Home What Works On the road: bridging inpatient-outpatient care

On the road: bridging inpatient-outpatient care

A mobile team helps drive readmission rates down

August 2017
Hand in hand

WHAT DOES IT TAKE to reduce readmission rates? For Milford Regional Medical Center in Milford, Mass., the solution was a mobile clinical team and a state grant.

In 2015, Milford Regional received a $1.3 million, two-year grant from the Community Hospital Acceleration, Revitalization, and Transformation (CHART) program, a $120-million state initiative for community hospitals. At the time, explains Annette Roberts, the hospital’s director of quality, Milford Regional—like hospitals nationwide—had average readmission rates that topped 20% and was repeatedly being penalized for excess readmissions.

To turn that around, the hospital used the grant to fund what it calls the high-risk mobile team. That team includes a palliative care physician assistant (PA), a pharmacist, a nurse case manager and a social worker. While the PA is a 0.8 FTE, the other three work full time.

“When we first launched the team, the readmission rate among high utilizers topped 34%.”

what-works-roberts~ Annette Roberts
Milford Regional Medical Center

The hospital also honed in on the readmission population it wanted the team to target. While team members initially concentrated on all Medicare readmissions, they eventually zeroed in on a certain subset of patients, many of whom are Medicare beneficiaries: individuals with three or more hospital admissions during the previous 12 months related to their chronic conditions.

“When we first launched the team in October 2015,” Ms. Roberts points out, “the readmission rate among high utilizers topped 34%.” While readmission rates fluctuate from month to month, team members have since frequently driven those monthly rates down into the low 20% range.

“And they don’t cherry-pick,” she adds. “Team members don’t say, ‘I can’t see those patients because they have too many comorbidities.’ They see the sickest of the sick.”

Identifying high-risk patients
Ms. Roberts is the team lead, and two physicians— one a hospitalist, the other an emergency doctor—are also part of the readmission team, which meets weekly to review patient cases.

Team members also make weekly visits to high-risk patients who have been discharged to SNFs. The four mobile members rotate between working days in the hospital and making home or field visits. Two team members always start their day outside the hospital, Ms. Roberts says. “They may not come to the hospital that day because they’re out seeing patients.”

Each morning, team members—as well as department heads, including hospital medicine and nursing—receive a report of all patients currently in the hospital who have had three or more admissions in the previous year. Those patients receive an automatic palliative care consult with the PA, if appropriate.

One team member in the hospital huddles in the morning with hospital case managers and social workers to go over which hospitalized patients are high utilizers. Once high-risk patients are identified, team members meet with patients, introducing themselves and outlining the program. Because the team is supported by a state grant, the service is free to patients—something members of the team explain.

“We make sure we’re not missing something in terms of services for those patients,” Ms. Roberts points out. Team members then accompany hospitalists on morning rounds with high-risk patients.

They give patients cards with their photos and contact information. Those cards follow patients going to SNFs and are placed in their charts for SNF personnel to call, if needed.

Preventing bouncebacks
After patients are discharged, Ms. Roberts says, mobile team members typically visit or call patients between five and seven times over the course of a month.

What do they address that helps keep patients out of the hospital? Many social issues, Ms. Roberts says, including lack of access to transportation. Many other factors are related to prescriptions. “Maybe patients can’t afford the medications they were discharged home with, so they’re not taking them,” she notes.

Or they went home with a medication they’re already taking, so are now taking twice. It’s a big help when the pharmacist reviews medications in the home. “Many prescriptions are outdated,” Ms. Roberts points out, “or the prescription has changed.”

In addition, team members provide education: diet control for some patients, or discussing how not exercising affects patients’ health. They make sure patients make follow-up appointments, and they connect patients to services they may not realize they qualify for.

“We had one patient whose husband was ill and a veteran,” she says. “We found a service that provides housekeeping for veterans.” The social worker has also connected patients with grants that provide eye exams and eyeglasses.

Getting started
In addition to helping lower readmission rates, team members have been able to cut down on the number of admissions being racked up by high utilizers.

“We used to see people being admitted eight or nine times a year,” says Ms. Roberts. “We’re now keeping their admission numbers way down.”

At the same time, new patients with three or more admissions during 12 months keep cropping up, so while one set of patients drops out of the high-risk group, others qualify.

To get the project up and running, Ms. Roberts says the team first worked with information technology to generate the daily report that identifies high-risk patients currently in the hospital. And since the program began, the ED has worked with SNFs to treat high-risk patients sent from SNFs to the ED. It returns those patients to the post-acute facilities, rather than admit them to the hospital.

“Those numbers are low,” Ms. Roberts says. “Many times, SNF personnel can take care of patients, but it’s families who want them returned to the hospital, even though that can increase delirium. For the families, it’s been a learning curve.”

The project also used grant funds to purchase care management software that allows the team to communicate with each other.

The original grant also helped pay for the pharmacy to deliver patients’ prescriptions to their bedside before discharge. “That was one piece we couldn’t sustain because the local pharmacy was purchased,” says Ms. Roberts. “But our pharmacist is very good about bringing patients’ medications, if they need them.”

With the current round of CHART funding running out next month, Ms. Roberts says the hospital is considering strategies to sustain or expand the mobile-team program. That includes applying for additional funding.

Project leads are considering more pharmacy involvement as well as implementing telemedicine for the mobile team.

And for the past two years, “the team has focused on chronic medical conditions, and we have not tapped into the population of substance abusers because we don’t have the resources or the right team composition,” Ms. Roberts says. “That’s something that, as we go forward and there’s a new phase of state funding, we’ll consider addressing.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the August 2017 issue of Today’s Hospitalist
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