A proactive approach to preventing readmissions

A proactive approach to preventing readmissions

Education, follow-up are the keys to success

If you wait until the day of discharge and spend 15 minutes explaining the discharge plan and educating patients on what they should do at home, your discharge plan may not be very successful.

"Most adults retain only 20% of what they are told, and if their only education is right before discharge, they don’t learn much. People are being readmitted because they don’t understand the importance of a follow-up appointment or how they should take their medication," says Teresa C. Fugate, RN, BBA, CCM, CPHQ, a case management consultant based in Knoxville, TN.

The patient population is more complex and challenging than ever before, and lengths of stays are shorter than ever. Patients often are overwhelmed by all the discharge information they receive, adds Cindy Reilly, RN, BSN, vice president of quality and patient safety at Marlborough (MA) Hospital, part of UMass Memorial Healthcare.

Reilly recommends that case managers start patient and family education early in the stay. "Forget teaching on Day 1. It’s not effective to try to educate patients when they are in crisis. However, you cannot wait until they are stabilized because that’s discharge day," she says.

At one hospital where she worked, Fugate created a disease-specific educational program for the top DRGs and produced folders, color-coded by DRG, that were placed in patient rooms. The folders outlined three or four goals for each diagnosis and included a script that clinicians could follow. For instance, for heart failure, the topics included signs and symptoms, weight monitoring, and medication. The information also was placed on a whiteboard on the wall.

Every clinician—physicians, dieticians, case managers, therapists, and nurses on all shifts—had a conversation with patients on an educational topic and documented what they covered every time they entered the patient room. The night shift clinicians didn’t talk to the patients at 2 a.m., but they did conduct the education as long as the patient was awake.

"It’s more important for the staff to talk about how to care for themselves instead of talking about last weekend’s football game or the NASCAR race on TV. Patients might prefer to talk about what’s on television, but that’s not why the patient is in the hospital. The goal is to make sure patients can take care of themselves at home," she says.

Bedside shift reports offers another opportunity for the nurse to repeat the discharge teaching, she says.

"Patients may get tired of hearing it over and over, but when they get home, they’ll be grateful that they learned how to take care of themselves," she says.

Make the follow-up appointments when the patient is still in the hospital, she suggests. "When the patient calls, it may take 30 days to get an appointment, but a case manager may be able to get them in to see a physician in two days after discharge," she says.

Talk to family members several days before discharge to find out a good date for a follow-up physician visit within three or four days of discharge, Reilly adds. "We involved the family because they are likely to be providing transportation. It doesn’t do much good to make an appointment with a physician if the patient can’t get there," Reilly says.

Since many Medicare patients are taking five or more drugs, set up a pharmacy consultation to make sure patients are on the right drugs and the right dosage and to educate patients and family members on how to take their medication, says Peggy Rossi, BSN, MPA, CCM, a retired hospital case management director who now is a consultant for the Center for Case Management. In addition, double-check that they can afford the medications and that they have transportation to get the prescriptions filled.

Multidisciplinary rounds are an important part of preventing readmissions, Rossi says. Use the opportunity to talk to the nurses and to educate physicians on patients’ living situations and alert them when you don’t think the patient can be safely discharged, Rossi says. Learn to say "no" when you feel the patient cannot be safely discharged, she adds.

Consider home evaluations for at-risk patients, Fugate suggests. Some patients may meet criteria for a home care evaluation. If not, consider sending a staff member into the home to assess the home for safety issues and to check the refrigerator and cabinets for high-sodium or high-sugar foods, depending on the patient’s diagnosis.

It may not be practical to send a staff member to a rural area to check on patients, she adds, but as penalties increase, it may be a good return on investment, she says.

Follow-up calls are a good way to reinforce the discharge plan and let patients know that somebody cares, Fugate says. "If nobody checks on them, they may interpret it that following their plan of care isn’t important. If they know somebody is going to call in a week to check on their weight or whether they’ve seen their doctor, they’re more likely to adhere to the plan," she says.

At Covenant Health System in Knoxville, TN, where Fugate was vice president for case management services until August 2013, case managers make post-discharge phone calls two days after discharge, a week after that and a week later and ask open-ended questions about the patient’s understanding of the treatment plan, medication regimen, and follow-up appointments. They continue to make the follow-up calls as long as needed.

"Open-ended questions are very important, because if patients can answer yes’ or no,’ they don’t go into the details of what is really happening," she says.

Fugate recommends developing scripting so the phone calls are consistent. Collect information during the phone calls and use the data to make improvements. For instance, track how many patients went to their follow-up calls on the day that hospital staff set up.

Marlborough (MA) Hospital has developed a process to make a recorded call to every patient within 72 hours of discharge. The recording asks a series of questions that patients answer by pushing buttons on the telephone. If there are questions or concerns, the call is transferred to a clerical employee who refers the callers to a clinician if appropriate.

"Patients need to ask questions, but clinicians are so busy that they may be hesitant. Case managers help the patient and family members feel empowered," she says.