8 Tips for Reducing Readmissions Through Better Transitions of Care

The hottest topic in acute-care medicine these days is improving patient transitions when patients leave the hospital. Managed care experts have known for years that this is a point of vulnerability where patient care can fall through the cracks and may lead to costly, dangerous consequences. Academic studies have verified the problem, and CMS is launching major initiatives to improve the situation. Several years ago, CMS began measuring 30-day readmission rates for three medical conditions that are common causes of readmissions (heart failure, acute myocardial infarction and pneumonia) because it believes short-term readmissions are an acceptable metric for poor care transitions. Beginning October 2012, CMS will begin cutting reimbursement to hospitals with high readmissions for these conditions, and the program is slated to expand quickly to all cause-based readmissions. This has created a maelstrom of activity, and hospitalists are in the center of the storm because of their pivotal role in managing patients though the discharge process.

Here are eight useful tips that research and practical experience have shown to be essential in improving patient care for the fragile 30-day post-discharge period.

1. Start discharge planning on the day of admission. Most of the time, hospitalists know if the patient can be discharged home or requires further institutional care soon after admission. This is the time to call case management and involve the family with important decisions that can take days to resolve. What facility will be required? What is the support system at home, and are community resources needed? Does the family and patient have realistic expectations about the patient's condition? Will they need end-of-life counseling or palliative care? What are the barriers to care (transportation, finances, provider access, etc.)? Waiting until the day before discharge all but guarantees an incomplete and suboptimal process.

2. Achieve consensus among the various hospital providers regarding the discharge care plan. Nurses, case managers, pharmacists and specialists must provide a consistent and coherent plan to the patient and the handoff providers. Unfortunately, it is not unusual for specialty consultants to pursue a discharge plan that ignores comorbidities, practical realities and patient wishes. Unit nurses, case managers and patients frequently hear conflicting messages from multiple providers, adding confusion to an already complex situation. Multi-disciplinary rounds are an excellent way to improve communication and collaboration, and many times a direct discussion with the specialists is needed to ensure everyone is on the same page.

3. Make special plans for patients discharged to a skilled nursing facility or post-acute facility. In today's world of short hospital stays, patients are discharged sicker, and many require rehabilitation in a skilled nursing facility. Almost 30 percent of Medicare patients are sent to a step-down facility, and younger patients often require SNFs as well. Institutions and providers vary widely in their ability to handle high disease acuity so it is imperative that the hospitalist plays an active role to ensure patients are sent to the appropriate place and provider. The concept of writing "DC to SNF" and letting the case manager decide where and to whom the patient will be transferred is not a wise strategy. The hospitalist must ensure discharge plans are communicated directly to the SNF provider. Patients usually require multiple visits during the first few weeks of transition — the old days of a physician visit once a month are inadequate  — which means hospitalists should choose the SNF provider that can service patients appropriately. Facilities vary in capability to manage complicated disease states and should be selected based upon the level of care required. Be aware, though, that identifying a provider and appropriate facility does not guarantee a successful transfer because of multiple barriers.

4. Prescribe discharge medications with a practical viewpoint.
Medication issues are the number one cause of short-term readmissions, and proper reconciliation discussion is a lengthy complicated process beyond the scope of this article. But most of the problems revolve around picking appropriate medications for the situation and taking into account insurance, financial ability, patient compliance, patient comprehension, potential side effects, family support and patient preferences. The choice of medications can be very different for SNF versus home transfers. Patients are unlikely to take more than 6-7 medications a day. Advising patients of all possible side effects is unachievable and irrelevant; prioritization based on likelihood to impact care is the goal. Experience has shown that physicians can supervise the process but rarely have the time or inclination to review the list with patients or investigate the issues. Optimally, a pharmacist should be involved in patient education.

5. Identify the follow-up provider and ensure the first post-hospital visit is scheduled before discharge.
Most patients require a provider visit within the first week to ensure an adequate transition. But patients sent to county clinics can have waiting times of weeks unless providers intervene. Some patients believe they have a primary care provider, but when attempting to schedule, find he/she no longer accepts them for multiple reasons. At least, a concise, one-page discharge note with essential information for the first follow-up visit is essential, and sometimes, an oral handoff to the provider is critical. Remember, the PCP is unlikely to review the note until minutes before the patient is seen, so the information must be arranged for quick reading. Don't forget specialty visits are frequently the first follow-up after discharge, so the note should be sent to them as well.

6. Educate the patient and caretaker with an understandable care plan.
This includes involving the patient in the design to reflect his/her preferences. The patient's medical IQ must be considered in the written and oral communication. As mentioned above, hospitalists must supervise but optimally are not the only ones informing the patient/family of the care plan. Patients must understand their medications including reasons for use, symptoms that are cause for alarm and monitoring requirements. Similarly, they must appreciate the importance of pending test results, discharge services like durable medical equipment, home healthcare and scheduled follow up visits. It is vital to delineate whom to call with questions or concerns during and after normal business hours.

7. Follow-up on the patient within five days after discharge. Because there are so many items that can fall through the cracks and so many barriers that can arise, some sort of follow-up contact is necessary soon after a home discharge to ensure the care plan is intact. Unfortunately, a timely visit to a provider is frequently not possible for a variety of reasons. Many alternative programs have been developed using telephone, home visit or specialized clinic follow ups. Physicians, extenders, nurses, case managers or even health coaches have been utilized. Some of the programs, such as provider home visits, are effective, but very expensive. Usually, a risk-assessment is done to identify the most cost-effective follow-up. Most of the studies demonstrating readmission improvement include a telephonic call center. The secret sauce is tailoring the interaction to the patient's needs, which means the caller must have access to the care plan and must be facile in obtaining needed resources quickly.

Patients sent to nursing homes also require follow-up. Hospital case managers usually facilitate the transfers and may not follow hospitalist recommendations. There are many reasons for this, including insurance authorization, bed availability, geography and even case management preference. Furthermore, if the patient is sent to an appropriate facility, he or she may not be assigned to the designated physician. That is why developing a patient follow-up and tracking system is vital, even in the nursing home situation.

8. Tailor the discharge note to the receiver. The content of the discharge note should vary depending on who will read it. For an outpatient PCP, the note must concisely address the needs of the first outpatient visit. For a SNF, the note needs information regarding IV medications, infections, mental status, end-of-life planning, family expectations and the names of the outpatient providers. Always include the caretaker's name and the correct contact telephone number.

Patient transitions from the hospital represent one of the most dangerous times in medical care. Improvement requires a coordinated and thoughtful plan accounting for multiple handoffs to providers. In addition, we must educate patients and families about complex, complicated and fluctuating care plans. The hospitalist role is central to improve this process and attention to these eight areas provides a framework for making a substantial difference.

Kerry Weiner, MD, is chief clinical officer of IPC The Hospitalist Company, Inc., headquartered in North Hollywood, Calif. Dr. Weiner oversees clinical operations of the company, focusing on education and leadership training for the company's 2,000 affiliated providers. IPC practices in over 1,000 acute and post-acute facilities in 27 states.

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