduce readmissions.
McKay-Dee is a hospital in the Intermountain Healthcare system. Many physicians at McKay-Dee-employed and independent-have offices on-site in the hospital's physician office wing, adjacent to the related inpatient floor. The proximity of physicians' offices to the hospital promotes follow-up care. Hospital patients also have access to an affiliated home health network, which provides coordination and support to help patients stay out of the hospital. If a patient does not have a medical home, hospital staff will help the patient secure one-either within the Intermountain network or with one of the community clinics with which the hospital partners.
St. John's efforts to coordinate inpatient and outpatient care include engagement of local primary care physicians. For example, the hospital sponsored a "heart failure summit" to bring physicians up to date on current guidelines for heart failure treatment-a step that could help reduce admissions, as well as readmissions. The hospital also provides electronic notification to community physicians via its electronic medical record system when one of their patients is discharged from the hospital with heart failure.
McKay-Dee and St. John's also run outpatient cardiac clinics and other services that provide education, rehabilitation, and ongoing management to help patients stay out of the hospital. St. John's makes resource centers available to support patients with heart failure, asthma, and diabetes. McKay-Dee has an outpatient heart clinic on-site to which it refers at-risk cardiac patients at discharge. Having these clinics and resource centers on-site provides clear advantages. For example, clinicians can send a heart failure patient with high fluid levels-or "overload"-directly to McKay-Dee's intravenous clinic, where successful fluid reduction can avoid an admission to the hospital. For more serious situations, patients can be admitted immediately.
These hospitals attribute their success at reducing readmissions to their commitment to clinical excellence. For example, Memorial City has achieved high adherence to recommended process-of-care measures for heart attack and pneumonia care during the initial inpatient stay, which it believes has helped reduce readmissions.
Mercy attributes a 47 percent decrease in readmission rates for its heart failure and chronic obstructive pulmonary disease patients to the installation of home monitoring devices. McKay-Dee has had success in reducing readmissions through efforts to target, educate, and follow up with heart failure patients.
However, the hospitals acknowledge they do not excel in all areas and need to continuously measure several aspects of performance to target areas in need of improvement. For example, Memorial City's interventions to prevent readmissions contributed to very low rates-compared to national averages-for pneumonia and heart attack, but just average rates for heart failure. This suggests that conditions, such as heart failure, require focused interventions.
While St. John's performance is above average on most quality measures reported by CMS, it has a surprisingly low score for documentation of heart failure discharge instructions. Although the problem may be more of a failure to document the delivery of discharge instructions than a failure to deliver them, it nevertheless indicates an area for improvement.
Sharon Silow-Carroll, MBA, MSW, is a principal, Health Management Associates, New York.
Jennifer N. Edwards, DrPH, MHS, is a principal, Health Management Associates, New York.
Aimee Lashbrook, JD, MHSA, is a senior consultant, Health Management Associates, Lansing, Mich.
This article is excerpted with permission from the following resource: Silow-Carroll, S., Edwards, J.N., Lashbrook, A., Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals, The Commonwealth Fund, April 2011.
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