Collaborate across the continuum to ensure successful transitions
Good discharge planning is just not enough
Executive Summary
As attention focuses on preventing readmissions, hospitals must improve their internal processes and forge relationships with post-acute providers.
- Patients are most vulnerable when they move between levels of care.
- Often, readmissions occur when the receiving provider doesn't have adequate information to continue the plan of care.
- Case managers should take the time to identify patients' needs and risks for readmission and communicate clearly with the patient and caregivers about what they need to do.
With pressure mounting to prevent readmissions, hospitals are examining their own discharge processes and collaborating with post-acute providers and community organizations to ensure that patients have what they need to have a safe and successful transition.
"Even if hospitals could do the perfect job of communicating with patients and preparing them to leave the hospital, if there is nobody at the next provider to take up where they left off, the process will fall apart. The best transition out of the hospital is only as good as the reception into the next level of care," says Amy Boutwell, MD, MPP, president of Collaborative Health Strategies and co-founder of the State Action on Avoidable Rehospitalizations (STAAR) initiative of the Institute for Healthcare Improvement.
It's not enough for hospitals to develop a discharge checklist and complete a process improvement initiative aimed at improving transitions, Boutwell adds. Hospitals also should meet regularly with providers at all levels of care and have a meaningful conversation about what each of them needs, she says.
Developing a close relationship with skilled nursing facilities and home care agencies is imperative in any readmission reduction program, says Brian Pisarsky, RN, MHA, ACM, senior managing consultant at Berkley Research Group and Centers for Medicare & Medicaid (CMS) alumni faculty for the Community-based Care Transitions Program (CCTP).
"These providers are just as interested in reducing readmissions as hospitals are. Medicare is monitoring readmissions from home care agencies, and skilled nursing facilities don't get paid when a patient is not in their bed," he adds.
The Affordable Care Act includes incentives for readmission preventions and quality as well as financial penalties for readmissions, points out Josh Luke, PhD, FACHE, vice president of post-acute services at Torrance Memorial Health System in San Francisco and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative. "The penalties and incentives should encourage hospitals, physicians, and post-acute facilities to work together better," he says.
CMS and payers already are looking at increasing the number of diagnoses that result in penalties for readmission, Pisarsky points out. "I'm sure that eventually hospitals will be penalized for every readmission," he predicts.
When patients transition from the hospital to the next setting, whether it's to home or a skilled nursing facility, it's a time of heightened vulnerability, Boutwell says.
Working relationships
"At one time the idea was that when patients no longer needed to be in the hospital, they were better. Now that patients are being discharged earlier, they often have ongoing care and support needs when they leave the hospital. Hospital discharge is only a milestone in their journey of recovery, not a finishing mark," she says.
The only way to ensure that patients get the care they need when they transfer to a post-acute provider is to forge working relationships with community providers, Pisarsky says.
Luke suggests that hospitals discharge patients only to facilities that coordinate care and meet the hospital's quality standards so patients can get the same level of care they have received in the hospital. Form a network with those facilities and meet with them regularly to collaborate on care, he says. The Total Wellness Torrance Post Acute Network includes seven privately owned skilled nursing facilities, a home health agency, and a hospice. All have committed to participating in quality initiatives and data-tracking efforts. (For details, see related article on page 28.)
It may take a while to develop a rapport with post-acute providers since they rely on hospitals for referrals and representatives initially may be reluctant to point out problems, Boutwell says. "But as the group continues to meet and everyone realizes that they are all there for the sake of improving care, the providers will begin to share specific and concrete information about patient care issues," she says.
When patients are readmitted to the hospital from a post-acute provider, it's often because they are sent with incomplete information or because the patient appeared different from what was in the paperwork, Boutwell says. For instance, the nursing notes might say the patient is alert and awake but the patient is confused and groggy when he gets to the skilled nursing facility and the staff send him back to the emergency department, she says.
Clear, timely communication with the receiving provider is essential, Boutwell says. "We rely on the antiquated discharge summary that may not get to the next provider for days or weeks. This is no longer acceptable. To ensure a good transition, there has to be clinician-to-clinician communication when the transition occurs. The handoff doesn't necessarily have to be physician to physician; it can be nurse to nurse or case manager to case manager," she adds.
Discharge planning should start when patients are still in the emergency department whenever possible, Pisarsky says. Hospitals are discharging sicker patients these days due to pressure from payers. This makes it imperative for case managers to start early in the stay to make sure patients have an adequate discharge plan, he says.
Case managers should conduct a comprehensive discharge planning assessment on every patient when they have been admitted or are receiving observation services, Pisarsky says. Don't make it a quick, cursory conversation. Ask questions and find out if the patient needs additional resources, he adds.
Case managers can help avoid readmissions, but if they don't have time to find out the patient's support at home or identify transportation issues or psychosocial needs, the hospital is going to be a revolving door for some patients, Pisarsky says. "Finding a reasonable ratio of patients to case managers could make the difference in hospitals staying in the black or being in the red," he says.
The responsibility for a safe and complete care transition belongs to the hospital as a whole, and not just the case manager, Boutwell says. "Transitions involve too many things across too many disciplines for just one person to be responsible," she says.
"Every patient needs a better set of basic services in the hospital to get ready to leave, whether they are the chief executive officer of a corporation, a frail elder, or a Medicaid patient. Hospitals need to raise the level of preparation and communication for patients across the board for everyone," she says.
In addition, hospitals must identify people with specific needs or risks in real time while they are still in the hospital, she adds. "There are a lot of readmission risk assessment tools available, but none are perfect. Hospitals need to adapt one of the tools for their own use or come up with a way to identify patients' needs," she says.
Hospital staff must communicate with patients and family members more clearly and consistently while they are in the hospital. "So often, nurses, doctors, and case managers whiz in and out and the patient and family is left with an incomplete picture of why patients are in the hospital, where they are going next, and what the patient and family needs to do after discharge," she says.
Case managers or other hospital staff need to make a follow-up appointment with their primary care provider or specialist while the patient is still in the hospital, make sure the patient can get to the appointment, and line up transportation if it's needed, she says. "It's not enough just to tell patients to follow up. Most readmissions are within two weeks," she says.
Collaborate with the patient's insurance plan's case managers to prevent high-risk patients from coming back, Pisarsky suggests. "Insurance companies don't want readmissions, either," he says.
It's essential for hospitals to develop a successful readmissions program, but it will take a lot of work, Pisarsky says. Start by reviewing your readmissions and drill down to find out why they occurred, he suggests. When patients are readmitted, talk to the patient and find out what happened — or didn't happen — to make the discharge plan fail, he says. When readmissions occur from home care or a post-acute facility, meet with the patient and the provider and find out what could have been done differently to keep the patient from coming back, Pisarsky suggests.
There's no one-size-fits-all solution to improving discharge planning, Boutwell says.
How hospitals assure safe transitions will vary from organization to organization. "The important thing is to get these tasks done," she says.
