Executive Summary
A case management team at UPMC Presbyterian Shadyside Hospital in Pittsburgh has developed an initiative to improve communication between the hospital and skilled nursing facilities in an effort to reduce readmissions.
• The team interviewed readmitted patients, analyzed trends in readmissions and what caused them, and researched readmission prevention tools.
• They developed a risk tool that assesses a variety of issues and use it to help identify patients who are at risk for readmission. The tool covers comorbidities, psychiatric issues, polypharmacy issues, emergency department visits and hospitalization, and other issues.
• They created a discharge checklist that lists the tasks that should be done for every skilled nursing discharge.
By developing a tool that can be used to identify high-risk patients and a checklist to use when patients transition, UPMC Presbyterian Shadyside Hospital in Pittsburgh has improved communication between the hospital and skilled nursing facilities and reduced readmissions.
“Like everyone in the healthcare industry, we were challenged with readmissions. Our department decided to focus on readmissions from skilled nursing facilities because we felt that case managers and social workers had more control over those than over readmissions in general,” says Ann Kostial, RN, BS, MHA, senior director of collaborative care management for the 1,282-bed acute care tertiary care hospital.
A team from case management interviewed patients who were readmitted, audited charts, and analyzed readmissions to identify trends in readmissions and the issues that caused them. A case manager who worked on the project researched readmission prevention tools and tools to predict patients at risk, says Bonnie Schuster, RN, MSN, director of collaborative care management at UPMC Presbyterian Shadyside.
The team took the information she gathered and worked with a medical director to develop a tool that could predict which patients were most likely to be readmitted. Then the team developed a checklist that includes tasks that should be completed for every discharge to a skilled nursing facility.
The risk tool assesses comorbidities and psychiatric issues; hospitalizations and emergency department visits in the past year; polypharmacy issues and problem medications; poor health literacy and lack of caregiver support, and the plan of care for things such as complex wounds or complex treatments.
The discharge checklist enumerates the tasks that should be done for every skilled nursing discharge. “When we analyzed our readmissions, we found breakdowns on our part. In some cases, when patients had specific clinical issues, the staff was going at light speed and sometimes failed to enter all the information in the discharge software,” Kostial says.
The checklist reminds the case manager to make sure the documentation in the record being transmitted to the facility is complete and accurate and that the staff at the facility are aware that the patient is at risk for readmission.
It lists specific items to be documented, including a description of wounds, information on the patient’s mental status, and needs for oxygen.
The checklist also helps the case managers determine if a skilled nursing facility is the right level of care or if a long-term acute care hospital (LTACH) might be more appropriate, Schuster says.
The first section asks the case manager to evaluate if a skilled nursing facility is the correct level of care, if the facility selected can carry out the treatment plan, if there is a nurse practitioner or physician assistant on site, and if the facility has medication available on site.
It reminds the case manager to request an on-site evaluation of the facility and to evaluate the need for a palliative care consult if the patient has had three admissions in the past year. It also reminds the case manager to discuss the risk of readmission and the plan of care with the patient and family and educate them on how the services at a skilled nursing facility are different from those provided by the hospital.
Case managers complete the prediction tool to determine if the patient is at risk for readmission. If the tool predicts that the patient has a high probability of being readmitted, the case manager or social worker who is facilitating the discharge uses the pre-transfer checklist to make sure everything is in place for a smooth transition to the skilled nursing facility.
After the patient is transferred, the case manager calls the nursing home to make sure they received all the information they need to care for the patient and that the transfer went smoothly.
If patients are readmitted to the hospital, the case manager calls the nursing home to find out what caused the readmission. “A large percentage of readmissions are because of a patient’s or family member’s request. Sometimes they don’t like the place they chose. Some nursing homes try to address whatever the issue is and to appease the family but, regardless of their efforts, sometimes patients and families just want to go to another facility. We try to work with the patient and family if they prefer another facility,” Kostial says.
When patients come back because they don’t like the facility to which they were transferred, the case manager and social worker in the emergency department try to find another nursing home spot for them if they don’t meet inpatient criteria. “We tread a fine line here. If we leave them in the emergency department until we find a bed, it affects patient flow. If we aren’t successful in placing patients from the emergency department, the patient is bedded in the applicable status and the inpatient care manager or social worker continues to work closely with the patient and family on a safe discharge plan,” Kostial says.
If there are clinical issues, the case manager refers the case to the clinical care team for review. “We investigate the issue and find out what we can do to prevent another readmission. Sometimes we determine that the patient isn’t at the right level of care and a long-term acute care hospital might have been a better choice,” Schuster says.
The new process was piloted on two units with high volumes of nursing facility referrals and readmissions from nursing homes. The tools in the pilot were on paper. The team is working with the hospital’s information technology department to develop a tool for the electronic medical record that combines elements of the case management department’s tool and a tool developed by the quality department.
“The quality department has a tool that uses historical information as well as admissions information to score the patient electronically. Their tool is clinically driven and uses lab values and patient history. Ours includes psychosocial issues such as caregiver support, and psychiatric issues. We are working in collaboration with them to see if we can combine the two tools,” she says.
