Excessive 30-day readmissions present an all-too-common challenge for many U.S. hospitals and health systems. An approach used by The University of Texas Medical Branch (UTMB) in Galveston, Texas, exemplifies how best to meet that challenge. Through an initiative launched in 2016, the facility not only significantly improved the care transition process but also enhanced both the patient experience and outcomes. By 2017, the organization was able to reduce 30-day all-cause readmissions by 14.5 percent and avoid $1.9 million of readmission-related expense.
UTMB’s goals were to:
- Use real-time data analytics to identify patients at highest risk for readmissions, to pinpoint the factors contributing to readmissions, and to act quickly and proactively to intervene
- Close internal gaps in information, communication, and care coordination during patient stays and during and after discharge
- Standardize processes for discharge and transitions of care from hospital to home
- Improve patient education materials and follow-up appointment scheduling to ensure patients get the care they need after they go home
Using Real-Time Data to Highlight Opportunities
UTMB recognized it would require data analytics capabilities, along with access to meaningful, actionable information, before it could move forward with its performance improvement effort. The organization therefore implemented a data analytics program that would allow for daily updating of data and provide its clinicians with timely visibility into a broad spectrum of readmission metrics for all-cause readmissions, unplanned readmissions, and emergency department (ED) visits.
An initial challenge was a 90-day data lag in the readmission reporting rate, which impeded the organization’s ability to drill down into reasons for readmissions. The lag posed a significant barrier to understanding processes and results when they matter most, at point of care and in the 30 days after discharge.
UTMB started analyzing the data to find information about patients as they moved through the care continuum—filtering patients by discharge date, admission diagnosis, unit, provider, and intervention. When the data indicated readmissions were common among patients with heart failure, for instance, UTMB developed collaborative relationships with outpatient care management services to develop a focused plan to facilitate smooth transitions for patients with this diagnosis. Supported by findings of a root-cause analysis for the causes of readmissions, outpatient services delivered a range of services to patients with heart failure who were at high risk for readmissions. Those services included transition care calls, home visits, assistance obtaining supplies, and continued care management services, as appropriate.
The data obtained through this analysis also were included on UTMB’s balanced scorecard, which was used to communicate progress on 30-day all-cause readmission rate reductions, thereby promoting further process refinements and the spread of best practices across the system.
UTMB also uses the real-time data analytics to monitor and identify normal variation, as well as variation due to special causes. For example, UTMB’s data demonstrate normal variation during the winter months, when an increased number of patients are admitted with influenza or pneumonia, which results in what can appear to be a slight increase in the readmission rate. Using the analytics, UTMB can see that this change in the numerical value is normal variation over time, and not a reason for concern. Likewise, UTMB can determine when changes in the readmission rate indicate special-cause variation and can then further evaluate performance to pinpoint areas where care transitions could be improved and avoidable readmissions further reduced.
All these tactics have helped UTMB better identify and respond to readmission trends.
Standardizing Care Coordination with Evidence-Based Protocols
Among the improvements UTMB implemented were two care coordination programs designed to help reduce readmissions.
CARE (Controlling Avoidable Readmissions Effectively). The CARE collaborative tackles unnecessary hospital readmissions by improving coordination of care and access to primary care, behavioral health care, and specialty care. It also aims to standardize processes and technology. CARE is led by a physician champion, and key stakeholder participants include nurse leaders, physicians, patient care facilitators, case managers, and social workers who meet monthly to confirm project alignment and support.
In addition to using data and analytics, CARE conducts detailed weekly root-cause analyses to identify reasons for readmissions and develop action plans to address the reasons for readmissions. Through CARE, UTMB has established standard processes, using structured fields in the electronic health record (EHR) for documenting patient complexity and comorbid diagnoses, thereby improving the accuracy of clinical documentation and better communicating patients’ medical needs.
Project BOOST (Better Outcomes for Older Adults through Safer Transitions). The CARE team also implemented Project BOOST, with a focus on establishing an evidence-based process for managing care transitions from the hospital to home. The process is based on a set of interventions developed by the Society of Hospital Medicine and includes standardized tools to identify high-risk patients, educate them on their conditions and possible medication side effects, schedule follow-up appointments, and perform medication reconciliation at discharge to prevent harmful interactions.
Delivering Personalized Care
Data and technology alone can’t prevent readmissions. As always in health care, the human element plays a critical role. UTMB addressed this element by adding patient care facilitators, who offer patients at high risk for readmission personalized, patient-centric care coordination.The patient care facilitators work with lists of patients deemed to be at high risk for readmission each day, as well as lists of patients who have been readmitted within 30-days of discharge. The facilitators use the patient lists for intensive rounding and case management while the patients are in the hospital, and to set priorities for making follow-up phone calls after discharge.
The lists include patients with three or more of the following indicators of high risk for readmission:
- Polypharmacy, defined as taking more than 10 medications
- Psychological problems, such as depression
- Principle diagnosis of chronic conditions such as previous stroke, heart failure, or diabetes
- Physical limitations, such as malnutrition or deconditioning
- Poor health literacy, including language barriers or poor reading skills
- Lack of basic social supports, including being homeless or socially isolated, or having no primary care provider
- Prior hospitalization, defined as nonelective admission within the past six months
- Potential for palliative care, as indicated by advanced or progressive serious illness
Discharge planning begins shortly after the patient is admitted to the hospital, using this eight-point risk assessment screening tool. The assessment is completed on the first day of admission for each new patient and is documented in the EHR.
The patient care facilitators actively manage high-risk patients, entering a customizable care plan into the EHR and following evidence-based practice standards. The standardized interventions include evidence-based teaching materials delivered within 24 hours of admission using the teach-back method, which seeks to ensure patients understand the guidance they have received by asking them to repeat or “teach back” what they have learned and how they plan to manage their care needs.
Customized Teaching Aids and Action Plans
These teaching materials are customized by condition (e.g., diabetes, chronic obstructive pulmonary disease, heart failure, or end-stage renal disease). Patients receive an action plan that outlines what to do and who to contact in the event of worsening or new symptoms. The plan uses the “stoplight” concept, providing both a visual and written reference of when patients should contact their providers following discharge from the hospital. Green means the patient should maintain the current plan, yellow is a caution indicator, and red means the patient should seek care as soon as possible.
Using teach-back and disease-specific patient education has been effective in helping patients better understand their care and has improved patient satisfaction with nursing and physician communication.
Further, a standardized electronic discharge form, housed in the EHR, outlines the discharge follow-up plan that includes the timing of the first follow-up appointment and whether a specialist or primary care is appropriate. Facilitators also address social determinants of health by linking patients with community-based organizations and home health services, especially for patients with social isolation or limited resources.
Another change is in the time follow-up appointments are made. Previously, they were made at the time of discharge, but now they are made using a centralized service within 72 hours after discharge, allowing the patient to go home and get settled before making the appointment. This approach reduces rescheduling and inadvertent overlaps in appointments and ensures the patient is scheduled with the appropriate service, whether primary care, behavioral health care, or specialty care.
UTMB credits the quality-improvement initiative with helping it make significant gains in its ranking among academic medical centers participating in the Vizient Quality and Accountability Study.a Ranked No. 76 in the nation in the 2016 study, UTMB rose to No. 9 in 2017 and to No. 4 in 2018 (behind only The Mayo Clinic in Rochester, Rush University, and NYU Langone).
The key to UTMB’s success has been its strategic, multidisciplinary, evidence-based, data-driven approach. Reducing readmissions takes more than a single program or a scattershot approach. A marriage of actionable, real-time data, standardized processes, and personalized patient and caregiver engagement is key to solving such a complex and challenging problem and earning measurable clinical and financial returns.
The care team must pull together, communicate fully, understand the end goal, and buy into the new processes to make them work. AT UTMB, stakeholders routinely review performance and trends and conduct deep dives into specific cases during team meetings. Since implementing these programs, UTMB has developed greater collaboration among providers and built bridges between inpatient and outpatient services, as well as across specialties.
The multidisciplinary nature of the CARE collaborative, for example, helps ensure communication of project priorities, activities, and progress toward the goal of reduced readmissions. With such a multidisciplinary approach, people, processes, and technology all work in harmony to support organizations’ goals and deliver real financial, clinical, and patient engagement results.
UTMB continues to build on its success and to refine its care transitions program. Future work will include collaborations with long-term care, skilled nursing facilities, and home health providers to further refine outpatient transitions, further reduce unnecessary readmissions, and to ensure patients get the care they need in the most appropriate care setting.
UTMB’s next phase of the clinical/financial analytics partnership includes a focus on five areas:
- Chronic diabetes management
- Chronic heart disease management
- Adult primary care
- Pediatric primary care
- Cancer screening and follow-up
Access to real-time data is helping clinicians identify patients who may be missing key screenings or preventive measures. The clinicians then can either reach out to bring these patients in for a visit or record notes in the EHR for physicians to provide the screening or prevention as part of an already-scheduled visit. UTMB has already experienced strong success in the first six months of this second phase of its 30-day readmissions reduction initiative.