Readmissions are the bane of all stakeholders in healthcare. Patients, caregivers, payers, physicians, and hospitals fare poorly when readmissions are high. Patients face exposure to hospital-acquired conditions and poor outcomes with increases in morbidity and mortality.(1) Hospitals face penalties, poor rating scores, lower patient experience scores, and reduced reimbursements; risk their shared savings; and incur higher costs. Insurers, both commercial and governmental, experience impacts on their star rating scores, costs of coverage, and member dissatisfaction. The complex and significant processes involved, especially in discharge planning and execution, make lowering readmissions a daunting task for any team.
Lee Health is one of the largest public not-for-profit safety-net health systems and have incurred multiple years of penalties from the Centers for Medicare and Medicaid Services (CMS) because of high readmission rates. The health system chose to reassign ownership to new executive sponsors (Venkat L. Prasad (VLP) and Kris M. Fay (KMF), who provided oversight and resources to the Readmission Task Force led by Marilyn Kole (MK) and Richard Macchiaroli (RM).
We improved our readmissions score from the first percentile to the 94th percentile in the country in 15 months. Daisy-chaining the inpatient and outpatient journeys helped define our approach. With a multi-disciplinary team and engaged leadership, we were able to implement creative solutions such as ED U-turns, advanced practice provider (APP) involvement in patient discharges and follow-up, use of dashboards, networking our community skilled nursing facilities (SNFs), and discharge planning with lounges.
Patient empowerment and hand-offs, which addressed important patient needs such as durable medical supplies, medications, transportation, food, and follow-up, were other important factors in a patient-centric approach.
When preventable readmissions are high, there is a collective dismay and concern among all those who provide, pay for, or receive healthcare.
Readmissions are a costly business; 30-day readmissions cost Medicare $17 billion a year.(2) Apart from its deleterious effects on patient outcomes, patient experience, and length of stay, readmission incurs penalties and adds significantly to the total cost of care. Nearly 20% of Medicare beneficiaries are readmitted within 30 days, and 34% within 90 days.(3) The diagnosis of diabetes adds nearly $30 billion yearly to readmissions, assuming a 16–24% readmit rate for diabetes.(4)
The Hospitals Readmissions Reduction Program (HRRP), in place since October 2012, has garnered penalties from hospitals with high rates of readmissions. In addition, commercial payers have been wary of having to pay for high rates of readmissions. Risk contracts and accountable care organizations (ACOs) incentivize low rates of readmissions and add risk for high rates.(4,5)
Heart failure treatment expenditures were $30 billion in 2012 and may balloon to $70 billion in 2030. A majority of these costs can be attributed to readmissions. Nearly 20% of heart failure patients are at risk of readmission within 30 days of discharge. Existing co-morbidities in 50–60% of patients make nearly 75% of readmissions unavoidable.(6,7) Heart failure is one of the most common reasons for readmissions in people older than 65.
Preventable readmissions make up nearly 13% of all hospital readmissions in the United States. Some of the common causes for readmissions include medications; diagnostic or care plan problems; poor, disjointed follow-up care; and lack of attention to social determinants of health. Health insurance status matters too.(8)
The big three diagnoses for readmits are chronic obstructive lung disease (COPD), congestive heart failure (CHF), and diabetes.(9) Focusing on these three conditions can prevent overwhelming the care teams in the initial stages of lowering readmission rates. Lee Health’s top three diagnoses (Figure 1) were heart failure, sepsis, and respiratory infections/COPD. The hardest patients to manage were those with sepsis; readmissions were often compounded by multiple co-morbidities, long-term complications, multi-organ involvement, compromised homeostasis, deconditioning due to prolonged hospital stays and immobility, lack of support at home, and health illiteracy about needs and support.
Figure 1. Lee Health Medicare Readmissions: Top DRGs
Factors such as co-morbidities, challenges with activities of daily living (ADLs), and lack of understanding of complex discharge plans and instructions, compounded by fatigue and apathy, add to the risks of readmission.(5,10) Inadequate use of pulmonary rehabilitation, nutrition status, recommended guidelines, and palliative care services add to readmits among COPD patients.(10) The role of medication reconciliations, optimizing laboratory abnormalities, addressing co-morbidities, post-discharge calls, and office follow up within seven days after discharge can contribute to lowering readmissions.(11,12)
Similar to clinical risk stratification scoring for social support, flagging the need for additional resources and help during transitions and using formal survey tools in the discharge planning process can help find care gaps and preempt the risk for readmission. Common factors noted in these studies of readmissions included lack of funds, lack of medication management, lack of support for basic needs, lack of community support, and lack of transportation.(13,14)
Our approach to lowering readmission rates included key tactics that connected the work of the patient journey across the continuum.
Coalition: One of our first steps was to develop a coalition. This included a physician-led multi-disciplinary task force (Figure 2) created with a large cohort of physicians, providers, and administrators from inpatient and outpatient areas. The project management team was engaged early on to help organize workgroups and develop a plan-do-check-act model for carrying out change and action plans. Their involvement helped track progress and provided infrastructure support for communications and meetings. The task force met monthly and scheduled several touchpoints with individual departments and champions; stakeholder communication was robust.
Figure 2. Readmission Taskforce Performance Scorecard
Senior Leadership Support: Another tenet of change management is the engagement of senior leadership. We ensured that population health chief officers (VLP, KMF) attended all meetings and emphasized the high priority of this endeavor, maintained the momentum, and motivated and appreciated the team’s work at every opportunity. The engagement of senior leaders provided an open door to the resources necessary to advance the work of the task force.
Data Management: Data drive meaningful conversations and action plans. Sharing validated data and exclusions helped tease the complexity in CMS calculations, definitions of planned versus true readmissions, inter-hospital transfers, and exclusions. We examined physician data by campus and group levels rather than by individual, which helped foster data transparency. Monthly distribution of data and a complete scorecard of activities with a color-coded progress report and data from each campus were cascaded to teams monthly and distributed to senior leadership.
Care Redesign: A new care delivery redesign (Figure 3) established processes and protocols for an emergency department (ED) U-turn program (Figure 4). Before implementing the ED U-turn process, patients frequently were admitted, as the ED lacked both knowledge and infrastructure to schedule patients into alternative care settings. The ED U-turn process was implemented after significant physician and case management education about care alternatives to patient admission.
Figure 3. Care Delivery Redesign Process for the ED U-turn Program
Figure 4. Processes and Protocols for the ED U-turn Program
ED U-turns involved huddles with multi-disciplinary team members at intervals throughout the ED visit to continually assess the need for admission and the barriers to outpatient care settings. An ED-embedded case manager was equipped with a newly designed electronic health record (EHR) patient readmission risk alert for potential readmissions early in the ED visit. After EHR identification of potential readmission, case managers informed the ED physician.
Per protocol, the nurse/doctor/case manager/APP/pharmacist team met to determine the most appropriate pathway for the patient. APPs from specific medical groups reviewed potential readmissions with the team and facilitated follow-up visits as appropriate with outpatient clinics. Physicians and case managers used ED schedulers onsite or via telephone from 8 a.m. to 5 p.m. Monday through Friday to schedule primary care and specialist outpatient appointments in the timeframe designated by the ED physician.
Each morning, ED schedulers worked referral queues for follow-up from their non-operational hours the evening before. If ED schedulers could not secure follow-up appointments, the case was escalated to the practice manager to create an appointment time for the patient within the designated timeframe. The complex care center, which rapidly evaluates post-ED and post-hospitalization patients, was critical in accommodating rapid follow-up appointments when primary care doctors could not.
The highest priority and most impactful U-turn workflows for readmission reduction were extended ED work-ups, ED scheduler follow-ups, Heart and Vascular Institute APP assistance for rapid chest pain and diuresis work-ups, and Complex Care Center referrals. Approximately 35% of patients at risk for readmission received alternative disposition with the ED U-turn process and were able to avoid readmissions. We reviewed patients U-turned from the ED regularly to monitor for any additional ED visits or hospital admissions and found no such correlation.
Managing Post-discharge Transitions: The importance of post-discharge follow-up appointments in reducing readmissions is well known.(2) After testing multiple methods for post-ED and post-hospitalization follow-up primary care provider (PCP) visits, we scheduled appointments through our scheduler at the transfer center within 5–7 days. For more urgent follow-up and/or access barriers, the patient was referred to our Complex Care Center or to a mobile hospital at-home team (DispatchHealth).
We also worked to improve access for post-discharge patients. Scheduling template management and standardization allowed PCP follow-up appointments within seven days of discharge, and the use of inpatient APPs to schedule appointments in outpatient offices improved no-show rates. By using APPs to coordinate outpatient follow-up visits, we were able to improve follow-up rates by 40–45%, especially in cardiology.
Skilled Nursing Facilities (SNFs): SNFs play a key role in transitions of care. Regular SNF medical director and ED medical director meetings were scheduled to create better alignment and transitions for patients discharged from our acute care facilities. We also piloted a nurse-to-nurse hand-off to enable discharging nurses and receiving SNF nurses to better address patient needs and status (Figure 5).
Figure 5. Nurse-to-Nurse Handoff Protocol
Optimized Electronic Medical Records (EMR): An integrated EMR helps care teams communicate and coordinate care plans and best practice alerts. We developed and tested a communication tool within the health system-owned SNF. The SNF and ED charge nurse could hand off a short summary of the patient coming to the ED for more accurate treatment and then plan the patient’s return to the SNF. We redesigned and revised the entire discharge process in Epic.
The after-visit summary (AVS) (Figure 6) went through several iterations to optimize content and size. It is now shorter, with an improved format and better location of critical information, including practice phone numbers and information on mobile urgent care at home (DispatchHealth). This enables patients to consider post-hospitalization options in lieu of an ED visit, risking readmission.
Figure 6. After-Visit Updates
Leveraged Vendor Software: Another tool that helped transitions was a vendor product, CarePort, that helped us obtain real-time insight into SNF transitions, transfers, and home health. This also allowed better patient selection of appropriate SNF options in the community and informed decision-making by care teams, caregivers, and patients.
Envisioning Mantra: One of our key messages to team members and stakeholders was “discharge to home.” Care teams championed a “home first” strategy and provided additional resources for patients at home. This mitigated inappropriate SNF transfers and allowed patients to be cared for at home.
Discharge Planning: Poor discharge planning adds to the risk of readmissions. We implemented a discharge lounge (Figure 7) to coordinate discharge planning at acute care campuses and standardized the processes of discharge through education, medication review, PCP follow-up appointments, and home support.
Figure 7. Discharge Planning
Non-traditional Partners: As we were exploring opportunities to reduce readmissions, one of our local fire chiefs contacted us about interest in a wellness check program led by emergency management services and the fire department, when local EMS groups visit recently discharged patients for wellness checks. Currently, EMS is working on a project to evaluate patients in their homes after a 911 call with a telemedicine connection to their physicians. We are discussing with our local emergency services department medical director a pilot that would enable EMS teams to evaluate patients in their homes.
Role of Advanced Practice Providers (APPs): Effective use of APPs in the ED helped immensely in transitions to home and added value to the discharge process. We assigned a hospitalist nurse practitioner (NP) from engaged large hospitalist groups to help the ED care teams navigate patients at home after extended work-ups with home resources and follow-up appointments with primary care or specialist physicians.
NPs reviewed ED charts and determined possible risks for admissions or readmissions to explore a more appropriate outpatient setting for follow-up. Key to this process was the hospitalist NP’s early intervention in the ED work-up. Early intervention in the ED was paramount to successfully U-turning ED patients.
Waiting until the ED physician had completed the work-up, documentation, patient and family discussion, specialist consultation, and called a hospitalist for admission was far too late in the process to begin trying to find an alternative care setting. Similarly, case managers were not able to fulfill the role of the hospitalist APP because of a lack of knowledge and ability to interact clinically with the ED team.
It was noted that experienced APPs were the most successful in engaging the ED clinical team. These experienced NPs were able to support physicians in planning and facilitating discharge instead of routing patients to an acute care bed.
Adding employed and independent community-based physicians to the task force allowed for creative problem-solving and support in piloting, implementing, and changing work processes. The physicians were committed and took a personal interest in improving the overall efforts to lower readmissions.
The ED U-turn and use of APPs in coordinating transitions, discharge lounges, and optimizing information flow in the after-visit-summary documents, along with robust engagement of SNFs, PCPs, and other stakeholders, were key initiatives that helped push our readmission rates lower.
Sustaining the low rates of readmission as task force members move on to other projects or barriers to discharge and follow-up resurface can be difficult. Regular monitoring has allowed us to reengage our task force and leaders to intervene early so that the gains made will not be lost and downward trends corrected before significant increases in readmissions.
Hospital readmission within 30 days of discharge is a burden that affects all stakeholders in healthcare, including patients who must cope with poor outcomes, hospital-acquired conditions, unpleasant experiences, and costs. For hospitals and health systems, avoiding penalties and optimizing shared savings makes lowering readmission rates imperative in value-based transformation.
Daisy-chaining and integrating inpatient and outpatient care during and after hospitalization can significantly lower readmission rates. Using multi-disciplinary teams, redesigning the discharge process, embedding case managers in the ED, and using APPs allowed us to improve our readmission rate from the first percentile to the 94th percentile. Addressing social determinants during discharge planning is critical in avoiding unplanned re-hospitalizations.
Keeping the focus on patients and their journeys, closely monitoring dashboards, and redesigning care are critical in ensuring ongoing success.
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