Statewide effort cuts readmissions
Participants focus on smooth transitions
Readmissions are not just a hospital problem. They are a problem that extends across the continuum of care, and providers at all levels of care must work together to solve it, says Tania Daniels, PT, MBA, vice president of patient safety for the Minnesota Hospital Association. The hospital association is a partner in the Reducing Avoidable Readmissions Effectively (RARE) campaign.
A broad-based coalition of 83 Minnesota hospitals and 93 community partners across the continuum of care, RARE has prevented 6,211 readmissions, helping patients spend a total of 24,844 more nights at home over the period starting Jan. 1, 2011, through the second quarter of 2013.
The Reducing Avoidable Readmissions Effectively (RARE) campaign has also reduced estimated inpatient costs by more than $40 million, according to Daniels.
The initiative was a joint project of the hospital association; Stratis Health, the Medicare Quality Improvement Organization for Minnesota; and the Institute for Clinical Systems Improvement. The partners collect and analyze data and provide education and coaching to each participating hospital.
The partners arranged for hospitals to participate in educational events on three models for reducing readmissions: Care Transition Intervention, developed by Eric Coleman, MD, MPH, and his team at the University of Colorado; Project RED (Re-Engineered Discharge) developed at Boston University Medical Center; and Safe Transitions, a program piloted in 2011 by 13 Minnesota hospitals under the direction of the hospital association.
The hospital association assisted each participating hospital in conducting an organizational self-assessment to determine what kind of patients were being readmitted and why. Then they analyzed the data to determine where the processes need improvement, developed a plan, and implemented strategies using resources and tools provided by the RARE partners.
"We learned early on that there is not one place for hospitals to start. The projects depend on the needs of the organization, and their interests," says Kattie Bear-Pfaffendorf, MBA, CPHQ, patient safety and quality specialist for the Minnesota Hospital Association.
The RARE initiative focuses on five key areas that can result in readmissions if they aren’t managed well. The areas are comprehensive discharge planning, medication management, patient and family engagement, transition care support, and transition communications, Daniels says.
Hospitals should start planning the discharge as soon as the patient arrives at the hospital instead of waiting until the last minute. Focus on ensuring that all of a patient’s needs are considered and included in a comprehensive discharge plan with input from the patient and family, Bear-Pfaffendorf says.
"Medication management is one of the areas that has been most challenging because it’s not always easy to get a comprehensive list of medications," she says. Some hospitals call the patients ahead of time to get a list. Others call after discharge. She suggests making sure that patients understand the purpose of the medications they are prescribed and take them in the correct manner at the correct time. When patients need to use inhalers or self-injected drugs, hospitals should provide comprehensive training and allow patients to practice with empty containers, she says.
Hospital staff should engage patients and family members in the discharge plan early in the stay and begin teaching long before discharge. "There is no time that’s too early to start education. We encourage hospitals to start working with patients and family members as soon as possible so they will retain more information," Daniels says. Engage patients and families on their literacy level and use the teach-back method to make sure they understand what you’re telling them. Use standardized materials written in plain language.
To meet the goal of transition support, some hospitals created the position of care transition coach, who meets with the patients in the hospital and follows up with a visit to their home. Some hospitals have partnered with the area’s emergency medical technicians to visit recently discharged patients when they have down time. One hospital has arranged with a local college for students in nursing, pharmacy, and medical assistance programs to do home visits.
Hospitals found they needed to improve communications when patients transition between levels of care, Daniels says. "Preventable readmissions require improved care coordination between hospitals and community partners. We’re working to increase communications and improve care transitions," she says.
For instance, some hospitals were sending post-acute providers discharge summaries that were 50 to 100 pages long, with key information buried in the document. The partners developed a list of 23 core elements that hospitals are encouraged to include in discharge summaries that are 21 pages or less. Key information that post-acute providers need includes current health status, follow-up needs, pending test results, red flags, medications, and special patient needs, says Daniels.
