EXECUTIVE SUMMARY
One health system’s care transition data showed improvements in length of stay, but less so in readmissions.
- Frequent flyer patients needed faster referrals and follow-up appointments.
- Changes made the process more effective and resulted in positive outcomes, including lowering the 30-day readmission rate from 12.9% in 2015 to 11.1% in the most recent data.
- Psychosocial issues can hinder a patient’s progress and must be adequately addressed.
When reviewing her health system’s care transition, a manager of case management noticed a trend: The length of stay was heading in the right direction, but the readmission rates bounced up and down.
“Readmissions didn’t have a steady decline. If it declined one year, it would go back up another year,” says Melanie Payawal, RN, BSN, PHN, CCM, ACM, manager of inpatient case management for Sharp Rees-Stealy Medical Centers in San Diego.
Payawal was determined to do something about it.
“I am a case manager at heart,” she says. “You see what’s going on with the patients, talking to them, seeing what they’re going through, and it hits you on a personal level. That was my motivation.”
Payawal worried about readmissions from the patient’s perspective, partly because she had seen her own grandmother bounced throughout a healthcare system in a different city before she died more than a year ago.
“When my grandmother was discharged, a lot of pieces did not fall into place,” she recalls. “I had to do case management for my grandmother, who had multiple comorbidities and renal disease.”
Seeing “frequent flyers” in her own patient population brought back those memories. “Oh, that patient is back in again. What’s going on with that patient? Did we do anything for this patient besides put home health in place?”
There were gaps in too-slow referrals to ambulatory case management.
“I’d look at all these cases, and it was a little painful,” Payawal says. “I did 75 case reviews with a very detailed look at the medical component.”
Then Payawal asked for input from ambulatory case managers, a skilled nursing facility, home health, and others.
“I started looking at trends to see if I could capture anything,” she says. “I also looked at avoidable days.”
She found that many patients did not have follow-up appointments scheduled. Or, if the appointments were scheduled, they were for 1.5 or two weeks later with their primary care provider. “That’s too long,” Payawal says.
“If we want to prevent a readmission, then they have to meet with the physician,” she adds.
Payawal drilled down deeper into the data to see whether these patients had any symptoms after discharge that could be handled at the primary care provider level before they worsen and require a hospital stay.
What she saw was eye-opening. Patients had symptoms that could have been handled earlier in the ambulatory setting, but there was too little follow-up, so these symptoms were missed, she says.
“I knew if we didn’t tie up that loop, we’re not doing any service for the patient,” Payawal says.
Another major finding was that several patients were delayed on discharges because of a lengthy MediCAL process. Patients were staying in the hospital for as long as months.
“We had to figure out a way to be more effective,” she notes.
“We looked at patients who stayed in the hospital for eight or more days,” Payawal explains. “Then we listed these patients in a report with their clinical information and other data, and we’d sit down and brainstorm to see if there was something we could do to help move the patient to the next level of care.”
The result was a 10.63% decrease in length of stay between 2014 and 2015, and a continued improvement through 2016. It was 4.8 days in 2014; 4.29 days in 2015, and 4.27 days in 2016, Payawal says.
The 30-day readmission rate was 11.1% in the most recent quarterly data available. It had been 12.9% in 2015, she adds.
The following are ways the organization used data and case management to improve outcomes:
• Obtain useful data. Using Medicare Advantage patient data, Payawal had data analysts provide a monthly report. Reports listed bed days, readmission, and length of stay.
The report also provided some trend information based on diagnoses. “But that doesn’t tell us the complete story of what goes on with patients,” Payawal says.
To get a fuller picture, Payawal took the detailed readmission report and list of patient names to perform a case review on some patients.
“Readmission reports list the number of days between when they were readmitted, so it’s a pretty comprehensive report,” she says. “To focus my energies, I use data as a guide, compare it with previous data, and go in that direction.”
• Use data effectively. “What I do with data is compare it to previous months to see if there is worsening of the numbers,” Payawal says. “If it looks like it’s getting worse from one month to another, I start focusing energy on that population.”
For example, a trend might be if Payawal notices there was a patient readmitted within a 14-day window, and she learns that patients like this one are not getting to primary care provider appointments on a timely basis.
Next, Payawal reviewed call center data and met with the call center’s leadership team to present her findings.
“I said, ‘We need to have our patients seen within five to seven days because, typically, patients are readmitting before they even see their doctor,’” she says. “We trained the leadership team on how to input the information into the discharge paperwork, so when they talk with patients they could solidify a time and date and put it in the paperwork before the patient is discharged.”
Payawal also asked the call center team to generate their own report to monitor their compliance.
• Deal with psychosocial issues. Psychosocial issues can impede a timely discharge and increase readmissions. Sometimes patients have no support at home. They live by themselves, and their families are uninvolved. When the patient has an acute event at the hospital and needs someone to care for him or her at home, there is no one, Payawal explains.
“So, we can’t discharge the patient because of these social issues, and, unfortunately, we see that issue a lot in the hospital setting,” she says.
Or, some patients may have to live with family members who weren’t involved before. Now, those same family members will be making decisions on behalf of the patient, she says.
“We offer them as much resources as we can and offer them some choices regarding the next level, which could be assisted living, and we help them determine what they can afford,” Payawal says.
For more information about Sharp Rees-Stealy Medical Centers’ program and the risk assessment tool, contact [email protected], or by phone: (858) 499-5564.
When reviewing her health system’s care transition, a manager of case management noticed a trend: The length of stay was heading in the right direction, but the readmission rates bounced up and down.
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