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Taking a bite out of readmissions

June 2009

Published in the June 2009 issue of Today’s Hospitalist

WHAT’S THE BEST WAY to reduce unnecessary readmissions? While the question has long vexed hospitalists, the rest of the world is realizing that the answer has major implications for health care.

The Obama administration’s budget proposal, for example, talks about $26 billion in savings that would result from reducing unnecessary readmissions. And a study in the April 2 issue of the New England Journal of Medicine made headlines by examining readmission patterns.

Anyone looking to cut down on unnecessary readmissions and hospitalizations would do well to start with Boston Medical Center, which is on the cutting edge of streamlining the discharge process with its project Re- Engineer Discharge (RED). In a study published in the Feb. 3 Annals of Internal Medicine, researchers from project RED showed how they were able to reduce “hospital utilization” “which included both 30-day readmissions and ED visits “by about 30%.

The study not only points to strategies that can streamline the discharge process, but highlights the challenges that await hospitalists who try.

A three-pronged approach
Project RED relied on a three-pronged approach. The first and most important element was the presence of nurse discharge advocates, who were responsible for executing most of the program details.

Discharge advocates worked with patients, family Researchers identify strategies to streamline discharges members and clinicians both inside and outside of the hospital to collect and computerize patient information. That information became a critical part of the second key component: the after-hospital care plan. That document contained information on how to contact providers, a calendar with follow-up appointments, a list of tests that were conducted, and directions on what to do if problems arise.

To make the information easily digestible, particularly for patients with a low level of health literacy, the document contained graphics like a color-coded schedule for medications. Once the after-hospital care plan was complete, the discharge advocate used it to educate patients before discharge.

Finally, clinical pharmacists called patients two to four days after discharge to discuss medications and ask about problems. The pharmacists then relayed any patient questions or concerns to the primary care physician or discharge advocate.

Cutting down on frequent fliers
Applying these strategies to a group of nearly 400 patients, researchers not only reduced hospital utilization, but found that significantly more patients from the intervention group reported seeing their primary care physician for follow up within 30 days. (See “Project RED outcomes,” below.)

Researchers estimated that the intervention produced a savings of 34%, or about $412 per patient, when compared to the control group. Brian Jack, MD, the principal investigator and associate professor of family medicine at Boston University School of Medicine, notes that the intervention was particularly effective in reducing hospital utilization among frequent flyers. In fact, Dr. Jack says, the biggest predictor of rehospitalization in the study was being previously hospitalized within the past six months.

“Our subgroup analysis,” says Dr. Jack, “showed that the intervention was even more effective for this group.”

Additional analyses found that the intervention helped reduce rehospitalizations among other subgroups: patients who screen positive for depressive symptoms, and men. “They don’t see their physician,” Dr. Jack says, “and they have more difficulty understanding how to take their medicines. They wait until they need to go the emergency room.”

Costs and benefits
Dr. Jack acknowledges that the estimated savings didn’t include staff costs. Their time was significant, with nurses spending 1.5 hours per patient and pharmacists spending 26 minutes each.

While hospital administrators may cringe at the idea of having nurses spend an extra 1.5 hours for every patient before discharge, Dr. Jack says that most nurses would not need that much time to collect data for the after-hospital care plan.

“Nurses don’t need to spend 1.5 hours if they already know the patient,” he says, adding that his medical center has now developed a software program that helps nurses enter data. “It could be as little as 10 minutes.”

Besides, he adds, administrators will see that improving discharges not only saves money in the short run, but produces long-term benefits because of the growing scrutiny on readmissions. Experts expect large payers like Medicare to eventually penalize hospitals that have high readmission rates. “The CMS is all over this,” Dr. Jack says.

A tough process
While the data point to clear benefits, the study also offers clues about how hard it is to improve the discharge process.

Despite the presence of discharge advocates, for example, only 53% of patients in the study had their medications reconciled. Dr. Jack says that in such cases, the nurse was probably unable to track down an intern to get a patient’s medication lists.

While an after-hospital care plan was ready to be delivered to most patients, 17% left without ever receiving the document, likely because they left either early or late in the day, when there wasn’t a discharge advocate on duty.

And despite the discharge advocates’ educational efforts, a large number of patients still needed help after discharge. During the follow-up phone calls, pharmacists found that 65% of the patients they talked to had at least one medication problem. Over half of those patients needed some action, like a call from their primary physician.

Reproducible results
Despite those challenges, Dr. Jack says that even hospitals that aren’t rich in resources could improve discharges by adopting elements of the after-hospital care plan.

He also points out that Project RED has been implemented at a number of hospitals since the study, and that preliminary data show that the system is producing results at other facilities. While many people ask him whether hospitals need dedicated discharge advocates, “we feel strongly that this could be easily assumed by the current staff of the typical medical ward.”

(Details of the document are online. Look for the “Toolkit” button on the left side of the page.)

To further streamline the discharge process, Dr. Jack and his colleagues are turning to technology and an avatar known as “Louise” to guide patients through the after-hospital care plan. When a patient is ready for discharge instruction, a nurse can roll a video screen with interactive software into the patient’s room. Louise then presents information from the patient’s discharge plan and asks questions to make sure patients understand the content. If patients can’t correctly answer a question about follow-up or medications, Louise automatically reviews that information again.

While Louise may lack a human touch, Dr. Jack says she doesn’t have to rush through the discharge summary, and she can present the same information over and over again.

“If the patient’s child comes into the hospital and wants to hear the discharge information,” he explains, “you just roll Louise in there and do it again. Louise has plenty of time.”

Edward Doyle is Editor of Today’s Hospitalist.