Providers collaborate to reduce readmissions
Program generates estimated $39 million savings
Executive Summary
By working together and meeting regularly, San Francisco Bay-area hospitals and post-acute partners have prevented an estimated 4,000 readmissions.
• The program included education for participating hospitals on evidence-based readmission reduction models and other available tools.
• Hospitals analyzed their readmission data and determined which patients were coming back and why.
• Representatives of hospitals and post-acute providers meet regularly and collaborate on better patient care.
A readmission reduction collaborative of San Francisco Bay-area hospitals and their post-acute partners has reduced hospital readmissions by 20% among participating hospitals, preventing more than 4,000 readmissions.
Using Medicare’s published rate of $9,500 in costs per readmission, the initiative has resulted in $39 million in savings for the healthcare system, according to Pat Teske, RN, MHA, implementation officer for the Avoid Readmissions through Collaboration (ARC) initiative.
ARC is supported by funding from the Gordon and Betty Moore Foundation, and led by Cynosure Health in partnership with the California Quality Collaborative.
"Readmissions not only cost $17 billion annually, nationwide, but they have a huge impact on patients. In order to reduce readmissions, hospitals need understand which patients are coming back and why and partner with providers in the community to make sure that resources are in place for patients to have a successful transition," Teske says.
In the first year of the program, the organization concentrated on education, informing participating hospitals about evidence-based readmission reduction models and training them on how to use the available tools.
Teske also worked closely with the hospitals to analyze readmission data and use the information to determine why their own patient population was coming back and what diagnoses readmitted patients had.
The causes of readmission have common themes, such as medication issues and lack of follow-up, but there is no one-size-fits-all, Teske says. "Some hospitals have huge issues with homelessness and how to help those patients get the post-acute services they need," she says.
Many hospitals found that a large percentage of patients were readmitted for heart failure, but that wasn’t always the case, she says. One hospital found that patients with sepsis were readmitted most frequently. Another determined that although it didn’t have a high volume of patients with HIV, those patients had the highest percentage of readmissions," she adds. Another found that the majority of readmissions were coming from a skilled nursing facility.
Talk to patients and find out why they are coming back, Teske suggests. Check with the primary care providers and find out if they knew patients had been hospitalized. Gathering as much data as possible will help hospitals and their community partners determine which initiatives will be the most helpful, she adds. Look at your processes and how they work. For instance, if your staff use teach-back in their patient education, make sure they are trained, and that they are using the tool effectively.
After conducting the detailed analysis, each hospital developed individual plans to improve their discharge process.
In Phase 2, the hospitals are working with skilled nursing facilities, home health agencies, and other organizations in the community to analyze why readmissions are occurring. "It’s like peeling an onion, layer after layer. When patients return, hospitals and post-acute providers and services are analyzing what happened, what didn’t happen that should have happened, and what the players can do to improve the process," she says.
Meeting with post-acute providers and having frank conversations has been one of the most effective strategies for hospitals in the ARC project, Teske says.
At the first meeting one hospital had with skilled nursing facilities, the representative from one facility mentioned that it wasn’t getting a form it needed with the other discharge information and that it always had to call to get it. Other facilities said they also were not getting the form. On the spot, the chief nursing officer made a call and had the form added to the discharge checklist.
"From that day forward, that point of frustration ended. That simple conversation helped so much with creating rapport and a good working relationship," she says.
Stay focused on improvement and continue to learn why patients are coming back. If you put a plan in place, monitor the interventions to make sure they are successful.
Use evidence-based models that have a proven success rate, she suggests.
(For more information about ARC and materials the initiative uses, visit www.avoidreadmissions.com.)
