Published in the March 2011 issue of Today’s Hospitalist
Perhaps no topic in health care is receiving more attention than unnecessary readmissions. And with Medicare promising to penalize hospitals for preventable readmissions in the not-too-distant future, the issue isn’t going away anytime soon.
The problem with preventing readmissions is that there are so many moving parts to not only a hospitalization, but the discharge process and a patient’s transition home.
The good news is that some organizations have made real progress in eliminating unnecessary readmissions. Here’s a look at the innovations being used by four institutions to reduce their readmission rates.
Go to the videotape
To prevent unnecessary readmissions, Kaiser Permanente hospitals and outpatient settings rely on many of the strategies you’d expect a huge health care system to employ, from standardized discharge summaries delivered on the day of discharge to follow-up phone calls. But what’s really striking about Kaiser’s efforts is how it gets much of its information on how to improve care.
That’s because Kaiser takes an almost anthropological approach to readmissions, using videotape to find “and fix “weaknesses in the discharge process. Clinicians, quality improvement experts and other staff members interview patients at the bedside or at home after discharge to get their impressions of their hospitalization. The videotaped interviews are shared with Kaiser employees around the country.
“We analyze the footage and create reports and videos that contain key scenes and point to emerging patterns,” explains Estee Neuwirth, PhD, Kaiser’s director of field studies. “We then share those videos with leaders, frontline physicians, nurses and social workers.” Looking at a hospitalization and discharge from a patient’s perspective, she adds, “shifts the way clinicians think about quality improvement and care delivery.”
Kaiser also takes the interview data, conducts a chart review and then interviews the patient’s provider. “We triangulate all those data to understand what we might have done differently to reduce hospitalizations,” Dr. Neuwirth says.
The radical approach was borne out of a common-sense observation. “We realized that providers typically see only one piece of the puzzle,” she explains. “Only the patient sees the whole puzzle, so we thought, ‘Let’s start with the patient.’ ”
The biggest single lesson to come out of the initiative has been the realization that many patients are simply not ready to begin making the transition home while they’re still in the hospital. According to Dr. Neuwirth, that comes as a surprise, even to experienced clinicians.
She cites one senior physician who is very involved in quality improvement efforts who watched a video of a patient explaining that, at the time of his discharge, he simply couldn’t process all the information thrown at him. “The physicians explained it really well,” the patient said on the video, “but I wasn’t ready to receive it. I wasn’t in the right frame of mind.”
Hearing the patient talk about his post-discharge problems, Dr. Neuwirth says, gave the physician a new perspective that he couldn’t get by talking to his own patients. “It really hit him that physicians weren’t doing anything wrong,” she explains, “but that the hospital isn’t the ideal place for patients to learn about their condition or medications.”
Another common concern revealed in the interviews: “Patients are given multiple telephone numbers,” says Dr. Neuwirth, “and they’re not sure who to call with a problem.”
The interviews led Kaiser to implement several solutions, including a special phone number for patients to call during their first week post-discharge. The interview process gets results, Dr. Neuwirth says, in part because patients are relaxed. “We’re asking them for their perspective,” she explains, “and we give them plenty of time to answer open-ended questions.”
Asking clinicians and leaders to leave their comfort zone in the hospital or office and serve as listeners and observers is also critical. “It changes not just how we deliver care,” says Dr. Neuwirth, “but the way we think about care.”
While the videotaping project can’t take all the credit, Kaiser was able to drive down its readmission rate in one southern California hospital from 13.6% to 9% in one six-month period.
When physicians resist change
Few people like change, and physicians are no exception. It should come as no surprise, then, that when presented with even the best ideas on what to do differently, some physicians aren’t impressed.
That was the case when the hospitalist group at Philadelphia’s Hospital of the University of Pennsylvania tried tackling readmissions. In 2008, the group became one of the first to participate in the Society of Hospital Medicine’s Project BOOST initiative, which uses “among many strategies “a checklist to improve discharge planning and communication.
At first, the hospitalist group revolted against using two items on that checklist: a screening tool for depression and health literacy.
The problem, explains Emmanuel King, MD, a hospitalist and director of clinical operations for his hospitalist group, was that hospitalists didn’t want to broach these subjects.
“They didn’t feel comfortable talking about depression unless it was clinically indicated,” he says. “They also didn’t know how they were even supposed to screen for health literacy.”
The group rolled out other elements of the checklist while they tried to figure out what to do with the depression and health literacy screens. According to Dr. King, physicians’ resistance started to fade when they saw that other parts of the checklist weren’t nearly as onerous as some had thought.
“They could check off boxes easily,” he explains, “and they didn’t feel like they were focusing on issues that weren’t related to why the patients were in the hospital.”
At the same time, hospital leaders presented preliminary data showing that the checklist was helping drive readmissions down. That paved the way for incorporating the two missing pieces.
To phase in those screenings, the group took a “lite” approach. Instead of conducting an exhaustive screening for depression or health literacy problems, they started with more casual questions.
They began asking, for instance, how those patients taking SSRIs were responding to their medication. “You don’t always have to formally ask if the patient is depressed or suicidal,” Dr. King notes.
For health literacy, the idea was again to start small, perhaps by asking patients if they have trouble understanding how often to take their medications.
Dr. King acknowledges that screening for depression and health literacy “is not something that comes naturally” to most hospitalists. Yet as physicians asked about these issues, he says, they began to see possibilities opening up.
“People saw that there was more at stake than just medical issues, medications and a diagnosis,” Dr. King says. “Physicians began to appreciate the true value of incorporating issues that aren’t the clinical problems you always focus on.”
That helped hospitalists start thinking about discharge planning on day 1. “Now, they more frequently start addressing challenges early on instead of focusing only on the chief complaint and figuring out how to discharge someone an hour before they leave,” says Dr. King.
Today, screening for depression and health literacy have been integrated into the hospital’s overall workflow ” and, in some cases, passed on to case managers. But the hospitalists remain sensitive to how those issues contribute to readmissions and poor outcomes.
“Those are,” says Dr. King, “no longer foreign concepts.” While the program initially saw a drop in readmission rates, those rates are once again on a par with the hospital average, he notes. “The more important change has been in culture around discharge,” he adds, “which we feel we’ve improved dramatically as an institution.”
Coaching in patients’ homes
When John Muir Health, an integrated delivery system in San Francisco’s East Bay, began targeting readmissions in 2007, it put several innovations in place. Those included outpatient electronic management for COPD and heart failure patients, and self-management programs for patients with diabetes.
But another strategy for discharged patients relies on the targeted use of transitional coaches. The coaches are full-time nurses, although the program draws on some student nurses from a local nursing program. The health system makes transitional coaches available for patients covered by Medicare or by John Muir’s IPA or managed care network.
While the coaches help patients with a variety of diagnoses, patients are typically frail and elderly and struggling with either clinical, functional or compliance problems ” or “all the above,” according to Jeffrey Frank, MD, an inpatient medical director for case management for John Muir Health. The system maintains two hospitals.
“The intervention is very limited, but it’s very effective,” Dr. Frank explains. “It goes right to the heart of the period that immediately follows hospitalization.” The transitional coaches visit patients at home 24 to 48 hours after discharge, before home health nurses arrive.
Their main objective is medication reconciliation. “They throw a lot of medications out of the medicine cabinet,” Dr. Frank points out. “They’re taking the discharge medication instructions from the hospital and doing their best to see that patients are taking the right drugs.”
Another goal is to see that patients make and keep a follow-up appointment with their primary doctor or specialist.
The coaches follow that home visit with a series of three phone calls to make sure patients are still taking the right medications and securing both follow-up appointments and other resources they need, like durable medical equipment. If problems arise, the transitional coach calls either the primary or the discharging physician. She also may refer patients to an outpatient case manager or disease management program.
“Their job is done within two weeks, with most of their work done in the first two days after discharge,” Dr. Frank explains, adding that using transitional coaches does not obviate the need for home nursing visits or home therapy. “It is,” he says, “complementary.”
While transitional coaches are in and out of patients’ lives quickly, the program has proven to be the most valuable of all the approaches the health system is taking to lower readmission rates.
“It’s more effective than disease management,” Dr. Frank notes. Readmission rates for patients enrolled in the transitional-coaching program have been cut in half, he says, down from a range of 22% to 25% (among patients with similar disease severity who aren’t eligible for the coaching program) to between 10% and 12%.
Getting med-rec right
While hospitalists may be ideal candidates to streamline the discharge process, they could often use help. Having pharmacists do medication reconciliation is a good example.
When Atlanta’s Piedmont Hospital began tackling unnecessary readmissions in 2008, it identified medication reconciliation as a key component because nearly half the hospital’s patients had medication reconciliation problems. While a number of hospitals are putting pharmacists on med-rec duty, Piedmont took that concept a step further by having pharmacists train pharmacy students to do much of the work.
Pharmacy students typically do five-week rotations in the hospital. Now, in addition to that standard rotation, students do another five-week rotation devoted exclusively to medication reconciliation, says clinical pharmacist Leah Eagle, PharmD.
The students work on two units that each have about 20 beds and are staffed by hospitalists. They begin medication reconciliation on admission, talking to patients about their medications and contacting pharmacies, nursing homes and primary care physicians to get the most complete, up-to-date list possible “a process than can be quite drawn out. A pharmacist reviews that list, ideally before new medications are ordered or administered.
The pharmacist and the students also work closely with the hospitalists. “We try to make sure that the hospitalist is fully aware of what the patient is taking at home,” Dr. Eagle says, “and if anything should be stopped or changed based on the information we get.”
The students and pharmacist also look for cost savings (maybe an oral or IV version of a drug is more cost effective), and they keep an eye on how long patients have been taking antibiotics.
According to Dr. Eagle, the program works well because pharmacists have a knack for spotting medication problems. “We can look at a medication history and say, ‘This patient’s in A-Fib, but I don’t see any Coumadin on the list. Maybe I should double check that with the patient.’ Or ‘This patient has glaucoma but isn’t getting eye drops, so I should check on that.’ ”
Should hospitalists be able to spot such discrepancies? “They’re seeing the patient for the first time, and they’re focusing on treatment,” Dr. Eagle says. “We’re looking only at medications vs. trying to figure out what is wrong with the patient.”
Many times, she adds, finding what’s wrong with a medication regimen requires digging “and a lot of imagination. “When I first started,” Dr. Eagle explains, “it was shocking how many different ways patients would take medications. It’s almost a rarity to see someone taking their medications exactly how they were prescribed.”
Some discrepancies are run of the mill, like patients who inadvertently double up on one therapy because they see multiple physicians or share a prescription with their spouse “and land in the hospital as a result.
Piedmont has successfully reduced unnecessary readmissions, and the medication reconciliation has undoubtedly played a part. By July of last year, the hospital’s 30-day readmission rate had fallen to 3.97%, compared to a rate of 13.05% before the hospital ramped up its efforts to cut down on readmissions.
Edward Doyle is Editor of Today’s Hospitalist.