Track, trend readmissions to reduce rehospitalizations
Look for the root causes of patients coming back
Now that the Centers for Medicare & Medicaid Services (CMS) is scrutinizing hospital readmissions, it's more important than ever for hospitals to thoroughly track and trend their readmissions, says Carol Everhart, RN, MMI, director of clinical informatics for Curaspan Health Group.
"Everybody knows that the stakes are high when it comes to readmission. The hard part is getting the right type of information so you can determine what you need to do. The hospitals that regularly review and respond to data trends are the ones lowering the readmission rate," she adds.
Hospitals shouldn't limit analysis of their readmission rates to aggregate data but should drill down and analyze the reason for each readmission as well as where the patients who are readmitted went after discharge, she says.
"Just knowing the readmission rate isn't enough. In order to identify the problem, you have to know the diagnosis, and more specifically, the discharge disposition," she adds.
Look at every readmission while the patients are still in the hospital and drill down to determine the cause, Everhart suggests.
"If case managers actually interview the readmitted patients when they are in the hospital, they can gain insight into the reason for the readmission. However, once patients are in the hospital, it's hard to stop the readmission. This means hospitals need to be looking at readmissions retrospectively as well in order to take proactive steps to prevent future readmissions," she says.
Look for clusters of readmissions, whether it's by diagnosis, returns from nursing homes, or patients being readmitted from the community. Use that information to determine where you need to institute process improvement measures to reduce the readmissions, she suggests.
When you identify a problem after discharge that could contribute to readmissions, look at your internal processes to see if you need to make improvements, or collaborate with the post-acute provider to make changes, she adds.
"Without comprehensive, precise data, you can't quantify which patients are coming back from which facilities or whether the problem is with one nursing home or all the nursing homes. Having good information helps hospitals determine where to start to make changes in the process in order to prevent readmissions," she says.
If patients are coming back from a particular facility or after receiving care from a particular home health agency, work with those providers to determine the root cause of the readmissions, she suggests.
"It may be that the facility or agency is not equipped to handle that particular type of patient, and that's causing them to bounce back to the inpatient setting," she says.
Sitting down with post-acute providers helps put a face on all the parties involved, Everhart points out.
"When hospitals and post-acute providers sit down and collaborate to get to the root cause of readmissions, they can determine what needs to change and reduce the preventable readmissions," she says.
When patients with pneumonia or congestive heart failure are frequently readmitted from a nursing home setting, it typically has a lot to do with staffing patterns, Everhart has found.
"Nursing homes are staffed with RNs during the 7 a.m. to 3 p.m. shift, but on other shifts they usually have fewer RNs or other staff who are trained specifically in the assessment process," she says.
For instance, if a patient with congestive heart failure has an episode in the evening, there often are limited staff on duty who are qualified to assess the situation and take steps to remedy it. Instead, the nursing assistant is likely to call an ambulance and send the patient back to the hospital.
If there is a pattern to these readmissions, the hospital case team should meet with the nursing home team to determine the times that patients get in trouble and collaborate on what to do. The nursing home may decide to educate the staff to call a physician for a consultation so the patient can be treated in the nursing home rather than the emergency department or be admitted to the hospital, she says.
When patients are readmitted after a heart attack, it's more likely that the reason for the admission is associated with medication, Everhart points out.
"It may be that they are not on medication or they aren't taking it properly. Failure to change lifestyle habits or adapt a healthy diet also are big factors in heart attack readmissions," she says.
When patients with heart attacks are readmitted, the hospital has an opportunity to evaluate patient education, whether they had smoking cessation counseling, a dietary assessment, or were educated about their medication, she says.
Look for problems in communication and clarity of discharge instructions, Everhart suggests.
"Make sure that the discharge instructions are clear and concise so patients will have an easier time learning what to do about medications and diet. The smoking piece is harder if patients don't have smoking cessation classes or a prescription for medication to help them stop smoking," she says.
Case managers should carefully document everything they do so the team won't waste time looking at discharge instructions if that's not the problem, she says.
"If there is a cluster of patients with a certain diagnosis who are being readmitted from the community, it may be that the screening process for post-acute needs is not as good as it could be. It could be that this group of patients would have benefitted from home health," she says.
Monitor your data frequently and make changes in processes when you start to notice subtle changes that may occur from month to month and indicate that there is a problem, she says.
"Regularly receiving, reviewing, and responding to data pays off not just in preventing readmissions, but in improving patient care. When hospitals discover a trend, identify the root cause or causes behind it, and implement a plan to address it, it's a win-win situation for the hospital and its patients," Everhart says.
[For more information, contact: Carol Everhart, RN, MMI, director of clinical informatics, Curaspan Health Group, e-mail: [email protected].]
Now that the Centers for Medicare & Medicaid Services (CMS) is scrutinizing hospital readmissions, it's more important than ever for hospitals to thoroughly track and trend their readmissions, says Carol Everhart, RN, MMI, director of clinical informatics for Curaspan Health Group.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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