The importance of strong care transitions is finally receiving the attention it deserves thanks to Medicare's hospital readmissions reduction program. Avoidable readmissions are a serious problem that costs our healthcare system an estimated $17 billion a year in Medicare payments. And with some 20 percent of elderly patients returning to the hospital within 30 days of discharge, the physical, emotional and financial toll on this vulnerable population is high.
Many hospitals choose a top-down approach to reducing readmissions in which administrators assess the situation and prescribe interventions. However, physicians, nurses and other front-line professionals often have a more complete picture of patient needs, communication barriers and other factors that contribute to healthcare fragmentation. For this reason, they are in a unique position to advise — and indeed to lead — the types of process improvements that help to reduce hospital readmissions.
As a practice management consultant with CEP America, I am privileged to work with the ED and hospitalist programs across the country. I have seen hospitals adopt a "bottom-up" approach in which professionals from many disciplines work together to reduce readmissions. So far, the results have been promising across some of our client sites. Here's how one such program approached the problem, and what we've learned so far.
Forming the Team
In response to the changing healthcare environment, Dignity Health of California formed Transformational Care Teams (later known as Performance Excellence Teams) to lead process improvement from the ground up. In 2013, Performance Excellence at Saint Francis Memorial Hospital formed a Readmissions Reduction Team. Current members include representatives from the hospitalist service, nursing, physical and occupational therapy, social work and community organizations, with additional disciplines looped in as needed. The committee meets weekly for an hour to discuss its ongoing improvement efforts.
Assessing Patient Needs
In the fall of 2013, the team determined that patient discharge education was lacking, and that lack of education was a contributing factor to readmissions. The group's first task was to identify which patients were most at-risk for readmission.
They started by analyzing demographic data provided by the hospital. As it turned out, the group most at-risk for 30-day readmissions had the following characteristics:
- White race
- Medicare beneficiary
- Diagnosed with chronic obstructive pulmonary disease (COPD)
- Living in the Tenderloin neighborhood (a poorer area of San Francisco)
The team also reviewed HCAHPS survey data to determine unmet patient needs. They found that many readmitted patients reported:
- Lack of understanding regarding their discharge instructions and medications
- Little or no follow-up care after leaving the hospital
Planning and Carrying Out Tests of Change
Armed with this information, committee members brainstormed appropriate interventions and focused on ways to enhance patient learning. They also looked for interventions that fit into existing workflow patterns.
After consideration, they decided on the following plan:
1. Check patients' understanding of discharge instructions. The nursing team developed a diagnosis-specific teach-back for COPD patients, which is used during discharge to ensure that patients understand their medications and follow-up care plan. The COPD teach-back program was rolled out to all patient units with particular attention to patient medication education. (The teach-back program was already in process, with the practice being reinforced with nursing staff during competency training days.)
2. Patient education materials. Before discharge, at-risk COPD patients receive a disease-specific patient education card with discharge instructions in plain language (third-grade reading level). The card covers medications, symptom management and when to call a doctor. It also includes a "Care Notes" section where patients can write down questions for follow-up. The idea was modeled on general and diagnosis-specific education cards used by nurses on Saint Francis' inpatient units.
To develop the card, the committee invited professionals from across the hospital to a one-day planning meeting. Departments contributing to the project included respiratory care, transitional care and pharmacy as well as representatives from Saint Francis' Patient Experience Team. A pulmonologist reviewed the final draft of the card for medical accuracy. To roll out the process, nursing leadership conducted staff education huddles on the unit, with modeling and ongoing reinforcement for sustainment.
3. Partnering with Community Resources. Through their collective experience, team members identified local resources that could assist them in providing strong care transitions for their target patient population. One of these was the San Francisco Transitional Care Program (SFTC).
SFTCP is a federally funded program operating in San Francisco County that aims to reduce hospital readmissions among high-risk Medicare beneficiaries. A social worker from the organization travels to the hospital to visit with eligible patients prior to discharge. The social worker uses a coaching model to build patients' confidence to manage their own care and provides them with tools that help them to organize their health information. SFTCP also assists patients in obtaining their medications and planning their initial follow-up appointment with a primary care physician and provides transport to two follow-up physician appointments. In addition, the social worker conducts home visits to ensure that patients' post-discharge needs are being met.
Promising Results, Excellent Buy-In
The above interventions have received robust support from Saint Francis' front-line staff and providers. Committee meeting attendance has been strong, with many members coming in on days off or after a shift. Members value the fact that their leadership seeks their input and expertise. In addition, participation allows them to suggest finishing touches that make the interventions more effective. (For example, placing the patient instruction cards near the printer where nurses can grab them on the fly.)
At Saint Francis Medical Center, readmissions continue to decline, though it is too early to attribute recent reduction to this program. In addition, Saint Francis has just received approval to add a patient navigator position. The navigator will support the above initiatives and help to enhance patient transitions. We can expect even more great results!
While Saint Francis and other hospitals are still collecting data on their process improvement efforts, preliminary evidence suggests that these nurse- and provider-led interventions are creating smoother care transitions for high-risk patients, which will hopefully lead to fewer avoidable readmissions. Their experiences are a testament to the power of a "bottom-up" approach that engages the expertise and experience of front-line providers.