When a quality improvement committee at Regions Hospital in St. Paul, MN, sought to reduce readmissions, the members realized that they did not have sufficient data to identify the reasons patients returned. Forty percent of their readmission records indicated “other” as the reason, rather than the possible causes listed.
The hospital team decided to try drilling deeper with “real-time interviews” in which a staff member would take the time to ask the patient a series of questions intended to collect more valuable data, explains Rory P. Malloy, MPH, senior performance improvement manager. The quality improvement committee addressing the problem of readmissions drew on demographic data and brainstormed all the possible reasons a patient may return to the hospital, then distilled that into a series of questions to introduce on a trial basis.
Once the real-time interviews were implemented, the downside immediately became apparent. Staff were taking about an hour to sit down with patients and draw out all the answers to the list of questions. Even though the interviews were to be conducted on about four admissions per day, just a fraction of all readmissions, spending all that time was too much for the hospital staff to work into their already busy days.
“Unfortunately, it’s one more additional process and you don’t have the people power to accomplish something like that,” Malloy says. “We tried for about a year and we only got about 10 or 15 actual interviews. It was that burdensome for the staff.”
Staff Time Reduced to 13 Minutes
Regions addressed that issue by employing a handheld electronic medical communicator that HealthPartners was already piloting at other facilities in the system. The multilingual device features a caregiver on screen who reads each question and then walks the patient through the possible answers, which Malloy says produces better data than simply putting a written survey on a tablet for the patient to answer. The patient can complete the survey with little assistance, freeing up the staff. The device allowed Regions to cut the staff time needed for each readmission interview down from an hour to about 13 minutes.
The hospital completed 110 interviews over four months, representing 5.2% of the total expected readmission population. The average patient age was 61.
“We’ve gathered a lot of really valuable information from the patient telling us why they’re coming back,” Malloy says. “We set up the survey in a manner where we address key areas like the hospital stay, where they went after, then we focus on the medication experience. After that, we address discharge and then the follow-up experience once they’re home.”
Regions found that one in three patients missed one or more medication doses after discharge, and 38.2% of patients were not confident taking their medications. Also, 39% were not confident in the treatments taught to them at discharge, with 32% saying the discharge process could have been improved. Forty percent of readmitted patients interviewed felt their questions were not adequately addressed at discharge.
Nearly half (41.67%) did not attend a follow-up appointment, even if it had been scheduled for them. Twenty percent of patients stated they did not follow their diet or nutritional plan scheduled for them, and 35% of that group said it was because they could not find or afford food. A majority, 67.59%, said they received a discharge follow-up phone call.
Follow-up Visits Missed Often
The lack of follow-up was somewhat surprising, Malloy says. Regions already recognized the importance of patients receiving follow-up care and so the hospital had taken steps to help patients contact a physician, and in many cases the hospital made the appointment before the patient left.
“Half of the population not attending an actual appointment was kind of an eye-opening experience for us,” Malloy says. “We also were surprised at the number of patients who did not follow nutrition recommendations or take their medications as instructed. In a lot of cases it was because they did not have transportation or access to the right food, so they ended up coming back to the hospital instead of outpatient care, because the hospital has mechanisms to get around those problems.”
Analyzing the data revealed that the hospital should put emphasis on connecting patients with a pharmacist, so they understand how and why to take their meds, Malloy says.
“Almost all patients remembered being told about their medications and using teach back, but a third of them didn’t understand it. So, there’s that gap we’re starting to explore.” Malloy says.
In the same vein, it appeared that patients would benefit from contacting a primary care doctor for follow-up as part of their discharge planning instead of just being told to make an appointment or to appear at one already scheduled. That is particularly important, Malloy says, because research has indicated that a patient who does not have a follow-up visit within 10 days is significantly more likely to be readmitted.
“The interview data is allowing us to look at our processes and develop strategies that better serve our patients,” Malloy says. “We’re continuing with the survey, adding some new questions and addressing some issues that were revealed as affecting readmission rates, such as homelessness and lack of access to resources in the community.”
Questions Delve Deep for Causes
These are some of the questions that Regions employed in the readmission interviews:
- Disposition?
- Home address
- Nursing home or TCU
- Family or friend’s home
- Other
- Noticed not feeling well?
- Day of readmission
- A few days before readmission
- More than a week ago
- Decided to return to hospital?
- Day of readmission
- More than a day before readmission
- More than a week ago
- Know whom to contact with change in condition? Yes/No
- Other treatment options attempted before readmission?
- Urgent Care
- Emergency Department
- Home remedies
- Primary Care Provider
- Called Nurse Care Line
- Other
- Followed dietary instructions? Yes/No
- Reason dietary instructions not followed?
- Didn’t understand them
- Couldn’t get right foods at store
- Couldn’t afford foods
- Don’t want to follow diet
- Was still hungry while following diet
- Other
- Taught specific cares or treatments upon discharge? Yes/No
- Confidence you understood care or treatment education?
- Very confident
- Pretty confident
- Somewhat confident
- Not confident
- Follow-up appointments scheduled? Yes/No
- How were follow-up appointments scheduled?
- Patient made appointments
- Friend or family member made appointments
- Primary Care Provider’s office called to schedule
- No one scheduled appointments
- Did you make it to follow-up appointments? Yes/No
- Reason follow-up appointments not adhered to?
- No transportation
- Scheduling conflict (time didn’t work)
- Could not get off work
- Could not find childcare
- Forgot or didn’t know about appointment(s)
- Other
- Received follow-up phone call? Yes/No
- Who called?
- Regions Hospital
- Primary Care Provider’s office
- Health Insurance Company
- Other
- Don’t know/remember
- How was the call helpful?
- Answered questions/addressed concerns
- Helped schedule follow-up appointments
- Answered medication questions
- Offered comfort, gave me confidence
- Other
- Understood discharge instructions? Yes/No
- Followed discharge instructions? Yes/No
- Reason discharge instructions not followed?
- Didn’t understand them
- They were too long/had too many pages
- Lost them
- Didn’t want to deal with them
- No one reviewed them with me
- Other
- Could discharge experience have been improved? Yes/No
- How could discharge experience have been improved?
- Waited too long
- Felt too rushed
- Received too many papers
- My questions weren’t answered well enough
- Family members not involved/included enough
- Other
